Depression Medication Choice Decision Aid Tool

The latest health 'snapshot' of the 33 OECD (Organisation for Economic Co-operation and Development) nations has revealed that Australia is now the second-highest prescriber of anti-depressant medications. However, not all antidepressant scripts are filled, and when they are, some patients choose not to use them for a number of reasons.

A new tool, the Depression Medication Choice decision aid, helped adults with moderate to severe depression and their primary care physicians choose appropriate medications together, according to a report published online Sept. 28 in JAMA Internal Medicine. Researchers developed the Depression Medication Choice (DMC) tool to enhance patient involvement in the decision-making process, in the hope that taking their preferences and circumstances into account would improve adherence and stave off premature discontinuation of antidepressants. The investigators then performed a cluster-randomized trial to assess the usefulness of the decision aid in real-world practice.

The study involved 297 adults treated during a 2-year period by 117 clinicians in 10 rural, urban, and suburban private practices across Minnesota and Wisconsin. These demographically diverse patients had moderate to severe depression as measured by scores of 10 or higher on the Patent Health Questionnaire–9 and were considering antidepressant therapy. They were randomly assigned to clinicians who chose antidepressant therapy in the usual manner (139 patients in the control group) or to clinicians who used the DMC to choose antidepressant therapy together (158 patients in the intervention group).

The DMC tool comprised several laminated 10-by-25-cm cards that presented general information about antidepressant efficacy and adverse effects “in terms that matter to patients: weight change, sleep, libido, discontinuation, and cost,” as well as a leaflet for patients to take home. 

Participating clinicians received training in using these cards to prompt discussion during a regular office consultation. Use of the decision aid did not add to the duration of office visits, which is key to routine implementation, the investigators said.

At 3- and 6-month follow-up, patients in the intervention group reported significantly greater comfort with the choice of antidepressant, with a mean difference between the two study groups of 5.3 out of a possible 100 points on a “comfort” scale. Patients in the intervention group also were more knowledgeable about antidepressants (OR, 9.5) and satisfied with their health care compared with the control group.

Clinicians also were more comfortable with treatment decisions, with a mean difference between the two study groups of 11.4 out of 100 possible points. And clinicians who used the DMC tool reported being more satisfied with the decision-making process.

However, there were no significant differences between patients in the two groups regarding control of depression symptoms, remission rate, or rate of response to treatment, as measured by mean PHQ-9 scores. There also was no significant difference in medication adherence. Since most of the clinicians in this study used the DMC tool with very few patients, “it is possible that our trial underestimates the efficacy of the decision aid when used repeatedly and expertly.

We're Out of Miltown

Back in 2006 ABC’s All in the Mind program presented what they called “in the spirit of Sigmund Freud and his One hundred fiftieth birthday” an interview with Jonathan Metzl. In a sense, the presenter offered “we are psychoanalysing psychiatry itself.” The timing for this was of course also related to Metzl just having published Prozac on the Couch: Prescribing Gender in the Era of Wonder.

The premise of the book is that the biochemical revolution in psychiatry, which displaced Freudianism from its central role in treating mental illness in the United States. The ABC program opens with the vey fitting jingle, Mother's Little Helper, and introduction along the lines “You may remember this 1967 Rolling Stones hit "Mother's Little Helper", a tongue in cheek tribute to a housewife coping with whinging kids and a demanding husband with a little help from the minor tranquiliser Valium.”

Jonathan Metzl sees himself as someone who on one hand is a practitioner of psychiatry and on the other hand someone who studies the kind of cultural history of the ways that depression came to be seen and thought of in present day American society but also internationally. His book examines, for example, how pharmaceutical advertisements, representations of depression in film and media and medical writings are framed.

The book gives a historic account of psychiatric medications in medicine and popular culture starting in the 1950s, a time when Miltown (Meprobamate) became really the first of the modern psychiatric wonder drugs. Prior to the 1950s these kind of drugs weren't an established phenomenon. Metzl tells the story of initial scepticism among psychiatrists and drug companies because, interestingly, they would ask who would use medication when there is talk therapy. However, within two months the demand for Miltown in the United States was so great that there were like these famous signs in the windows of pharmacies saying 'We're out of Miltown.

So whilst the biological basis for depression was perhaps beginning to be addressed through medication Metzl suggests that the rhetoric by which these drugs came into being, again in popular representation, took a lot from Freud even if there was an implication that Freudianism was being overthrown. In the first chapter aptly called The Freud of Prozac, Metzl argues that the ways that these drugs were understood in the popular realm, biology owes a lot to Freud with regard to gender.

Metzl looks at these medications through the lens of what are the implications for gender He says even though we think of Valium as being the 'mother's little helper' for the popularity of the Rolling Stones’ song and in part because of the fact that according to some studies up to 70% of prescriptions for Valium in the United States were written to white middle class women. He goes on, Miltown set the stage for Valium by creating a set of connections between the anxieties of motherhood, or more aptly the anxieties that people who were creating a certain kind of public rhetoric had about the role of mothers in society, and treatment with psychiatric drugs.

Metzl discusses the cultural history of the ways that depression came to be seen and thought of. We saw that for women, overwhelmingly, depression came to be described in popular articles in relation to the women's roles as mothers, or being married, or menstruation.. For men, there was almost nothing about men getting depressed and it impacting their roles as fathers, or as boyfriends, or as anything that might imply emotions or inner-lives. Depression related to aggression, athletics, sports and, to a little bit lesser extent, work. And so we would see articles about famous athletes who got depressed and couldn't win races, or hit the ball, or something and then they would take Prozac and they would start winning again.

However, Metzl never gives an alternative to the Freudian father/superego, mother/unconscious, and his interpretations of women are filtered through this distorting lens. Hence, his sometimes absorbing and adroit presentation of examples is hamstrung by an interpretive paradigm that is no broader than that which he seeks to question.