Our correspondent spoke to Professor Philippe Fossati of the Hôpital de La Salpêtrière in Paris to hear some of his views on challenges and issues around contemporary management of patients with depression.
Without wishing to devalue the importance of clinical assessment of patients, I am excited that we are beginning to define depression better at a biological level.
There is a lot of active research into genetic markers of depression, neuroimaging and preclinical work on depression that could soon translate in ways that will help clinical practice.
Many other medical specialties are ahead in this regard and some already use biological markers in diagnosis and evaluation. Take cardiovascular medicine for example – where it is routine to use a range of biomarkers within an integrated composite that is used to prognosticate and guide management. I work in a large neurology department and in the past decade we’ve seen other psychiatric diseases move in this direction, with for example diagnosis and assessment Alzheimer’s disease now involving blood markers, spinal fluid assessment and MRI as well as clinical evaluation of the patient.
We would be wrong to try to look for any single biomarker in depression but we do need biomarkers indicative of mood regulation and cognitive regulation. The likelihood is that there needs to be a set of biomarkers.
Turning to treatment
I view the combination of psychiatric and psychotherapeutic approaches to the care of patients with depression from a number of perspectives. Firstly, on a practical level – a real and common issue is: is psychotherapy available? Not just access to a service but also access to competent therapists and appropriate psychotherapy. By that I mean that some patients may need therapy to support interpersonal relationships, others require psychoanalysis and so on.
The second issue is – and I think we don’t know the answer to this – when should we combine psychotherapy and pharmacotherapy? It might be presumed that two approaches are better than one, but this isn’t always the case. In fact some data suggest the reverse. There is also a question of when to apply psychotherapy – should remission be induced using drug treatment and then psychotherapy used to consolidate drug treatment?
Then thirdly, how do we define psychotherapy? There are as I mentioned a number of different types of therapy and in depression – we also call upon cognitive behavioural therapy (CBT), which is not really a form of psychotherapy.
It takes time
The way we define remission in depression is based on using mood scoring systems, yet the real endpoint we are seeking is a state where there are no residual symptoms and a full recovery of patient function. It takes time for patients to fully recover from their depression. Patients experience a change in their ‘relationship with themselves’, that can affect confidence and erode their social reputation. We need to assess and address these factors.
It takes time for patients to fully recover from their depression.
There is research and study – not all of it new – that shows we are capable to addressing the complexities of brain diseases. Studies looking at deep brain stimulation as a therapeutic manoeuvre suggest that if we can identify the physiopathological abnormality in a neurological disease, we may be able to treat or target that abnormality.
In depression, we give antidepressant drugs that target the serotinergic system, and while that is not an incorrect approach, there may be abnormalities at a biological level that need to be targeted more directly. Indeed we know that depression is not a disease where “one size fits all”.
Things are changing and we will move and progress to an era when we can offer truly individualized medicine to patients with depression, but I hope we don’t loose the features that make us good psychiatrists and practitioners, able and willing to truly interact and engage with our patients as people.