Psychiatric researchers currently look at symptoms of depression - such as sleeping and eating habits, ability to concentrate, and level of interest in normal activities - as a way to gauge whether patients are getter better when they participate in clinical trials for antidepressant medication. However, patients feel they're well when they return to their usual, normal self; function normally; and feel optimism and self-confidence. The study is published in the January issue of the American Journal of Psychiatry.
"Depressed patients clearly have different perceptions than researchers running clinical trials about what it means to stop feeling depressed," says lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital and associate professor of psychiatry and human behavior at Brown Medical School. "Clinical researchers have identified a patient as being in remission from depression, based on certain behaviors or symptoms, but the patient may not feel any better. We may need to broaden our definition of remission from depression."
A fundamental question in the management of any disease - whether depression or high blood pressure - is how well treatment works. "For other medical conditions, there are clear-cut treatment goals. For epilepsy, it is eliminating seizures. For high blood pressure, it is to reduce blood pressure to a normal range. It is equally important to clearly outline goals of treatment for depression," Zimmerman says.
However, because there is no way to measure biological markers for depression - like measuring cholesterol or blood pressure - mental health professionals rely on symptoms as an indicator of recovery. Full remission is defined as "a relatively brief period" during which a patient has very few symptoms.
While normal functioning is often mentioned as an important part of remission, it is rarely used to identify remission in treatment studies, the authors note. In clinical trials for antidepressant medication, remission is defined according to scores on symptom severity scales such as the Hamilton scale and the Montgomery-Asberg Depression Rating Scale.
"If the primary goal of treatment for depression is to stop feeling depressed," Zimmerman says, "we need to have a clear definition of what that means - both by the patient and the mental health professional."
The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project surveyed 535 psychiatric outpatients at Rhode Island Hospital who were being treated for major depressive disorder. The patients were asked to rate 16 potentially relevant factors that would indicate they were in remission from depression. Then, they were asked to choose the single most important factor. The results show that depressed patients do not consider symptom resolution as the most important factor in defining remission. Patients more frequently rated five factors as very important in determining remission from depression: presence of positive mental health; return to usual level of functioning at work, home or school; feeling in emotional control; participating in and enjoying relationships with family and friends; and feeling like your usual, normal self.
The findings thus suggest that patients consider many factors other than the disappearance of depressive symptoms as being important in determining remission, the authors state.
"Some patients may have no symptoms of depression, but they do not feel that they have returned to their normal selves because they are not functioning normally or they still lack the confidence in coping with the normal stresses of everyday life. Others may have mild symptoms but consider themselves free of depression. It's important to determine whether mental health professionals should expand their definition of remission beyond symptoms of depression," Zimmerman says.
Founded in 1863, Rhode Island Hospital (www.rhodeislandhospital.org) is a private, not-for-profit hospital and is the largest teaching hospital of Brown Medical School. A major trauma center for southeastern New England, the hospital is dedicated to being on the cutting edge of medicine and research. Rhode Island Hospital ranks 13th among independent hospitals who receive funding from the National Institutes of Health, with research awards of more than $27 million annually. Many of its physicians are recognized as leaders in their respective fields of oncology, cardiology, orthopedics and minimally invasive surgery. The hospital's pediatrics wing, Hasbro Children's Hospital, has pioneered numerous procedures and is at the forefront of fetal surgery, orthopedics and pediatric neurosurgery.