Heterogeneity of depression – major challenge

Even when excellent clinical guidelines are available, therapy and medication should be personalized.

Among the group of psychiatrists, eight from the Philippines and two from Malaysia, they agreed that their most significant challenge was the heterogeneity of the condition. It was agreed that different patients have different problems and, in the face of this, each patient needs a different approach. Even when excellent clinical guidelines are available, therapy and medication should be personalized.

However, this is not possible, as one clinician pointed out, because we cannot yet pinpoint the precise underlying causes of many of the facets of the condition. Therefore, precisely treating depression in all its various guises is not yet feasible. Encouragingly, the group seemed optimistic that in the future such tailoring of therapy will exist.

Time is precious – especially at the outset

Spending more time with the patient during their first visit yields a good return

Until then, however, it seems that the key initial strategy is taking a good medical history. As one doctor explained, spending more time with the patient during their first visit, in her experience, yields a good return. Understanding what the patient’s biggest problems are and seeking to tackle these first seems to form the basis of a good, working doctor-patient relationship.

Re-establishing normal functioning is seen as fundamental. But, better still, might be to improve functioning better to avoid or cope with the types of stressors that could trigger relapse

Generating just such good doctor-patient relationships was one of the ways that psychiatry was noted to have changed over recent years. Instead of the clinician telling the patients what to do, working together with the patient, gaining their trust and working towards their goals is now seen as paramount in modern practice. Re-establishing normal functioning is seen as fundamental. But, better still, might be to improve functioning better to avoid or cope with the types of stressors that could trigger relapse.  And key to the attainment of such goals is the partnership between patient and doctor.

Patient-doctor partnership often includes the family in Southeast Asia

In Southeast Asia the patient-doctor partnership is frequently extended to include the patient’s family. The family attends treatment sessions – not just the patient. One clinician said that, upon first meeting a patient, he asks whether they wish the family to remain.  Once it is clear what the patient’s wishes are, only then the session begins.

Basic questions during the taking of a patient’s history include finding out ‘who they were before’ and this is then used as a basis for determining treatment goals and the pathway that can be travelled in so doing. “I’d rather interact with the patient than use assessment tools,” we were told, “The most precious time is that spent interacting with the patient.”

Assessment tools – gauge progress and act as reminders

Other clinicians agreed with this sentiment but also have their patients undergo self-assessment testing prior to each session. This serves two purposes. Firstly, such assessments serve as an objective tool that allows patients (who are frequently rather pessimistic in outlook) to gauge their improvement over time. Secondly, these assessments serve as reminders to clinicians to look for symptoms that the patient might not be aware of, such as cognitive impairment. 

Almost all the clinicians included in the session routinely assessed cognitive symptoms

Indeed, almost all the clinicians included in the session routinely assessed cognitive symptoms. Unsurprisingly, over the past few years, with increasing emphasis on the importance of cognition, the group was more aware that it should be asking more than a single question on concentration. “We no longer just ask “How’s your ‘concentration’?” We elaborate and ask questions about decision making, planning, and memory. We also try to discover the root causes of cognitive deficiencies – and we don’t just attribute them all to depression.”

Overall remission levels vary

Levels of overall remission varied between clinicians’ practices. The lowest levels were below 20% but this was in a geriatric clinic where co-morbidities likely influence outcome. It was generally observed that remission rates declined with increasing age. The highest remission rate of 60% was reported by a clinician who suggested that the less urban location of her practice was a likely contributory factor. She saw lower remission levels even in non-natives (foreigners and those who had arrived there through intermarriage), suggesting that social integration also plays a role in successful remission.

Overall remission rates of 30-40% were volunteered. However, remission is difficult to accurately quantify

Overall remission rates of 30-40% were volunteered. However, remission is difficult to accurately quantify. Patients fail to come back to the clinic – but whether this is because they are better or are far worse is an unknown. Another observation was that the better resourced a patient was, the greater their chance of attaining remission as additional modalities could be added. However, resources were not the sole reason for of success.

Questioning questionnaires

Questionnaires in English are useless if patients read another language, or if they are illiterate

Use of questionnaires appeared challenging. For example, most self-administered questionnaires are written in English - which are useless if patients read another language or if they are illiterate. Also, patients are impatient and don’t want to take questionnaires. They just want to get better as quickly as possible and appear to want an instant quick fix. “Don’t talk so much, doctor. Just give me the medicine,” was how one doctor described some of her more impetuous patients’ responses.

Presentation delayed by medical tourism

One of the main features of Southeast Asian practice is the late presentation of patients

However, it appears there may be good reason for their impatience. One of the main features of Southeast Asian practice is the late presentation of patients. And the reason for this is that frequently, due to stigma and family pressure, patients’ first ports of call when they become ill are practitioners of traditional medicine – faith healers and witches.  “It’s an uphill battle,” one clinician said, “By the time we see patients, they are pretty bad. They see traditional healers. Sometimes they spend a fortune and families even travel abroad if there are rumours of ‘a really good one’.” As he explained, this limits therapeutic options for depression management upon disappointed return. By this point, psychotherapy alone is unlikely to help and most patients receive medication straight away.

Stigma of mental illness driving inappropriate practice

The others agreed. Instead of visiting a psychiatrist, one clinician explained, they’ll go and see a gastroenterologist because they have digestive problems brought on by anxiety. Even well-educated people prefer natural remedies to psychiatry. The problem is that even once we see them, patients are topping up their medication with traditional remedies or pills obtained from the internet. We have no idea what drug interactions are going on.

Clearly, the stigma of mental illness remains huge in Southeast Asia. However, with such powerful psychiatric champions as those interviewed here, undoubtedly this will change in the foreseeable future.