According to current studies, one German in five suffers from illnesses in the category of depression, and the diagnosis “burn out” is particularly widespread among employees. It is clear that once such a diagnosis is made, it involves restrictions for the sufferers, generally combined with laborious and complex therapeutic routines.

This makes it all the more surprising that, while the disease normally establishes a very complex and occasionally conflicted relationship between patient and doctor, the therapeutic culture of depression has previously been virtually ignored as a topic for studies. Now, concept m has entered this terra incognita with a fundamental study. This shows that the diagnosis of depression is also a burden on the doctor treating it, and sometimes a serious one.

The doctors are faced by a dilemma in many respects. First, they feel subject to pressure to intervene quickly and (pharmaceutically) massively, possibly to prevent suicide. This quick response is also strongly sought by patients, who are suffering badly. Many patients try to exercise massive influence on their doctor and to influence them in their therapeutic decisions.

Second, there is the awareness of a “life which has become derailed”, which requires a much more fundamental approach to achieve a genuine improvement. A biographical and symptomatic aetiological approach generally fails to produce a clear and unambiguous result. Although it is putting it rather strongly, doctors see that their treatment is not reaching to the core of the disease, and – at least partly – is locking in an unhealthy state.

The second dilemma doctors face is the result of the causal orientation of their training. According to this, diseases must have causes, e.g. infections result from pathogens. Depression essentially lies outside this system.

Even when a depression is clearly diagnosed, there are several theories about its aetiology, with different implications for therapy. It is not possible to identify a clear cause, and there is no gold standard for therapy, only a process of feeling your way.

The preference for drug-based therapy, particularly among GPs, can also be explained by the fact that this is closest to the normal approach, and everyday routines from practice take hold. Treating the side effects of drug-based therapy in particular results in a reduction in pressure in the doctor-patient relationships, as the doctor can enquire about undesired effects and fall back on the familiar causal structures, reverting to the classic drug-based approach to treating the additional symptoms.

The study shows that doctors have difficulty accepting depression as a diagnosis for their patients, because of its far-reaching consequences. They have trouble with the attachments patients form with them, and they have problems with the loose medical consensus on the possibilities of treatment.

According to the study, various types of doctor can be distinguished in treating depressed patients. There are five most important groups.:

The self-protective type, with a thick skin
This group is primarily older GPs who regard therapy as an administrative act and prefer giving drugs in the form of injections, to avoid the battle over compliance from the start. They have no desire to be caught up in long tales of suffering.
Holistic idealists
The representatives of this group are generally younger doctors or older colleagues who have come to regard their own practice critically, and they regard administration of psychotropic drugs as palliative medicine. They feel they should devote themselves (and their time) entirely to the patients, and suffer because regulated medicine does not permit this.
Experienced pilots.
This group are primarily psychiatrists with a wealth of experience, who see their main task as guiding patients through the depression. They expect from the start to work with the patients over an extended period. The disease is treated in regular consultations, with drugs seen only as a supportive measure.

Empaths who understand the patient
This group is made up of GPs who have often gone through depression themselves and accordingly feel a great deal of sympathy for their patients. They take time for them outside their office hours, and use the contact with the patients as an element to form trust for their treatment. As they regard depression as essentially a metabolic disturbance, they are inclined to drug-based therapy.

Conservative pragmatics
GPs with experience of depression, neurologists and psychiatrists in this segment regard the disease as a relatively simple matter which can be solved practically. They rely on the broad repertoire of established drugs, which are prescribed in large doses to “bring patients out of depression quickly”. They are dubious about innovations in therapy.

If you have questions, feel free to contact Rochus.winkler@test.local

This article appeared on December 7th in Planung&Analyse.