Research Changing Methods of Treating Depression

NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington. Depression is a big challenge for psychiatry. Diagnosis can be difficult. Too often, treatment fails, and the problem is frighteningly common. Fifteen percent of us will battle depression at some point during our lives. Now, new research shows doctors may sometimes be too quick to diagnose clinical depression when the problem is normal sadness after the death of a loved one or a divorce or similarly stressful circumstances.

And there's also new research about the treatment of bipolar disorder, where people experience mood swings between depression and mania. This is a less common condition, but no less perplexing.

Later in the program: money, money, money, money. The presidential candidates report the results of the last three months fundraising, the continuing battles between the White House and Capitol Hill on Iraq funding and the fate of the attorney general.

If you have questions for guest Political Junkie Mara Liasson, you can send them to us by e-mail now: talk@npr.org. But first, new research on depression. We're going to start with the shifting line between sadness and depression. We'll get to questions about bipolar disorder a bit later.

Our number here in Washington is 800-989-8255 - that's 800-989-TALK. E-mail is talk@npr.org. You can also join the conversation on our blog at npr.org/blogofthenation. And we begin here in Studio 3A with NPR health policy correspondent Joanne Silberner. Hello, Joanne.

JOANNE SILBERNER: Hello, Neal.

CONAN: And how big a deal are these new findings about distinctions between sadness and depression?

SILBERNER: Well, it's hard to tell in a real world. The way this study was done was people looked at survey results, how people answered certain questions. And they looked at how they answered questions that would diagnose them depression if you followed a strict cookbook definition of depression, and they looked at whether they had life events that might have explained them.

Now, when you get a real clinician - an experienced, trained clinician -sitting down with a real patient, you might see something different. The clinician might be very well aware that the person had just gone through separation from a partner or loss of a valued job or something like that might explain it. So in the real world, it's hard to tell.

CONAN: But it seems to suggest that normal grief can sometimes be misdiagnosed as depression.

SILBERNER: Well it can, but how many times that happens is hard to tell, you know, because of this cookbook - you know, does it meet the cookbook definition? And the cookbook definition is two weeks of unremitting sadness that affects your ability to do the things you normally do, as well as for - a bunch of other symptoms, you know, sudden loss or gain of weight, an increase or decrease in appetite, suicidal thoughts, recurrent thoughts of death. You know, you have to meet this strict criteria.

What the survey looked at is who meets that strict criteria, those strict criteria, and who doesn't and who had a loss and who didn't. So it could very well be if you're being very careful and going by the book, you might get over-diagnoses.

CONAN: And not only over-diagnosed, but if you are over-diagnosed, perhaps over-medicated.

SILBERNER: That's possible. That's a big debate in psychiatry and psychology today.

CONAN: Well, let's hear from a psychiatrist, then. Joining us here in Studio 3A is Dr. Darrell Regier. He's director of research at the American Psychiatric Association. Nice to have you with us on the program today.

Dr. DARRELL REGIER: (Director of Research, American Psychiatric Association): It's a pleasure to be here.

CONAN: And why is there any question about diagnosing depression. Doing a little reading, it turns out it's not so easy.

Dr. REGIER: Well, as Joanne mentioned, this study was really a re-analysis of some survey data and was not a study, really, of actual practice of psychiatrists and how they assess patients and decide to put people on treatment. Was it was is actually a very interesting test of the hypotheses or questions about diagnostic criteria that are really embedded in the cookbook, or the "Diagnostic and Statistical Manual of Mental Disorders" that's produced by the APA.

And a decision was made in about 1980 that when depression is diagnosed, it would be important to know if somebody had just had a major loss of a loved one, or if there was something else going on in their life, perhaps a loss of a job and so forth. And there was really a hypothesis set up that if you lost a loved one, it would be categorically different than if you lost a job or had a separation or something like that.

And what this study did is it actually tested that. Did people who lost a loved one and were grieving that death, were they different than people who had lost a job or a divorce or something like this? And what they found is that when you look at the correlates of those two situations, that they had the same amount of service use. They had the same number of symptoms.

They had fatigue. They had some - the same level of impairment. The only thing that was really different was that people who had lost a loved one had more thoughts of death or suicide, which you might expect as a result of a death actually having occurred.

CONAN: Let me put this another way. If you had a certain set of symptoms, which you just described, there was an exception for grief. If you just lost a loved one, there was an exception - all right, we'll not take that too seriously, or at least not yet. And now there are more - there's more than one exception. Is that fair enough to say?

Dr. REGIER: Well, what they - well, that's the question. Should it be an exception? In other words, the question - the assumption that the authors of this article made was that if you make an exception for grief, you also ought to make an exception for other losses and shouldn't count those folks as having a mental disorder.

Now, the alternative to that is maybe you shouldn't have any exceptions, and what you really ought to focus in is on the level of severity of the symptoms that the person has. So if somebody lost a spouse or a child to death, and they came in after three or four weeks and were having acute suicidal ideation and the like, you shouldn't say goodness, I ought to wait to decide to treat this person for another month because maybe this is part of normal grief.

So what you ought to do is really treat the person on the basis of the severity and the impairment of the symptoms rather than whether or not it followed a particular event.

CONAN: Mm-hmm. So individual cases, as opposed to trying to follow some rigid guidelines.

Dr. REGIER: Exactly.

CONAN: All right. Let's get some listeners in on this conversation. 800-989-8255 is our phone number - 800-989-TALK. E-mail is talk@npr.org. Our guests are Joanne Silberner, NPR's health policy correspondent, and Dr. Darrell Regier, who's the director of research at the American Psychiatric Association, and we'll begin with Kathy, Kathy calling us from Boise, Idaho.

KATHY (Caller): Hello.

CONAN: Hi, Kathy. You're on the air.

KATHY: Good, I'm glad that I got in. Dr. McGee(ph) was - I was just listening as I waited on the phone, and Dr. McGee was talking about treating the symptoms, not necessarily the cause, which I actually thought was kind of neat Because I listened to the promotion this program when it was coming up. And essentially what I heard was you don't want to diagnose these people with depression because of the stigma involved.

And I thought since I have cycling depressions, I said, wow. You know, that's really nice. It's actually reinforcing the stigma by saying gee, we don't want to diagnose somebody with that.

(Soundbite of laughter)

KATHY: So I was a little bit concerned about that and thought that sometimes in our trying to be fair and organize things, that sometimes we actually put more stigma than there already is on something like this.

CONAN: And I'm sure Dr. Regier would be proud to be Irish, but his name is Regier and not McGee.

KATHY: Oh, I'm sorry.

CONAN: Please go ahead, doctor.

Dr. REGIER: Well thank you. I think that's precisely one of the issues here. It's almost as if saying that if you really have a serious depression and it followed some event, that you shouldn't take it as seriously, whereas in reality, I think what we all should do as clinicians is if somebody comes in and has a legitimate depressive illness, whether it followed a loss or if it seemingly appeared spontaneously, that that needs to be treated as a real illness that one has to make a decision of what the best approach is.

Should it be a psychotherapy? Should it be a supportive therapy? Or should medication be added? But it certainly should not be looked at like many people do - if it's a loss, you just need to buck yourself up, and, you know, you ought to get over this.

And the point is that sometimes, these stressors come and they interact with an individual's vulnerability and genetic vulnerability and we don't know, you know, with a given individual what a stress is going to do in terms of actually helping to precipitate a serious, clinical depression.

CONAN: Just let me follow up on Kathy's questions, though, about stigma. Reading an interview with one of the coauthors of this study, he said that yes, there is - for good or real - there is a stigma. And if you can avoid labeling people as depressive, it's probably a good thing.

Dr. REGIER: No question.

KATHY (Caller): That's what I was really concerned about. I thought, huh, that the people who are trying to help, who are working on it, are actually reinforcing the stigma by saying, good heavens. You know, we wouldn't want to diagnose somebody as having depression.

(Soundbite of laughter)

CONAN: If they didn't have - Joanne?

SILBERNER: Well, being that the stigma issue is - has just bedeviled. Research in this - everything in psychiatry - you know, research and treatment and payment for treatment. And I agree with the caller's concern that if you're saying, my God, you wouldn't want a diagnosis with depression. You're saying this is a terrible disease and I don't want you near me, and, you know, just keep this away and this is bad. And that is a concern. I'm sure that the authors didn't mean it that way. I'm sure that they, you know, they meant it in a sense that they didn't want to see people treated for depression, though, who don't actually have it.

KATHY: The other thing that I do know is when you have symptoms of depression, it's persisted for a while. You tend to have losses because you tend to be less able to cope with things that come up in your life. So it would be really difficult sometimes to untangle that. A person could lose their job. A person could have all kinds of losses and the cause of that might be the depression.

CONAN: Yeah, and that gets back to each individual case, doesn't it, Dr. Regier?

Dr. REGIER: Yes, indeed. And, in fact, I think what the benefits of this particular study are that I think rather than showing that a particular context really should determine whether - how you evaluate a person's depressive illness, but it actually does exactly the opposite. It shows that the kind of reaction that people can have from the loss of a loved one or the loss of a significant part of their life - a job or a spouse or something like this - can have equally severe consequences, or seemingly, in a given individual, and that each individual really needs to be treated, you know, as an individual and looking at the severity disability associated with that depression.

CONAN: Kathy, thanks very much for the call.

KATHY: Thank you for taking my call.

CONAN: We're going to take a short break. Afterwards, we'll take more of your calls about this new study on depression guidelines. We'll also talk about new research about treating bipolar disorder. Again, if you'd like to join us, 800-989-8255 - 800-989-TALK. E-mail is talk@npr.org. This is TALK OF THE NATION. I'm Neal Conan in Washington.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. We're talking about news on depression this hour. A study in the archives of general psychiatry suggests that guidelines for diagnosing the illness may be a little too broad. Our guests are NPR Health Policy Correspondent Joanne Silberner. Also with us, Dr. Darrell Regier. Of course, you're welcome to join the conversation. Give us a call: 800-989-8255. E-mail: talk@npr.org. You can also read what other listeners have to say at our blog, npr.org/blogofthenation.

And let's see if we can get another caller on the line. And this is Scott. Scott's with us from Alta Loma - is that right - in California.

SCOTT (Caller): Alta Loma, California. That's correct.

CONAN: Go ahead, please.

SCOTT: Thank you for taking my call.

CONAN: Sure.

SCOTT: Neal, I'm mostly interested at this moment in how this study was funded, because it sounds very much like an ongoing conservative movement to try to take the very human endeavor of diagnosing and treating illness - especially psychiatric illness and psychological illness - and turning it into a cookie-cutter computer program flowchart process, such as, you know, under the ACOM guidelines which the doctor may be familiar with and various other guidelines that are being promulgated by the insurance industry to try to limit the diagnosis and treatment of illness.

CONAN: Well, Joanne, who's behind the funding of this study?

SILBERNER: You know, right before I walked in here, I wanted to know that same thing. I went to the journal. I looked to the place in the journal article -where journal articles usually say where the funding was from, and maybe I need new glasses, but I just didn't see it.

CONAN: So it wasn't listed?

SILBERNER: I didn't see it.

CONAN: Do you have information on that, Dr. Regier?

Dr. REGIER: Well, I know that the original study that provided the information - the data - was the National Comorbidity Study that was funded by the National Institute of Mental Health. In fact, I was at the National Institute of Mental Health and authorized the funding of the study when that happened back in 1990. This particular analysis was done by a group at New York University at Columbia, and it doesn't say if they received any additional funding. It wouldn't take a lot, because all it was was a computer reanalysis of existing data.

CONAN: Scott's analysis of it, listening to what you were saying, I was not hearing cookie cutter, I was hearing each case has to be treated separately.

Dr. REGIER: Right. What this did - I mean, despite what came out in the media about this - is that this was really a wonderful example of testing of the diagnostic hypothesis in the diagnostic and statistical manual to see if they held up. And the DSM is not a Bible, despite what a lot of people have said - it's not the Bible of psychiatry. It's a scientific textbook and set of guidelines.

And basically, what they did is they were testing whether or not the guidelines were internally consistent. Should be grief be treated the same way as other kinds of losses? And they basically said no, it shouldn't. But I think the key point to remember is this is a study - is a test of our diagnostic criteria. It's not a study of the appropriateness of treatment.

CONAN: Scott, thanks very much for the call. There's also news on treatment for people suffering from the bipolar disorder. Joining us now is Dr. David Miklowitz. He joins us from the studios of Member Station KGNU in Boulder, Colorado. And it's nice to have you on the program today, doctor.

Dr. DAVID MIKLOWITZ (Professor of Psychology and Psychiatry, University of Colorado; Author, "Bipolar Disorder Survival Guide"): It's nice to be here.

CONAN: And the study that just came out of the New England Journal of Medicine suggests that people with bipolar disorder do not need an antidepressant in addition to a mood stabilizer. In fact, it turned out the people who got placebos instead of antidepressants did just as well.

Dr. MIKLOWITZ: Okay, there are two studies, and both of these studies came out of the systematic Treatment Enhancement Program for Bipolar Disorder. The one that appeared in the New England Journal of Medicine has found that when you optimize medication treatment with mood stabilizers - which are drugs like Lithium and Valproic - for people with bipolar depression, then you don't get an additional bang for your buck, if you will, from adding an antidepressant into the mix above getting a mood stabilizer plus placebo.

It's not that these patients were treated with placebo. All of them were on mood stabilizers, but adding this other medication did not speed up response - adding antidepressants, that is.

CONAN: And, in general, the fewer medications the better.

Dr. MIKLOWITZ: Certainly. Yes.

CONAN: And the Journal of Medicine study also mentions that antidepressants are commonly used for manic-depressive illness. Why would doctors do that if there's no evidence that the drugs help?

Dr. MIKLOWITZ: It's a good question. I think, though, there is evidence that the drugs helps in other phases of the illness. For example, most recently, Dr. Lori Altshuler at the UCLA Medical Center was able to show that if you can stabilize patients on combinations of mood stabilizers and antidepressants, then you're better off leaving patients on them than taking them off because they will have a recurrence of their depression if you take them off of it.

What we've shown is something different, that when you have an acute episode of depression, that adding an antidepressant in the mix is not a necessary part of treatment. You can achieve stability with a mood stabilizer alone as long as you're optimizing treatment.

The worry about antidepressants is that they can cause mania, and they can cause a condition we call rapid cycling, where people go in and out of episodes very rapidly. So I think the episode - that the evidence is mixed in terms of whether these are good drugs to use or not. But in our study, we're finding that stabilizing depression is not - the benefit is not added by adding an antidepressant.

CONAN: Mm-hmm. Is there sometimes a tendency among psychiatrists to say, look. I think I need to do something about this…

Dr. MIKLOWITZ: Yes.

CONAN: …and this might help.

Dr. MIKLOWITZ: Yes. And I think you have to consider - it was interesting, the point was made earlier in the show about treating each patient individually. As you go along through the treatment of bipolar disorder, you're going to see considerable ups and downs, and some of these episodes are going to be quite debilitating to the person. And I think it is reasonable at some point in that illness course to say let's try an antidepressant.

What our study is showing, though, is that during an acute episode, that may not be the time to introduce an antidepressant. Instead, what we're finding is it may be useful to add an intensive psychotherapy.

CONAN: And does that work well?

Dr. MIKLOWITZ: Okay, now that gets to the second study we did in the same dataset. That was the one just published in the Archives of General Psychiatry. And what that found is that if you take patients who are bipolar and have depression, if you add an intensive psychotherapy onto their medication regimen of mood stabilizers, with or without antidepressants, you'll get - patients will get better faster, and they'll stay well longer if they're getting intensive psychotherapy as opposed to medication alone, plus a few case management sessions. So that suggests that psychotherapy is a very important part of the effort to stabilize episodes of bipolar depression.

CONAN: Let's see if we can get some more listeners involved in the conversation. Here's an e-mail. This is about bipolar disorder. And you're going to have to help me with this, Dr. Miklowitz, because…

Dr. MIKLOWITZ: Okay.

CONAN: I was diagnosed - writes Nancy - bipolar 10 years ago and put on a Depakote/Wellbutrin regimen for depression because Paxil made me hypomanic, and my brother takes Lithium. I do not believe my diagnosis was considered terribly severe. I stopped taking both medications seven months ago, and since stopping I really have felt okay. I did notify my psychiatrist and have seen him in the duration. Does bipolar go into remission, and/or might I have been misdiagnosed?

Dr. MIKLOWITZ: Well, misdiagnosis is always a worry, and that's one of the reasons we think that really, the first step in treatment is doing a thorough diagnosis. The lady has described a regimen that's commonly used in bipolar disorder, the combination of a mood stabilizer, Depakote, and an antidepressant, Wellbutrin. That's not an unreasonable combination to be on depending upon the presenting symptoms.

Now the fact that she's been well for seven months does not mean she's not bipolar, because we know that in an average year, about 40 percent of patients will have a recurrence. About 60 percent in two years. So it's not unusual for people to go periods of time without having a recurrence when they're not on medications. Medication reduces the likelihood of recurrence and elongates the periods between episodes. But you can't conclude you don't have the illness just because you haven't had an episode in a while.

CONAN: All right. Let's see if we can get some more callers on the line. And we'll see if we - which direction we go. Rosetta - Rosetta's with us from Portland, Oregon.

ROSETTA (Caller): Yes.

CONAN: Hi, Rosetta. Go ahead, please.

ROSETTA: I'm calling because we had a teenager diagnosed with depression, and it was during the time where there was a whole, you know, what's safe to give a teenager. And what we found is the Prozac actually made everything worse. And just taking care of her, making sure she got exercise, ate well and, you know, went to counseling, she's been fine for the last two years without any meds. I think the meds, people or doctors jump to it too quickly, and I can't stress more that the individual patient - that's so important. I mean, you really have to look at each person, especially when you're talking to teenagers.

It's hard being a teenager, and she had some serious life events at the time. And I think they pushed us really hard to the Prozac too quickly.

CONAN: Dr. Regier?

Dr. REGIER: Yes. Well, I think this is a serious issue. I think what most physicians would like to be able to do is to have the skills to assess what the level of depression is. And one question is if you went in to see your primary care physician, or if this was a psychiatrist that started your child on an antidepressant?

ROSETTA: We started with psychiatry in an emergency room, went to a family pediatrician and back to psychiatry. And they all talked, and everyone - everyone pushed. I mean, it seemed like, oh, another teenager with depression -Prozac. And the second bout of it, after we finally got it - her off of it, because it turned her into a - turned her into a zombie, we played with different levels. We finally got her off of it, and she was good. And then a while later, they said, oh, she needs it again.

And we fought it. We ended up putting her on it again, because they made us, as parents, actually feel bad that we weren't doing the right thing for our child. So we tried it again, and we ended up with a zombie child again, so we took her off. And we've been off, paying close attention to it, checking in with a counselor. You know, I heard you just saying does it - you know, with the other person, maybe doesn't mean she doesn't have depression. She just doesn't need the Prozac.

Dr. REGIER: Well, that's wonderful. If you have that level of both clinical attention from your physicians and also as parents, you're able to really support your child through this. And certainly, what you're describing is a child who's having some relatively severe side effects. Being a zombie is not considered a, you know, normal effect of an antidepressant medication.

So I think the - in your particular case, if, in fact, with supportive help and within a judgment of whether or not medication or additional psychotherapy might be needed as the child continues to develop is the best way to go with this particular clinical situation.

Dr. MIKLOWITZ: Can I just add one thing?

CONAN: Go ahead, Dr. Miklowitz. Yeah.

Dr. MIKLOWITZ: Yes. About the treatment of adolescents, I think one of the thing we're learning - not only from the step program, but also from the recently-published treatment of adolescent study which looked at both antidepressants and psychotherapy together - that in a lot of these conditions, it's best to combine an active psychotherapy with an antidepressant, and that you actually get a better outcome if you put the two together than if you consider either one of those alternatives alone.

The other thing, too, is that Prozac may not be the right treatment for a particular child. It may be that that child would do better on a mood stabilizer or different kind of antidepressant. And then there's a subgroup of teenagers who do fine with psychotherapy, as the lady who's just called has illustrated. So it's not a one-size-fits-all treatment algorithm.

CONAN: Rosetta, thanks very much for the call, and we wish your daughter the best of luck.

ROSETTA: Thank you.

CONAN: Bye-bye. That - you just heard Dr. David Miklowitz, a professor of psychology and psychiatry at the University of Colorado. Also with us is Dr. Darrell Regier, director of research at the American Psychiatric Association, and Joanne Silberner, NPR health policy correspondent. You're listening to TALK OF THE NATION from NPR News.

And here's an e-mail we got from Richard in Oklahoma.

Is there any way to quantitatively diagnose depression through blood testing or CAT scanning or something like that, or is it always in the eye of the physician? I'd like both of the doctors to weigh in on this - Dr. Regier, first.

Dr. REGIER: One of the things that we're trying to move the field further toward is actually getting more quantitative severity assessments of depression and using some of the standardized instruments that were used, for example, in another study that was funded by NIMH in addition to the one that Dr. Miklowitz is talking about, and that is the STAR-D program, or the treatment of major depression.

And the way they entitled this was "measurement-based care." We need to have better measurement. They used a quick-inventory depression scale. Many other physicians are using something called the PHQ-9, which is a patient health questionnaire nine-item that covers the nine symptoms of depression, and then rates them from zero to three so you can have a score of zero to 27. Above 20, it's a pretty severe depression.

And I think what is important about this measurement approach is that you can follow whether or not your treatment is really working or not. If it's not working, you need to change it. You just don't stay with it. And I think that's the direction that the field is coming to for both primary health care providers and for psychiatrists. But, you know, there's a tremendous amount of research that's going on in the imaging area, in the genetics area, in the what we'd call pathophysiology or neuroscience areas of trying to understand the actual mechanisms of depression and where we can best enter with - whether it's psychotherapy or with medication.

CONAN: Dr. Miklowitz?

Dr. MIKLOWITZ: Yes. I can tell you that bipolar disorder's extraordinarily difficult to diagnose, and this is particularly true in children. We've often wished we had a litmus test or a brain scan or a blood test of some sort that could diagnose the disorder. Right now, we rely heavily on structured diagnostic interview, both not only with the patient but also often a family member as well. Historical records become very important. There are clinicians around who claim they can diagnose bipolar disorder with a brain scan, but the data simply aren't there.

There are differences between bipolar brains, say, and the brains of people with schizophrenia or brains of people with depression, but they're not specific enough to be able to look at a brain scan and be able to say this is a bipolar brain and this is not. So I think that's a long way off still.

CONAN: And Joanne Silberner, clearly, on the level of calls and e-mails that we've gotten on this subject, people are very concerned about it and have a lot of questions. Are there places they can go to find out more general information?

SILBERNER: Yes, there are plenty of places they can go. One of my favorite Web sites is the one run by the government called medlineplus.gov, and you can put in a keyword and see more about that. National Institute of Mental Health has a Web site that's quite good. There are two organizations that work with people with mental illness and their families. One's the National - why, they've changed their name, haven't they? It was the National Alliance for the Mentally Ill, if it's still that.

Oh, and then National Mental Health Association - they changed their name. They're now Mental Health America. Both of them actually have - you can go down to your local area and see what kind of support groups are available. You can get help with things like finding some financial support, because some of these diseases can be nearly bankrupting.

CONAN: Yes. And if you didn't scribble those down quickly enough, we'll get that information from Joanne and post it on our Web site at npr.org, and at our blog at npr.org/blogofthenation so you can look at all those links later today, as soon as we get them up. And Joanne is trying to scribble them down now.

So, anyway, thanks to our guests. Dr. Regier, we appreciate your time today.

Dr. REGIER: Thank you.

CONAN: Darrell Regier is director of research at the American Psychiatric Association. He was here with us in Studio 3A. And Dr. David Miklowitz, we thank you for your time today.

Dr. MIKLOWITZ: Thank you for having me.

CONAN: Dr. Miklowitz, a professor of psychology and psychiatry - I can say that properly - at the University of Colorado. What does it mean that I can't say it properly?

Joanne Silberner is NPR's health policy correspondent, also with us here in Studio 3A. When we come back from a short break, the Political Junkie is out on vacation. Mara Liasson is here to peek inside the campaign coffers with us. They are bulging. If you have questions about those or other events in the week in politics, give us a call: 800-989-8255, 800-989-TALK. E-mail: talk@npr.org.

I'm Neal Conan. We'll be back after the break. It's the TALK OF THE NATION from NPR News. Transcript provided by NPR, Copyright National Public Radio.