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Rudolf Saltwire Article Feb 2022
Dr. Rudolf Uher, the Canadian Research Chair in Early Intervention in Psychiatry, is a professor in Dalhousie University's faculty of psychiatry as well as a practising psychiatrist with Nova Scotia Health. - Stuart Peddle

Stuart Peddle | Posted: Feb. 22, 2022, 8:40 a.m. | Updated: Feb. 22, 2022, 8:40 a.m. | 6 Min Read

Saltwire News: https://www.saltwire.com/atlan...


HALIFAX, N.S. — A Nova Scotia psychiatrist is one of the contributors to a World Psychiatric Association Commission report that advocates for a balanced, personalized approach to treating people suffering from depression.

The commission undertook a study under the auspices of the medical journal The Lancet. Their resulting document, entitled Time for United Action on Depression, was released worldwide late Tuesday.

“Where it perhaps differs from some previous reports is that rather than keep working (for) the miracle treatment, we should consistently use what we have,” Dr. Rudolf Uher, the Canadian Research Chair in Early Intervention in Psychiatry said in a recent interview. “And using the interventions and treatments we have could make a huge difference. They're just not getting to most people who need them.”

Uher, a professor at Dalhousie in the faculty of psychiatry and a practicing psychiatrist with Nova Scotia Health, said there's also recommendations for policy-makers, for patients and families, communities, treatment providers as well as researchers.

Uher said this call is equally for all of society as well mental health and medical professions to tackle some of the major environmental causes of depression.

“Poverty, violence, inequality of access, discrimination, bullying – there's all this as well. For the medical profession, the call is to use treatments and interventions early in a way that's collaborative, that's inclusive of families and that is personalized where it fits the treatment for individuals.”

The Lancet invited experts on the topic of depression to come together for the study three years ago.

Those involved began the process of bringing all the knowledge together that was found through global experiences and research into clinical depression.

One of the conclusions is that by far, not enough is being done for people with depression, Uher said.

Existing options include psychological treatment for the majority of affected people and some kind of more intensive treatment for the minority who don't get adequate benefit from the common ones, he said.

Inequality

In higher-income societies, half of those with depression are untreated. In impoverished areas, that can be up into the 80 or 90 percentile.

“It's a two-sided conundrum,” Uher said. “Because on the one hand, the planners of the health services feel like it's a deluge. We have too many people coming to us with mental health problems. On the other hand, when we do something systematic in the community, we ask everyone, we find that perhaps half of the people who have clinically significant depression don't seem to be … accessing treatment.”

There are hurdles in the systems that are contributing to this potential mismatch, Uher said. There may be both over-diagnosing and under-diagnosing going on at the same time.

He added that it might be even more accurate to term it “under-accessing treatment” rather than under-diagnosing, because people may be disabled or very negatively affected by depression and don't ever see a health professional.

Stigma

“In an ideal world, the relationship between who is unwell and who gets treatment is directed by severity – by how bad the depression is. When it reaches a certain level, the kind of watchful waiting, 'let's see' is no longer reasonable and we should start effective treatment. But that's not how it is.

A sense of self-stigma – of accepting a weakness – is a problem for some people.

“There's a huge difference between males and females, between less and more educated, between urban-rural, between majority and racialized populations in just where the threshold is in seeking care. And unfortunately all this plays into it.”

Those who are untreated will be disproportionately more males, less educated, racialized and less wealthy people.

In Nova Scotia, some minority cultures are harder on themselves, while with other people like African Nova Scotians, previous traumatizing experiences with authorities undermines the willingness to seek treatment.

“And it could be other mental health issues, like depression often comes with anxiety. The effort that's required to go and seek treatment often requires making a phone call or mentioning something that may feel very private and that's not easy for people who are anxious. So sometimes the people who need it the most find it the most difficult to access.”

And if the first treatment options don't work as expected, it's often another hurdle to go back and seek another treatment option, he said.

Recommendations include equality of access for all the sectors of the population as well as early access with interventions, new mothers, and provisions for youth mental health.

“The age between 12 and 24 is very important,” Uher said. “That's when most people experience their first issues with depression, anxiety or related problems.”

Support

“Thanks to a lot of support here in Nova Scotia, there's this huge input both from the health institutions but also charitable input. Philanthropy is very strong in Nova Scotia,” Uher, who is originally from the Czech Republic, said. “The Dalhousie Medical Research Foundation is supporting a lot of what we're doing and thanks to it, we're running several projects that directly link to the goals of the medical mission.”

One of those aims to determine what works for whom, psychological treatments or antidepressants.

“And what we try to do is really do the best job on both sides because trying to demonstrate one is better than the other, that's the wrong question. That would not be helpful. It's easy to do either treatment sloppily enough to get the other to shine. But the question that we're interested in is what works better for whom? Can we have a good guess? Because if we know you will likely improve with just psychological treatment, we will invest into it – throw everything in it – but if we know for another person that they will end up needing an antidepressant or one of the other projects were running is even starting two medications immediately for those who we predict non-response so that we shorten the trajectory from becoming ill to getting better. That's what interests me.”

The most recent project, funded through the DMRF and called TIDE (Treatment Interrupts Depression Early), brings that question to young people who are experiencing depression for the first time in their life.

“The reason we want to go there is that we feel at that stage, the decision about initial treatment and the experience they get with the initial treatment provision can have even more repercussions for long (term).”

If a young person is listened to, is included in the driver's seat of decision-making choices, they are more likely to access and accept treatment for many years to come, Uher said. And if they get early successful treatment it can change their relationships with the services and the disease. They will feel more empowered and confident in their ability to get help.

“I came here to do this research. I was in London in the U.K. previously and part of the reason I came here was because we saw an opportunity. There was a chair of early interventions but there was also long-running experience of people in Nova Scotia – being the population, the people in the community – being good collaborators in research. And this got confirmed.”

“So I believe we can drive a lot of positive difference from here in Nova Scotia.”