Are medications useful in treating depression?

When is psychotherapy and when is medication?

In order to uncover a depressive disorder that requires treatment, targeted questions to the patient concerned are usually necessary. As a rule, the patients spontaneously describe only partial aspects of their complaints, which are sometimes reflected as physical symptoms (stomach pressure, dizziness, globus feeling). Depending on the severity of the depression, psychotherapy or pharmaceuticals come first in therapeutic considerations.

In Germany, around 10% of patients in an average family doctor's practice suffer from depressive illnesses [4]. Women get sick twice as often as men.

Even if it is controversial whether the prevalence of depressive illnesses has increased in recent years, the data from the health insurance companies indicate that depressive illnesses are becoming increasingly important in the world of work. Due to the special characteristics of depressive illnesses (significantly longer sick leave times, higher rate of chronification and permanent disability), questions of treatment and assessment of depressive disorders play a very important role in practice. The care of depressed patients by GPs is not easy. The recently published National Care Guidelines "Unipolar Depression" [1], which were developed by 28 psychiatric, psychosomatic, psychological and general medical societies in a process lasting several years, may help in the various decisions to be made here.

The guidelines not only contain a large number of recommendations on diagnostics, immediate therapy and accompanying measures. They also make statements about strategies in the event of unsuccessful treatment and provide help with the indication for specialized treatment offers, especially for patients with somatic or extensive psychological comorbidities.

Diagnosis

Depressive disorders can best be classified according to their severity in everyday life. This is determined by the number of existing symptoms and the extent of the impairment in lifestyle. Depressed mood, loss of interest and joylessness are the core symptoms and are sufficient for the diagnosis of a mild depressive episode.

If there is also a severe and persistent impairment of self-esteem, repeated repeated suicidal thoughts or sleep disorders, at least one moderate episode must be assumed, which can be important for the therapeutic approach.

If there is an additional pronounced lack of drive and other impairments (appetite disorders, sleep disorders, severe concentration disorders, etc.), a severe episode is assumed. The symptoms must last over 14 days.

The symptoms mentioned must be asked specifically and completely, since depressed patients often spontaneously describe only partial aspects of their state of health. According to the more medical model of many patients, these are often physical complaints such as stomach pressure, constipation, tightness in the throat and chest, globus feeling, functional disorders, dizziness, tension-related muscle pain, exhaustion, subjective memory disorders and loss of libido.

In the course of the diagnostic work-up, special attention must be paid to suicidality. A clinical distinction must be made here between different manifestations. Do fantasized suicide plans exist and the patient rejects agreements such as a suicide pact, i. H. the assurance to contact the doctor before irretrievable action, the referral to, if necessary, inpatient, psychiatric treatment is essential.

therapy

The question of the differential indication of psychotherapy and pharmacotherapy, which is often discussed, occupies a large part of the guidelines.

In accordance with most international guidelines, psychotherapeutic intervention is primarily recommended in the presence of mild depression.
In view of the risk-benefit ratio in the case of mild depression, drug treatments should only be given if the patient has clearly positive previous experience, if the patient clearly wishes, and if symptoms persist after other interventions.

Psychotherapeutic interventions usually require referral to specialist or psychological-psychotherapeutic hands. Despite the relatively good density of psychotherapeutic care in Germany, waiting times have to be accepted in principle. However, preliminary discussions to clarify a therapy indication are often to be carried out within shorter periods of time and experience has shown that the waiting time for a therapy place is easier. The psychotherapy procedures offered in Germany as part of statutory health care can provide proof of effectiveness.

Procedure for severe depression

In moderate depressive episodes, it is assumed that psychotherapy and drug treatment work equally well. One problem with pharmacotherapy is the well-known low compliance and high drop-out rate as well as the lack of sustainability after discontinuation. A recent meta-analysis has again shown the equivalence of psychotherapy and pharmacotherapy in acute treatment and the inferiority of second generation antidepressants compared to professional psychotherapy carried out by trained therapists in the follow-up [3].

It is also worth mentioning that modern antidepressants are now assumed to have an effective latency of less than a week. If there is still no significant improvement after three weeks, the probability of a treatment success drops to less than 20%. Differential recommendations for individual preparations are not given.

St. John's wort can also present studies on the effectiveness in moderate depression, but with this drug in particular, the high risk potential z. B. pointed out in multimorbid patients because of unpredictable drug interaction (oral contraceptives, anticoagulants, anticonvulsants, antivirals).

In the case of severe depression, pharmacological (co-) treatment is generally considered to be sensible. This is especially true in the presence of severe sleep disorders. A combination with psychotherapy is clearly superior to drug monotherapy. In individual studies, psychotherapy alone was able to show good effectiveness in severe depression - this must be taken into account if there is a corresponding patient preference.

It is important for general practitioners that if there is no response after about three to four weeks, the treatment strategy must be reviewed for the reasons mentioned.
Increasing the dose beyond the recommended daily dose is not recommended for SSRIs and has been shown to have no effect. It makes more sense to either change the preparation or the substance group or to add a second preparation, whereby only the combination of mirtazapine with an SSRI or a TCA is recommended. Augmentation with various anticonvulsants or beta blockers and other substances is not recommended.

If no improvement is achieved through drug treatment over a period of about six weeks, a referral to a specialist or psychological psychotherapist is advisable at the latest.

Maintenance therapy

If drug therapy is successful, continuation for at least six months is strongly recommended. However, it is also known that the sustainability of a successfully completed psychotherapy, especially to the extent that it is provided by the local contract psychotherapy, is at least as good a prophylaxis.

Critical to antidepressant therapy, it should be noted that meta-analyzes in recent years have confirmed the suspicion that the placebo effect largely explains the effect in the area of ​​mild and moderate depression. Only in the area of ​​severe depression is this significantly below the verum effect [2].

Special therapy procedures

The complementary therapy methods often discussed in public, such as electroconvulsive therapy, repetitive transcranial magnetic stimulation, vagus stimulation or even deep brain stimulation, show different levels of evidence.

Electroconvulsive therapy can be used as a last resort and if you have positive previous experience in selected hospitals. Controlled studies indicate that rTMS is effective in the area of ​​moderate depression, and there is already evidence of light therapy for seasonal depression. The other procedures mentioned continue to have an experimental character, even if the spectacular nature of their individual successes makes some patients think of this option.

Medical Attitude

Finally, it should be pointed out once again that depressive illnesses are to be seen in close connection with unfavorable biographies or life circumstances characterized by losses, insecurities and impaired self-esteem. In this respect, a major risk factor for depressive illnesses lies in complex personality factors. Dealing with the affected patients must take this into account.

The doctor can shape the feeling of helplessness, rejection and threatened social isolation through patient presence, combined with a relatively active and supportive approach at the beginning. The offer of clear and reliable support and the promotion of personal resources also allow for many patients sole therapy in the context of a general practitioner.

Avoid trivializing and hasty consolation or advice, the feasibility of which and personal consequences cannot be foreseen. Likewise, the amateur “interpretation” of unconscious or hidden affects should be avoided.

The formulation and development of concrete and achievable “mini-goals” (daily structuring, promotion of enjoyment, careful abandonment of social withdrawal) are helpful for most depressed patients.

In the case of chronic personality impairments or persistent strong psychosocial stress factors, it is recommended that the patient be referred to psychotherapy or specialist medical treatment as soon as possible.

According to current knowledge, the quality of the therapeutic relationship plays a role in all approaches. H. the degree to which the patient is “subject to being taken care of” plays a decisive role.


1. Hardener M, Klesse C, Bermejo I, Bschor T, Gensichen J, Harfst T, Hautzinger M, Kolada C, • Kopp I, Kühner C, Lelgemann M, Matzat J, Meyerrose B, Mundt C, Niebling W, Ollenschläger G , Richter R, Schauenburg H, Schulz H, Weinbrenner S, Schneider F, Berger M (2010) Evidence-based therapy for depression - The S3 guideline on unipolar depression. Neurologist 81: 1049-1068
2. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT (2008) Initial Severity and Antidepressant Benefits: A meta-Analysis of data submitted to the Food and Drug Administration. PLoS Medicine 5 (2): e45
3. Spielmans GI, Berman MI, Usitalo AN (2011) Psychotherapy versus Second-Generation Antidepressants in the Treatment of Depression. J Nerv Ment Disord 199 (3): 142-149
4. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC (2005) Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: 629-40




Prof. Dr. med. Henning Schauenburg
Clinic for General Internal Medicine and Psychosomatics
Heidelberg University Hospital
Prof. Dr. med. Jochen Gensichen
General Practice Institute
Jena University Hospital