Depression need not win over us

Dear Dr. Camardi:

I came in with my 78-year-old mother who was quite depressed that time we saw you. I recall how you went over with your students the thinking behind what goes into how you prescribe antidepressants.

Well the reason I’m writing to you is that I need to be placed on antidepressants now and I wonder if you would go over what you said that time with my mother.

One of the most interesting transitions in medical thought I have witnessed over the past 30 years is the evolution with which we in the profession look upon depression.

In the mid-’70s when I was in medical school, the persona presented of a depressed patient was one of a weak-willed type who just can’t seem to cope with the world. Today, we have a greater understanding of the disease of depression as a biological syndrome, where pharmacology and psychotherapy (including spirituality) have made great strides in helping the patient with this challenging condition.

It has been recognized that depression is one of the most common medical conditions in the world. It has been estimated that as many as one in five Americans will deal with depression at some point in their lives. In geriatric patients, there was at one time a prevalent theory that depression was a normal part of aging. I simply have not found this to be true.

In general, older patients, having already faced and successfully dealt with many of life’s challenges, have been tempered by the stresses of life and tend to be rather mentally robust and flexible. It is this worldly pragmatism that makes caring for them such a joy for me.

However as problems build up with time — especially the loss of a spouse and health concerns that lead to loss of past freedoms — the signs of depression can present themselves. All of this is worsened if familial support structures are not in place.

As I see my patients battle depression, the important clues are hopelessness, loss of interest in activities that once were a source of pleasure, restlessness, poor sleep and a sense of decreased energy.

One of the big mistakes that can be made is if the diagnosis of a mental condition is made when other medical conditions have not been excluded and antidepressants are administered.

This is not to say that the two conditions cannot coexist — they often do in the geriatric patient — but the management of physical illness must be coordinated with the treatment of mental illness or the result is often counterproductive.

This is why you witnessed me take such measured steps with your mom. Prescribing antidepressants effectively can be very demanding on all concerned, and I tend to look at the challenge from two perspectives.

When one looks at the drug literature, all antidepressants are roughly equal in their effectiveness, so I go by which antidepressant will my patient be able to tolerate with comfort. Key to all of this is drug interactions with the patient’s current medication regimens.

Another key point is go “low and slow.” I have found that the magnitude of the starting doses is the key reason why geriatric patients cannot tolerate the medication in the beginning, leading them to stop because it made them sick.

The next key aspect is the growing problem of follow-up visits. This class of medication can take up to six to eight weeks to begin to see an effect, so I like to see the patient by the second week into their treatment and then every 6-8 weeks thereafter for the first six months.

Because of many issues ranging from insurance problems, physician availability, health system policy or the fact that patients simply do not want to go to the clinic that often, adequate follow-ups do not occur with the result that treatment is interrupted, ceases completely or is deemed by the patient as too demanding. And trust me when I say that nobody is happy with this situation.

However something that is beginning to gain traction in this area is the concept of the “Medical Home” or the “Virtual Medical Visit.”

A computer connection establishes an audio/visual session between the doctor in his office and the patient in their home. Logistics, HIPPA regulations and reimbursement policies are ongoing barriers, but should be surmountable in the near future. From my vantage point, this is the direction we should be taking.

Depression need not win over us — and with enough work and ingenuity we can control it and meet each day with the best effort we can give.

Dr. Michael Camardi is a geriatrician at the Carilion Center for Healthy Aging and an assistant professor of medicine of the Virginia Tech Carilion School of Medicine. His column runs monthly in Extra.

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