A woman stops to look at a makeshift memorial, Friday, Aug. 15, 2014, in San Francisco, for actor Robin Williams. (AP Photo/Eric Risberg) Photo: (AP Photo/Eric Risberg) Canadian doctors are reporting high rates of severely depressed patients who aren’t responding to usual treatments, increasing their risk of developing the kind of crippling depression Robin Williams is said to have battled for decades.
New research involving more than 1,200 patients with major depressive disorder, or MDD, from across Canada found nearly one-quarter, or 22 per cent, suffer treatment-resistant depression, meaning depression that has not responded to at least two different antidepressants from different classes.
The study provides a snapshot of hard-to-treat depression, “one of the most prevalent psychiatric disorders encountered by primary care physicians in Canada,” the authors write in the Canadian Journal of Psychiatry.
“These findings emphasize the persistence of depressive symptoms in a large proportion of patients with MDD,” they said.
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About 11 per cent of Canadians will meet criteria for major depression at some point in their lives.
Robin Williams had been suffering severe depression before his body was discovered in his California mansion this week, and the gifted comedian had spoken candidly about his struggles with the illness before his death.
The vast majority of depressed people don’t take their own lives. But, “every time there is a tragedy in the public domain it causes people to revisit an ongoing story — and that is that depression has an enormous impact on the lives of Canadians,” said senior author Dr. Sidney Kennedy, a professor of psychiatry at the University of Toronto.
Depression not only costs the economy billions in underperformance at work, unemployment and disability, “it kills a substantial number of Canadians every year,” said Kennedy, who holds the Arthur Summer-Rotenberg chair in suicide studies.
Treatment-resistant depression can be especially harrowing. People suffer repeat bouts of what can feel like paralyzing depression. They report a greater number of side effects from antidepressants, including dizziness, confusion, tremors, rapid heartbeat, weight gain and sexual dysfunction.
In the study, patients were considered to be treatment resistant if they had no, or minimal improvement in symptoms after two or more trials from different classes of antidepressants lasting a minimum of six weeks.
“Once you get to that level of severity you’re at greater risk of recurrences, you’re at greater risk of medical complications and the risk of suicide is increased,” Kennedy said.
A total of 135 family doctors from across Canada participated in the study. Each reviewed the charts from the last 10 consecutive patients, aged 18 to 75, they had treated for major depression. “We asked them to select in order, so they weren’t cherry picking,” Kennedy said.
Of 1,212 patients, 263 were classified as treatment-resistant.
They tended to be older (in theirs 50s), were more likely to be on long-term disability, were more likely to report signs of substance abuse and anxiety and tended to be on multiple drugs, including anti-psychotics.
They were also more likely to be overweight or obese.
Kennedy said any doctor who sees a patient with treatment-resistant depression should screen for other diagnoses, including bipolar disorder, where mood stabilizers, and not antidepressants, are considered the first treatment choice.
“I do think we probably don’t move quickly enough.”
But only half the patients with treatment resistance were screened for bipolar, “which means a few questions asking if there were any times when they behaved in an impulsive or reckless way, or where they spent money they didn’t have or where they felt they had boundless energy, only sleeping one or two hours a night.”
Treatment resistance doesn’t mean the person is resistant to all treatments, Kennedy stressed. “We mean based on what would be a reasonable number of treatments to expect the average person to get better.”
But when one drug isn’t working the tendency is for doctors to merely increase the dose, or add more drugs. “That’s often a sign that things aren’t going well,” he said.
Patients in the study waited six to eight weeks before their medications were switched. That exceeds guideline recommendations that a change should be made after two to four weeks if there’s no improvement.
Kennedy said Canadian family doctors and psychiatrists are better informed about the management of depression “than many of their colleagues in other countries.”
“But I do think we probably don’t move quickly enough,” he said.
“If patients are not showing any improvement in two to four weeks, they should be going for follow-up appointments and saying, ‘what can we do next?’ ”
Doctors should ask about mood, energy, interest and suicidal thoughts. “It may also be a question of family doctors being quicker in some cases to look for specialist support,” Kennedy said.
The study wasn’t able to capture how many of the patients had access to counselling, he said. “But we support strongly psychotherapy options like cognitive therapy as a treatment.”
skirkey(at)postmedia.com
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