Education and debate

Should depression be managed as a chronic disease?

BMJ 2001; 322 doi: 10.1136/bmj.322.7283.419 (Published 17 February 2001)
Cite this as: BMJ 2001;322:419

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  1. Gavin Andrews, professor of psychiatry (gavina@crufad.unsw.edu.au)
  1. WHO Collaborating Centre for Mental Health and, School of Psychiatry, UNSW at St Vincent's Hospital, 299 Forbes Street, Sydney, 2010, Australia
  • Accepted 25 October 2000

In 1970 L G Kiloh and I finished recruiting patients for a prospective study of depression in admissions to a new general hospital psychiatric unit. When we published the 15 year follow up we discovered that our patients had not done at all well.1 Only a fifth recovered and remained continuously well, three fifths recovered but had further episodes, and a fifth either committed suicide or were always incapacitated. An English 15 year follow up study published at the same time showed identical results.2 The obvious conclusion was that people admitted to hospital in the 1970s with a depressive illness did not have a good prognosis. In retrospect, I ask why more of those who relapsed did not return to us for treatment. These results are not atypical. A detailed 12 year follow up in US specialist care showed that patients on average had symptoms in 59% of weeks and met full criteria for a depressive episode in 15% of weeks.3

Depression seems to be a chronic recurring disorder, seldom well managed if one simply waits for the patient to initiate further consultations.

Summary points

The burden of depression is not being reduced

The episodic nature of depression and the acute response to treatment means that episodes seem easy to treat

They can be if patients comply with drug and cognitive therapy regimens

The main problem is the next recurrence, if patients do not to come for treatment at all

To reduce the burden of depression, we argue for a chronic disease management model

We should manage depression proactively to ensure long term compliance with treatment

Methods

I identified references to remission and relapse of depression during the writing up of the Australian national mental health survey. References to long term prognosis came from my earlier work. A conference question, …

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