Exploring the new neuropsychiatry.
by David J. Hellerstein, M.D.
The Crucial Importance of Treating Depression to 'Remission'
Getting better isn't good enough...you need to aim to get 'well'!
The third key concept of the New Neuropsychiatry is the importance of what we psychiatrists call 'remission.' In the past decade we have raised the bar, aiming for a higher goal of treatment. We have realized it is important not only to get a patient's depression to 'respond' to treatment (symptoms about half-way better) but to get the person so much better that their symptoms are basically no different from a person without depression.
In brief, research has shown that getting better (achieving 'response') isn't enough. When I was training to become a psychiatrist in the mid-1980s, our goal was response: get the depression mostly better, so a person could sleep much of the night, or so that they wouldn't be crying every day. Unfortunately, as we have discovered, response doesn't do it! Better isn't enough: we need to aim for 'well.'
First, a definition. In contrast to 'response' which means 50% or more improvement, 'remission' is defined as 'much better,' so that one's score on a depression rating scale is essentially no different than a person without depression or an anxiety disorder. On the Hamilton Depression Rating Scale that psychiatrists use to measure the effects of medicine, a total score would have to be 6 or less, compared to perhaps 20 to 40 when a person is in the throes of depression.
How to get to remission? That's the topic for another posting, but basically, the tools include psychotherapy and antidepressant medications, of course, as well as exercise and other behavioral changes, and perhaps meditation, mindfulness and/or breathing exercises--in short, whatever it takes to get there!
The importance of achieving remission of disorders is twofold:
1) if you don't get disorder into remission, damage to one's brain and life continue, and
2) if you can get into remission, it looks like you can limit or even reverse brain injury that occurs as a result of depression. Beyond that, getting disorder into sustained remission allows for people to start to get their lives back.
Let me just mention two pieces of evidence that have convinced psychiatrists of the importance of remission.
First, researcher Lewis Judd did studies in the late 1990s showing that 'residual symptoms' were a significant risk factor for return of depression--and for depression becoming chronic. After medication treatment, if a person still had just a few remaining symptoms, it basically doubled their risk of getting depressed again. To state it in the reverse way, if you can get a more complete response to antidepressant treatment, Judd's research would suggest that you may be protected against having future episodes of depression.
Second, an important MRI imaging study by Thomas Frodl, who re-scanned people with and without depression over a 3 year period. I mentioned in a previous posting that when they were followed over time, people with depression showed significantly more decrease in the brain's gray matter in several areas compared to people without depression: "Compared with controls, [depressed] patients showed significantly more decline in gray matter density of the hippocampus, anterior cingulum, left amygdala, and right dorsomedial prefrontal cortex."
Frodl went beyond this, however: he compared those patients whose depression went into remission with those who didn't remit, and he found the following:
"Patients who remitted during the 3-year period had less volume decline than non-remitted patients in the left hippocampus, left anterior cingulum, left dorsomedial prefrontal cortex, and bilaterally in the dorsolateral prefrontal cortex."
In brief, remission led to significant slowing of damage to the brain. Frodl's conclusion is similar to our take-home message from Judd's work: "It is likely that an early start of treatment with antidepressants and psychotherapy may prevent neuroplastic changes that, in turn, worsen the clinical course."
What is the importance of remission in the real world? In Heal Your Brain, one of the cases I discuss is "Cindy P.", a 32-year-old woman who came for treatment after the birth of her third child sent her into a 'postpartum depression.' As I got to know her better, it became clear that she had had depression since the birth of her two older children, twins, and that she had dropped out of graduate school because of depressive symptoms including difficulty concentrating: she was unable to read journals or work on her PhD thesis.
Eventually we were able to get Cindy P.'s disorder into remission--for the first time in over five years.
And then...an interesting thing occurred, perhaps six months into remission. One day Cindy came into session and announced, "I'm able to read books again!" She had worried that she might have 'early dementia' and had basically resigned herself to never finishing her PhD.
Instead, as her remission continued, she described 'meeting my old self again'--her pre-depression self. She found that she was, in her words, able to 'expand my life' and to 'have fun again.' Soon Cindy re-enrolled in graduate school, and was back on track to getting her PhD and then looking for academic jobs.
In retrospect, after several years of good functioning, Cindy has indeed gotten her life back on track--and I realize that our old goal of 'response' was far too modest.
In the age of the New Neuropsychiatry, 'better' is no longer good enough-we need to start aiming toward 'well'