Treatment outcomes for depression: challenges and opportunities (2020) Wolpert et al.

[Cheshire]

Abstract

Depressive disorders are common, costly, have a strong effect on quality of life, and are associated with considerable morbidity and mortality. Effective treatments are available: antidepressant medication and talking therapies are included in most guidelines as first-line treatments. These treatments have changed the lives of countless patients worldwide for the better and will continue to do so in the coming decades. However, although treatments are effective for some people, there is great room for improvement. This Comment highlights ten key statistics relating to the limitations of depression treatment outcomes that we feel warrant greater attention.

A considerable proportion of, particularly child and adolescent, patients show improvement without treatment,1 while a substantial number of patients do not show improvement with treatment (table).5 This finding means that patients are taking treatments with the risk of negative side effects, who either might have recovered without treatment (whether medication or psychotherapies) or might not improve with treatment.4 Moreover, all types of recovery without treatment have been generally grouped together as so-called spontaneous improvement. The multitude of ways in which people might recover have been largely understudied, such as exercise, community engagement, and engagement with nature.6

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30036-5/fulltext

Our lack of knowledge cannot be put down to a scarcity of research in existing treatments. In the past decades, more than 500 randomised trials have examined the effects of antidepressant medications, and more than 600 trials have examined the effects of psychotherapies for depression (although comparatively few are conducted for early-onset depression). However, less than 20% of drug trials and less than 30% of therapy trials have low risk of bias, making the outcomes uncertain. Typically, such trials do not have sufficient statistical power to examine for whom a treatment is effective, resulting in no reliable evidence on who benefits most from which treatment. Also, many different outcome measures are used in treatment research, making it impossible to merge the results of trials without interfering noise. Additionally, longer-term effects are not examined in most trials. Despite more than 1000 trials having been done, very basic questions of real-life importance to people with depression and those trying to help them have not been answered.

 

[chrisb]

Is "having depression" the same as "having a depressive disorder"? They sound different and yet the title refers to "depression" and the first sentence to "depressive disorder".

 

[rvallee]

Our lack of knowledge cannot be put down to a scarcity of research in existing treatments

Quantity is not superior to quality when that quantity is mostly doing the same things over and over again and rarely focuses on relevant factors. Truth is the quality of research in this field is abysmal and even the quantity is unimpressive given the repetition and inability to unanchor from old beliefs and simplistic aphorisms.

So, yes, the lack of knowledge is entirely down to scarcity of competent high-quality research. Well, that and the fact that we know next to nothing about the brain and have no means of actually testing for depression, which leads to various unrelated things being lumped together based on superficial characteristics. But the horrible quality of research and overbearing presence of beliefs and ideologies is responsible for at least 90% of the lack of progress.

Too many assertions, too little genuine understanding. Even physicists are very careful with making assertions about the most-tested scientific theories known to science. Mental health research and clinical practice is dominated by confident assertions based on absolutely nothing, reflective of a juvenile field that still has to learn to walk before it starts demanding trophies for having thought about winning a marathon.