Untreated MDD: Brain Changes, Cognitive Burden, and Comorbid Anxiety

In "Untreated MDD: Brain Changes, Cognitive Burden, and Comorbid Anxiety," the panel turns to what a delay in treatment may actually cost the patient.

Dr. Alva brings Dr. DeBattista in on emerging neuroimaging work linking a longer duration of untreated illness to measurable brain changes. He asks him to persuade a skeptical colleague, to draw the parallel to the duration of untreated psychosis literature, and to stay candid that the evidence remains associational.

Dr. DeBattista concedes the work is primarily associational, but he finds it compelling and notes it has been accumulating for more than 25 years. He argues most colleagues are not truly skeptical that duration of illness affects outcome, because the principle is universal across medicine. Intervening earlier in hypertension or diabetes avoids complications later, and he sees no reason depression should be exempt. What colleagues may not appreciate is that morphologic and functional changes appear early in the course of illness. He then reframes disability as a cognitive problem rather than a mood problem. Patients in his clinic can carry profound suicidal thoughts every single day and still function at a high level. It is far harder to function when they cannot think, whether they are stacking boxes in a warehouse or operating as a surgeon. He points to changes and losses in the brain that worsen over time. Patients take a cognitive hit with every depressive episode, and those hits accumulate. He adds that depression is one of the modifiable risk factors for subsequent dementia.

Dr. Alva then asks Dr. Shirikjian about comorbid presentations where somatic symptoms get double counted. She insists on looking at the patient first and ruling out other medical illness. Many of her patients are in their twenties and open with exhaustion as their single complaint. Taking that at face value, she says, is not doing the job. Patients will eventually offer that they are sad every day without ever using the word depression.

The next episode in this series, "MDD Care Across Primary and Specialty Settings: Referral, Triage, and Safety," features Dr. DeBattista and Dr. Oyedeji on which parts of the journey primary care can own.