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Winter doldrums: What does research tell us about depression?

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The third Monday in January is popularly known as “Blue Monday” and is thought to be the most depressing day of the year. In fact, the phrase was invented for a British travel company to sell more flights to sunnier locales, with little evidence to suggest it has any relation to depression.

Despite its commercial origins, Blue Monday is an opportunity to bring to light how common depression is and the steps that can be taken to treat and prevent it.

Dr. Joseph Puyat

It is important to distinguish between a depressive mood, which we all experience from time to time, and major depressive disorder, a clinically diagnosed mental health issue. Major depressive disorder, which we will refer to as depression, is the leading cause of disability worldwide. In Canada, 1 in 20 people each year experience depression, costing taxpayers $32.2 billion annually.

CHÉOS Scientist Dr. Joseph Puyat has a growing body of work that focuses on understanding the prevalence, impact, and treatment of depression in British Columbia.

“We use a combination of administrative databases, like MSP, physician billing, and hospital records, to answer specific questions about depression in the province,” he explained.

Understanding the treatment patterns of people living with depression

One of those questions is whether or not people who have been diagnosed with depression receive adequate treatment.

There are generally two categories of treatment available to people with depression: counselling and antidepressant medication.

The minimally adequate treatment threshold for depression is receiving four or more counselling sessions in a year, or for antidepressants, 84 days or more of medication.

In a study published in 2016, Dr. Puyat found that of the 110,000 people diagnosed with depression in B.C. in 2011, only half received minimally adequate treatment.

The majority of patients in the study who received minimally adequate treatment received antidepressants, with only 13% of the 110,000 people receiving minimally adequate counselling treatment.

“The large gap between counselling and antidepressant treatment access suggested that there could be differences in how physicians were providing these treatments,” he said.

Understanding how people living with depression interact with the medical system

In B.C., and elsewhere, most people with depression see a general practitioner (GP) to receive care for their mental illness, including counselling services.

In general, caring for people with mental health issues requires longer, more frequent visits with GPs. This means that GPs can be incentivized to avoid taking on patients with depression because of the time required and the financial consequences of these patients. GPs may also be incentivized to prescribe antidepressants, rather than counselling, as a way to decrease the time needed for these patients.

In 2008, the provincial government introduced incentives that aimed to close the widening gap between the number of people with depression and those who receive treatment. The incentive scheme increased the types and number of services doctors could bill the province for when seeing patients with mental health issues.

Dr. Puyat investigated whether or not these incentives impacted mental health care in the province by analyzing the treatment trends before and after their implementation.

He found that over the five years following the introduction of the incentives, there was no change in the proportion of the population who started treatment for depression, compared to before, but that there were minor changes in the types of treatments received.

Prior to the introduction of the incentives, there were noticeable declines in continuity of care and the percentage of people who were receiving counselling, with prescription of antidepressants rising.
“What we found is that the incentives worked to stabilize the trends that we saw before their introduction,” he explained “The decline in the percentage of people who received counselling slowed and there were less antidepressants prescribed after the incentives were put in place.”

Overall, however, the impact of the incentive scheme was minor, only changing the trends by a few percentage points. This suggests that there are additional barriers to care that were not addressed by the incentives.

Depression is the leading cause of disability worldwide. In Canada, 1 in 20 people each year experience depression, at a cost of $32.2 billion annually.

Co-occurrence with other health issues

People who live with chronic disease, such as diabetes or heart disease, are more likely to experience depression. Not only does this combination have serious implications for health and quality of life, it also significantly increases health care costs.

Dr. Puyat’s research shows that 13% of the people diagnosed with depression in the province in 2012 also had a chronic health condition.

Compared to people with depression only, people with chronic health conditions and depression were generally more likely to receive counselling treatment, receive a greater number of counselling sessions, and more frequently visit a GP for mental health issues.

However, the findings were not the same for all chronic conditions. For example, people with cardiovascular disease were less likely to receive either antidepressants or counselling treatment. People with COPD and asthma were more likely to see a GP for their mental health while people with diabetes were less likely to do so.

These findings highlight the fact that we need to look at specific patient factors when designing efforts to improve mental health care — one strategy may work well for one group of people but not for another.

Where do we go from here?

“Our focus over the past decades has been to get people who are diagnosed with depression on to treatment,” said Dr. Puyat “This has not worked well and we continue to see a rising burden of depression across Canada.”

Getting people on to treatment is not enough, he says. What we need is to identify ways to optimize treatments and understand why some groups are disproportionately affected by depression.

“We have seen that people with chronic illness are more likely to be depressed. The annual prevalence of depression in women is 60% higher than men. People living in cities and in low-income neighbourhoods are more depressed,” he said “We need to address why these disparities exist and how treatment can be tailored to specific groups of people.”

Finally, we need to take a step back and consider ways of promoting mental wellness and resilience before depression occurs.

“Depression is more than just a medical issue,” he noted “There are societal factors at play that need to be incorporated in to how we address this growing public health issue.”

In 2019, Dr. Puyat was awarded a Scholar Award from the Michael Smith Foundation for Health Research for a series of upcoming research projects aimed at exploring ways to reduce the prevalence of depression at the population level.

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