Prof. Koen Demyttenaere, Gasthuisberg University Hospital, Leuven, Belgium, dealt with the diversity of depression. This begins with the amazing variety of ways in which patients can differ with a diagnosis of a major depressive disorder (MDD) according to the DSM-5 manual.

To be diagnosed with MDD, the patient must meet five of nine symptoms listed. Mathematically, this potentially results in 227 different unique symptom profiles. It is possible that two patients with MDD - at least in theory - have only one common symptom.

Two patients diagnosed with MDD may have only one symptom in common

A striking feature of the patients in the STAR * D study is that 21% of the participants were diagnosed with anhedonia but no depressive mood - a phenomenon also known as "depression without depression".

This led Prof. Demyttenaere to his second topic - the fact that the lack of a positive affect hardly plays a role in the assessment of the outcome. “Are psychiatrists too little interested in fun and joy?” He asked.

Is Anhedonia the Most Specific Symptom in Depression?

Neither the HAM-D nor the MADRS scale evaluate a positive affect situation and they only insufficiently assess the hedonistic ability to experience.

To avoid this bias, he prefers the Center for Epidemiological Studies - Depression (CES-D) scale, where six of the twenty items deal with negative mood and another four with the lack of positive mood.

Anhedonia is arguably the most specific characteristic of depression, he said.

Prof. Demyttenaere and colleagues also developed the Leuven Affect and Pleasure Scale (LAPS) to more appropriately account for positive affect and anhedonia in the patient's perspective.

Diversity in symptoms, expectations, and beliefs

We are faced with a very heterogeneous clinical picture in depression and have a bewildering variety of scales with which we can assess the response to treatment. In addition, expectations can vary widely among patients themselves and between patients and doctors. One must never forget this because it affects the outcome, the psychiatrist stated.

The top priorities for patients are to live full lives, to enjoy life, and to be satisfied with themselves. For doctors, the reduction of negative feelings, the reduction of depression and anhedonia as well as increased involvement in the social environment and in leisure activities are in the foreground.

The greater the differences in expectations between patient and doctor at the start of therapy, the worse the outcome after six months, says Prof. Demyttenaere.

Treatment personalization

Patients are more likely to perceive their depressive symptoms to subside under antidepressant pharmacotherapy

• if they are convinced that their disease is less influenced by social factors
• if you think your doctor has understood your concern and
• if the consultation lasted longer.

Differing beliefs about the causes of depression and the doctor-patient relationship have a negative impact on outcome

The outcome is also influenced by demographic diversity. It is often complained that a 47% response rate in the first ill patient is disappointing; however, in certain populations the rate was much better. Of patients with at least 14 years of academic education with no history of trauma or distress, and women, 63% responded to initial treatment.

Symptomatic remission is not enough

This topic was taken up by Prof. Malcolm Hopwood, University of Melbourne, Australia. The psychiatrist emphasized that improving the functional status is the cornerstone of remission. However, he doubted that the doctor and patient would agree on the criteria for remission.

A reduction in negative affect in week 1 is a predictor of achieving remission in week 6 - however, the effect size is only half as great as that of the improvement in positive affect status. With sensitive and more targeted inquiries as to whether the positive mood has also improved, we might be able to adapt the treatment more effectively to the individual situation of the patient and the occurrence or lack of an early response, he said.

Prof. Hopwood and colleagues have developed the CHEER index - a tool that family doctors can use to determine whether depressed patients are emotionally dulled. It works as a reminder or suggestion to start a conversation with the patient about his mood and what he appreciates most about the treatment.

Our job is to support the patient in his goal of a fulfilled life, whatever the therapy

We believe that symptomatic remission is not enough. The psychiatrist says that improving the functional status is particularly important for the patients, especially in order to be able to perform their tasks at work again.

In the panel discussion on the importance of psychotherapy, Prof. Hopwood was asked about the patient's desire for a fulfilling life. He sees it as the therapist's task to support the patient in his goal of a fulfilled life, whatever the therapy. Prof. Stephen Stahl, University of California San Diego, USA, who chaired the symposium, added that it is necessary not to suffer from depression in order to be able to lead a fulfilling life, but that alone is not enough.