Intended for healthcare professionals


Depression should be managed like a chronic disease

BMJ 2006; 332 doi: (Published 27 April 2006) Cite this as: BMJ 2006;332:985

Editorial Message Accurate, Facts Not

Although few would disagree with the premise that depression is often recurrent and could therefore be considered a chronic (if episodic) disease, Scott’s editorial on “this much misunderstood disorder” in some places increases rather than reduces widespread ignorance.

Scott states that most depressive disorders and not mild. In fact in numerous epidemiological studies most
episodes are indeed mild. When studied in a large and generally unselected population there is a correlation
between the prevalence and symptoms. Specifically presentations with fewest symptoms are most common and
those with maximum symptoms (eg 9 of 9 DSMIV major depression symptoms) least common - in what is normally
described as a half-normal distribution. 1 The result is sub-syndromal mood disorders (increasing recognized as
important)2 are more common than mild (by ICD10) or minor depression by RDC criteria which are in turn at least
four times as common as moderate and severe depressive disorders (by either ICD10, RDC or DSMIV).3

Of even greater concern, is the repetition of the much misquoted citation that “15% of all patients with depression
will eventually commit suicide.” No one wishes to deny that suicide in the affective disorders is an extremely
important topic but lets not condemn many sufferers with such deterministic statements without first getting our
facts straight. Two much cited reviews of largely hospitalized depressed patients suggested that the proportionate
mortality (the percentage of the dead who died by suicide) was 15% but it these were later misquoted as referring
to case-fatality rate (the percentage of the original sample who died by suicide) in all patients with mood disorder.45 As most people suffering depression are not hospitalized it should be obvious that this figure cannot be applied to
“all patients” as Scott suggests. Fortunately, several groups have been prepared to study this area scientifically. In
an excellent meta-analysis, Bostwick et al (2000) found (case-fatality) the suicide rate to be 2% not 15% (2.0%
for outpatients diagnosed with an affective disorder) and only 6.0% for suicidal inpatients.6 Some will rightly
criticise a meta-analysis for lack of sample size in one single prospective study. However, more recently Høyer and
colleagues in Denmark followed up a high risk sample of 53,466 patients previously admitted for depression as
inpatients. Suicide was the cause of death in 3141 (6%) cases.7 Interestingly risk was higher in those with unipolar
depression than those with bipolar disorder.

I suggest it is time for BMJ editorials to undergo the same degree of scrutiny as major papers otherwise potentially important messages such as those carried here will be lost under a cloud of erranous scientific "facts"

1 Rucci P , Gherardi S, Tansella M, et al Subthreshold psychiatric disorders in primary care: prevalence and
associated characteristics. Journal of Affective Disorders 76 (2003) 171–181

2 Pincus HA, Davis WW, McQueen LE. 'Subthreshold' mental disorders. A review and synthesis of studies on minor
depression and other 'brand names'. Br J Psychiatry. 1999;174:288-296.

3 Barrett J, Barrett J, Oxman T, et al: The prevalence of psychiatric disorders in a primary care practice. Arch Gen
Psychiatry 1988; 45:1100–1106

4 Guze SB, Robins E: Suicide and primary affective disorders. Br J Psychiatry 1970; 117:437–438
5 Goodwin FK, Jamison KR: Suicide, in Manic-Depressive Illness. New York, Oxford University Press, 1990, pp 227–

6 Bostwick, J.M., Pankratz, V.S., 2000. Affective disorders and suicide risk: a reexamination. Am. J. Psychiatry 157
(12), 1925– 1932.
7 Høyer EHOlesena AV. Mortensen PB. Suicide risk in patients hospitalised because of an affective disorder: a
follow-up study, 1973–1993. Journal of Affective Disorders 78 (2004) 209–217

Competing interests:
None declared

Competing interests: No competing interests

30 April 2006
Micheal D Sriescoldu
University of Leeds