Despite improvements, much depression remains undiagnosed

February 18, 1997|By Susan Gilbert | Susan Gilbert,NEW YORK TIMES NEWS SERVICE

There is a perception in some circles that everyone either is taking an anti-depressant or knows someone who is taking one. Prozac and Zoloft are household words, and the sales of these drugs have soared to the point where the global market for all anti-depressants is estimated at $6 billion a year.

But at the same time a panel of experts recently concluded that depression is still being under-diagnosed and under-treated.

For most people with clinical depression, the disorder is either undiagnosed or misdiagnosed, the panel reports in last month's issue of the Journal of the American Medical Association. Of those who have been depressed for 20 or more years, about half have never taken an anti-depressant, the report says, and fewer than one-third of those who take medicine get an adequate dose for a long enough time.

What is most surprising about the findings is that they come from studies done after Prozac, the first of a new generation of anti-depressants, came into widespread use.

These drugs, selective serotonin re-uptake inhibitors, increase the brain's level of serotonin, a neurotransmitter that influences mood.

Not only are they safer than their predecessors, they have achieved a certain celebrity status, factors that doctors say have made them more acceptable to patients and doctors.

"I would have believed that the vast majority of people with chronic depression would have been treated and treated better," said Dr. Martin B. Keller, a panel member and chairman of the department of psychiatry and human behavior at Brown University School of Medicine. "I was almost horrified."

While some psychiatrists who were not on the panel found the report overly pessimistic, they agreed with its overall conclusions.

"There's no question that depression is still under-diagnosed," said Dr. T. Byram Karasu, chairman of the department of psychiatry at Albert Einstein College of Medicine in New York City.

The National Depressive and Manic-Depressive Association, a professional group in Chicago, convened the panel last year to examine the gap between the knowledge and treatment of depression and to find out why it exists. Panelists for the conference included psychiatrists, family doctors, patients and representatives of insurance companies. Their lodging and expenses were paid for by Bristol-Myers Squibb, the manufacturer of Serzone, an anti-depressant.

The panel estimated that 24 percent of women and 15 percent of men would suffer from clinical depression at some point in their lives.

The annual cost of the illness was placed at $43 billion in medical expenses, absenteeism and lost productivity at work and premature death.

One of the biggest obstacles to diagnosis and treatment is people's attitudes toward their symptoms, the panel said. Some people mistakenly assume that being sad most of the time is an aspect of their personality or a normal response to a troubling situation. Others realize that they suffer from depression but do not seek help out of fear of being stigmatized at work or at home, according to the report.

Incomplete therapy

The panel reports that when patients are treated, many do not complete their drug therapy. Market research has found that half of all patients stop taking their medicine within 30 days because they are troubled by the side effects, which include nausea, insomnia and sexual dysfunction. But medical evidence indicates that depression requires long-term treatment to prevent relapse, Keller says.

Another problem is that primary-care doctors often fail to recognize signs of depression in their patients, despite several recent education campaigns by the National Institute of Mental Health and other groups.

The panel found that many doctors spend too little time with their patients to make a diagnosis, or that they dismissed the signs of depression as hypochondria. When doctors do prescribe anti-depressants, they often give too low a dose for too short a period in an effort to minimize side effects, the panelists said.

Finally, the report concluded that limited mental-health insurance coverage is a major barrier to adequate treatment. Ninety-three percent of people with health insurance have mental-health benefits, said Eron Shosteck, a spokesman for the Health Insurance Association of America.

But Keller said few plans approved psychotherapy for depression anymore because it is too expensive, leaving anti-depressants as the only treatment option. But he and his colleagues also found that some managed care plans discourage doctors from prescribing the newer anti-depressants because they are more expensive than the older ones.

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