John Greden, MD: Challenges and Best Practices in Treating, Identifying Depression


John Greden, MD, discussed the challenges physicians face in diagnosing, identifying, and treating depression, and the populations that are still severely underserved.

Major depressive disorder (MDD), according to the World Health Organization, causes more damage to patients worldwide than any other condition. One of the reasons this condition affects so many so negatively is because it is often hard to diagnose patients, as many of them are reluctant to speak about their symptoms. Physicians face a multitude of challenges in treating these patients, and many of them are part of underserved patient populations.

John Greden, MD, the founder and executive director of the University of Michigan's Comprehensive Depression Center, sat with MD Magazine at the American Psychiatric Association's annual meeting in New York City to discuss the challenges physicians face in diagnosing, identifying, and treating depression. He also talked about the populations with the condition that are still severely underserved and gave some advice to his peers in psychiatry and primary care on how to speak to patients about the presence of depression without forcing them out of their comfort zone.

John Greden, MD:

Clinical depression. The World Health Organization categorizes it as number one—the world's most disabling disorder. More than cancers, heart disease. Why? Because it's prevalent, common, starts young, and because we have not had any guided treatments. So the starting point for doctors is difficult, and when people are in these [treatments] their thinking, their mood, their appetites, their sexual functions, their physical pains, all of them are affected dramatically.

The doctors see these people a lot, they guess—sometimes they're lucky and they hit this—but fewer than 40% achieve remission in the best trials right now. Fewer than 40%—37% [to be exact]—so we can do better than that if we do have some guidance. Clinicians really face battles about how you get people well and keep them well.

Since depressions start when people are young—the peak ages of onset are 15-24—so often, those patients are not screened by doctors. So the young, the youth, adolescents, college students, are all sort of underserved. We should be starting earlier.

The people who have some of the remaining stigmas, we still have some, don't walk into their doctor's office usually and say, "doc, I'm depressed." They talk about pains. They're underserved.

The individuals who essentially have medical conditions that sometimes have a greater risk of depression—heart disease, cancers—they're underserved.

So we're talking about multimillions of individuals. There are 16 million people who have a new episode of depression every year. We're in New York City, that's the population of New York State, of this area. It's a lot of people, and we can do better.

How you guide people to being more frank is to use language that is straightforward. Other than sneaking in, you can just say, "How's your mood been? Are you sleeping? Are you enjoying things? Can you actually concentrate? Are you feeling good when you get up in the morning?" If you start getting the wrong answers, you can instead ask how long this has been going on, and when it gets to some of the symptoms that are the ones that actually tend to scare doctors, you need to be ready to ask, "Has it ever gotten so bad that you haven't wanted to go on living? Have you had thoughts of actually doing something? Do you have the means? If so, what are they, tell me about them, and let's think about how we keep you safe until we get you better—and we will get you better."

The advice for the primary care physician is really important because they take care of most of the people with depression, and if they can do it well, they don't end up having their lives get wrecked and then have to also end up channeling into a different referral or professional. So the advice is to do those things, but also keep track of it, like measuring blood pressure. Have the patients complete a simple scale. They can measure their own symptom severity. They can call when things start going badly. Tell them to stay on the medications, stay away from the alcohol—it doesn't help, it doesn't help sleep, it doesn't help depression—to exercise. All of the stuff that you're grandmother would have told you is pretty good exercise material for depression, too. It's the kind of stuff that we all should be doing.

Transcript edited for clarity.

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