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Dealing With Depression

New studies show that cases of depression are common and often inadequately treated. Gwen Ifill discusses these new findings with Dr. Thomas Insel, director of the National Institute of Mental Health.

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  • JIM LEHRER:

    Finally tonight, new findings on depression and its treatment. And to Gwen Ifill.

  • GWEN IFILL:

    Several new studies show serious cases of depression are often more common than many people realize, and often treated inadequately. Among some of the findings in today's special issue of the Journal of the American Medical Association: About 16 percent of Americans or nearly 35 million people suffer from severe depression in their lifetime. Treatment rates have improved. 57 percent of people with serious depression received treatment. But it's often inadequate. Only 21 percent received treatment considered adequate for their condition. We get more on these studies now from the director of the National Institute of Mental Health, Dr. Thomas Insel.

    Dr. Insel, how widespread is depression? We understand it more commonly now to be a disease rather than just a bad feeling, but how widespread is it really?

  • DR. THOMAS INSEL:

    It's widespread in the sense that it's a global problem. Last year the World Health Organization published a study in which it claims that… this was actually the number-one source of the burden of disease. That is created the greatest disability of all medical illnesses globally. So this is a sense that it is not just an American problem.

  • GWEN IFILL:

    Is there any group that is disproportionately affected by it, young people, gender wise anything like that?

  • DR. THOMAS INSEL:

    It's largely an equal opportunity illness. It does affect women more than men. In the past the figure for women versus men was as much as three to one; that gap is closing. With this study it looks like it's one point five to one.

  • GWEN IFILL:

    Who gets treatment? Even if it's an equal opportunity disease who gets treatment and let's talk about the finding where that treatment they get is enough.

  • DR. THOMAS INSEL:

    The good news from this study is that more people are getting treated than in previous studies. In the study that was done about ten years the figure was something like one third getting treatment. Now we have the figure going up to over one half. That's an improvement. The bad news is that the treatment they're getting is most of the time not considered adequate.

  • GWEN IFILL:

    You mentioned that term adequate, minimal treatment — that term. What does that mean? How do you know what is adequate minimal treatment?

  • DR. THOMAS INSEL:

    Well, in this study there was an operational definition of adequate that had to do with whether you were getting medication or psychotherapy or both. In the case of medication it meant that you received medication for at least a month and that you had four visits with a physician during that time or sometime during the course of the depression. In the case of psychotherapy, it was at least eight sessions of 30 minutes' duration. That was considered adequate.

  • GWEN IFILL:

    If people are not getting enough treatment or it's not going long enough, what's the reason for that? Is the caregiver who is not paying close enough attention or is it the recipient, the beneficiary at the treatment who is just shying away from it for stigma reasons or reasons?

  • DR. THOMAS INSEL:

    Those reasons and there are more. So you have a situation where we are doing better but we're certainly not doing well enough. And that means in this case that part of the problem is the patients are ending up in the… in a primary care physician's office; primary care physician either doesn't detect depression or he or she may detect it but not treat it adequately, that is, not enough medication, not long enough. There may not be enough people available to provide the kind of psychotherapy that we know works for depression, a brief targeted psychotherapy that really goes after the symptoms we know is quite effective. Not very many people well trained to do that currently.

  • GWEN IFILL:

    Is a primary care physician also likely to say, "I don't want to bring up the idea of depression in case you become more sensitive to it, you fall for it. If I suggest it you might get depressed."

  • DR. THOMAS INSEL:

    I don't think that's so much of an issue. But there is the problem if you bring it up and the patient needs to be referred, who do you refer to? There's a real disparity in the nation in terms of what's available for mental health coverage. Rural areas don't have as much. Certain parts of our urban centers don't have as much. So there's always the problem that once you know and you have to do something about it, it's not easy to figure out what the next step is.

  • GWEN IFILL:

    These studies today also document the links between depression and many other illnesses particularly cardiac illness — cardiac — people who are survivors of heart attacks. What's the link there?

  • DR. THOMAS INSEL:

    This is a great mystery and in some cases quite a surprise. It's now become clear that the presence of depression really isn't telling us just that there's a mood disorder but that there's a disorder of many systems in the body. That includes endocrines — there's an increased rate of diabetes, increased rate of strokes, increased rate of osteoporosis. Now we know more than ever that there's an increased risk of heart disease, a risk that may be comparable in fact to being a smoker. The story that's in the JAMA this week which is of particular important is that we know that if people have a heart attack and they develop depression after the heart attack, there's a very increased risk of dying of cardiovascular causes. It's about three-and-a-half fold versus someone who is not depressed. We don't know the mechanism for that yet. The story in the journal this week is really asking the question, does it help to treat and if so what kinds of treatments are necessary?

  • GWEN IFILL:

    So there's a real link you're establishing between depression and actual death as a result of other diseases?

  • DR. THOMAS INSEL:

    Absolutely. In the case of dying of cardiovascular death after a heart attack there's almost no cardiovascular measure we have that increases the risk as much. So your enzyme changes, the presence of an arrhythmia, the amount of actual damage. None of those are as predictive of dying of cardiovascular causes as is the presence of depression.

  • GWEN IFILL:

    One of the studies talks about the economic fallout, economic fallout from this including a term I had never seen before: Present-eeism which I guess is the opposite of absenteeism.

  • DR. THOMAS INSEL:

    The idea being that when people are depressed either they don't go to work or if they do go to work they are productive while they're at work. That's I think being observed more and more in corporate America where we find people who are showing up but not simply able to really engage.

  • GWEN IFILL:

    Is there a way to quantify in dollar terms what that loss is?

  • DR. THOMAS INSEL:

    We try to do that. I think the figure in the journal today is something like $40 billion or something in that range. It's a tough number to actually find out the details for. Part of the difficulty is how do you know when someone is working at full capacity or not?

  • GWEN IFILL:

    As you begin to chronicle and gather this sort of information in a special issue like this one, do you also begin to figure out how you address some of these gaps in care that you're talking about?

  • DR. THOMAS INSEL:

    That's really the challenge for us now. I think we have to remember that this is a disorder like a lot of other chronicle medical disorders, diabetes, hypertension and others, that we really do know how to treat. We have very good medications. We have very good psychotherapies. They work. The problem is not enough people get them.

  • GWEN IFILL:

    Should primary care physicians be in the position now of just screening everyone who walks in the door routinely as part of their annual physical for mental illness or for depression?

  • DR. THOMAS INSEL:

    It certainly would be one way of having a great public health impact. We know this is a very common illness. As you mentioned at the beginning it's affecting something like 15 million Americans every year. It's important to begin to screen for it and to notice it. One of the things that makes this particularly to me relevant is that being depressed, of course, raises the risk of suicide. And suicide is a very real consequence of this illness. There are about 30,000 suicides a year in the United States. That's almost twice the number of homicides. People don't often recognize that. But it's a very severe public health problem.

  • GWEN IFILL:

    Among young people the rate is even higher.

  • DR. THOMAS INSEL:

    It's the third leading cause of death in people between the ages of 15 and 24. But actually they don't have the highest rate of suicide. The highest rate of any particular group in the United States is among white males over 65. For them, the rate is about six fold higher than the national average.

  • GWEN IFILL:

    Really? Well, Dr. Thomas Insel, thank you so much for helping us out with this.

  • DR. THOMAS INSEL:

    My pleasure. Thanks for having me.

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