- Accessibility. The World Mental Health Survey Initiative showed that only 22 percent of all individuals with 12-month major depressive disorder received even minimally adequate treatment. Out-of-pocket payments are high, and practitioners who accept insurance often have waiting lists.
- Diagnostic challenges. Diagnostic reliability has been a problem since the DSM-I was published. Attempts to subtype major depressive disorder by clinical features, onset, trigger, state, comorbidity and other associated features haven’t led to specific treatment methods for different subtypes. Diagnosis takes two weeks, which can put a patient experiencing suicidality at risk.
- Burnout and bereavement. Major depressive disorder, burnout and bereavement often have similar symptoms. Often, significant underlying major depressive disorder has been misattributed to burnout. Burnout is predominantly a job-related condition, while major depressive disorder is a persistent mental condition. The DSM-III introduced the “bereavement exclusion,” which warns against diagnosing major depressive disorder after the death of a loved one. Failure to identify patients attributing their symptoms to burnout and disqualifying a patient from a diagnosis of major depressive disorder simply because the clinical picture emerged after the death of a loved one risks misdiagnosis and stems the opportunity to provide treatment specific to patients experiencing major depressive disorder.
- Initial and next-step treatments. Many clinician efforts to select the antidepressant most likely to benefit their patient don’t work because many patients can’t tolerate a high enough dose to optimize benefits. Of those who can, only about half to two-thirds respond, and about one-third achieve remission. Many patients remit, relapse and experience recurrence of symptoms, often within weeks to months after remission and multiple times in a life span. At least one-third are considered to have treatment-resistant depression, a more debilitating form of illness than those with major depressive disorder, which can lead to increased mortality from suicide as well as all-causes mortality. Many clinicians don’t have evidence-based pharmacologic choices for either first-step or next-step treatments.
- Difficult-to-treat depression. The concept of treatment-resistant depression, based solely upon failure to achieve remission with two or more adequately delivered medication trials, may no longer be appropriate. Dr. Zisook wrote the “concept of difficult-to-treat depression has been proposed to replace treatment-resistant depression.”
- The role of “out-of-the-box” interventional therapeutics. Fifty years ago, there were tricyclic and monoamine oxidase inhibitor antidepressants. Physicians searched for medications that were better tolerated, worked more quickly, were more effective for a broader range of patients and had more sustainable effects. New medications and classes of antidepressants have been developed, but until recently, studies focused on traditional treatment strategies, while research on “out-of-the-box” treatment methods were neglected.
- Training. Antidepressant medication plus psychotherapy over medication alone is a more effective treatment for major depressive disorder. But since 2013, the Accreditation Council for Graduate Medical Education standards require learning various therapy methods. But half of psychiatrists don’t use psychotherapy, and only 10 percent regularly provide psychotherapy with medications.
Physician burnout, depression and suicide. Physician distress is increasingly recognized as a professional and public health crisis. High rates of career dissatisfaction, secondary trauma or second victim phenomena, burnout, substance use, depression and suicide are receiving national attention and calls for action. Though efforts have been made to curb physician burnout, less attention has been given to recognition and treatment of major depressive disorder in physicians.
