What plan sponsors need to know about depression: a top 10 list.

“There’s always a path ahead, no matter how severe your mental illness is,” said Chief Neuroscience Officer Dr. Diane McIntosh at TELUS Health’s Annual Conference 2021, emphasizing the way forward as she outlined her “workplace depression top 10.”

1. Depression is very difficult to define.

A depression diagnosis is generally based on the patient experiencing five out of nine symptoms nearly every day for more than two weeks, with a change in previous functioning. In addition, the patient must have either a depressed mood or anhedonia (a loss of pleasure in things the patient normally enjoyed). 

“Then there’s a constellation of other symptoms, and when you take all the permutations and combinations together, there are more than 1,000 different ways that depression can present,” said Dr. McIntosh.

2. All mental illnesses have biopsychosocial origins.

Risk factors for depression include biological, psychological and social factors. Of particular relevance in a time of social distancing, Dr. McIntosh said social support is one of the greatest protectors of our mental health, and a lack of social support is a powerful predictor of depression.

3. Men and women are different.

Women are twice as likely to develop depression and many other mental illnesses, perhaps in part because of the lifelong effect of estrogen on women’s brains. In addition, women’s bodies metabolize medications differently, so women and men require different treatment plans.

4. Depression is an inflammatory illness.

Cortisol is a hormone that helps people manage stress, but chronic stress keeps cortisol levels too high for too long. Over time, cells in the brain become resistant to cortisol and damaged, and that leads to an inflammatory cascade that ends up damaging and killing neurons. The good news is that people grow new brain cells every day – and this is in fact necessary to recover from depression.

5. The mind and body are connected.

Having a physical illness such as obesity, diabetes or heart disease makes it more likely that someone will develop a mental illness – and the reverse is also true. 

6. Depression can become a chronic disorder.

The more episodes of depression someone experiences, and the worse those episodes are, the more likely it is that there will be structural and functional changes in the brain. This can lead to greater treatment resistance and greater cognitive and functional impairment. People with depression have the best chance of full recovery if they receive treatment within the first six months. After someone has had symptoms of depression for a full year, the likelihood that they will completely recover is less than 10%.

“We have to treat depression with a sense of urgency,” Dr. McIntosh said. “We need to intervene much earlier and on a preventive level so that we prevent people from ending up with a functional impairment … If we don’t treat early and completely, if we don’t treat every symptom, that increases the likelihood of long-term harm.”

7. Personalized treatment is essential.

Mental illness is on a spectrum, and people need different interventions depending on whether they are healthy, stressed, experiencing functional impairment or in crisis. Healthy and stressed people may benefit from self-care and social support, including exercise, professional coaching, dietary support, mindfulness and meditation, intermittent assessment and e-solutions. In addition, stressed people may benefit from psychotherapy, financial or parenting support, mental health education and sleep tools. At the functional impairment and crisis levels, people need professional help. For functional impairment, this may include psychotherapy and care from a general practitioner/nurse practitioner supported by a psychiatrist. People in crisis need care from a general practitioner, psychiatrist or psychologist and may also require support through a disability management program.

8. Medication choice must be individualized.

Dr. McIntosh emphasized the value of a wide range of medication choices (there are 20 approved first line, second line and third line options for treating depression in Canada), because each one is a unique chemical entity and it is critical to find the right medication for each person. 

9. No drug will work if it’s not taken.

“How often are you taking your medication?” is the question Dr. McIntosh asks her patients, because she knows that some people never fill their prescription and that, among those who do, 40% stop taking their medication within a month and 75% stop taking it within three months. Choosing the right medication – one that maximizes adherence – requires a patient-centred approach that starts with the patient’s need but also considers many other factors including side effects. 

10. Medicine has changed – but not enough.

One area of medicine that Dr. McIntosh feels is a move in the right direction is virtual care. “Virtual care is absolutely critical for the survival of the healthcare system, and I believe it will improve health outcomes because it really goes where patients are,” she said. “When I started doing virtual care about three years ago, I was really anxious about it but my patients love it – the time savings, not having to get child care, not having to put money in the meter, not having to drive for hours. It’s been remarkable … It democratizes medicine and I think it’s really going to change the way we practise in the long term.”

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