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

Over-extending the illness model for “depression” … again.

Three related papers concerning Depression in the same issue of the
BMJ; Scott, 985-986, Gilbody et al 1027-1030 and Layard 1030-1033 (BMJ 29
April 2006) deserve comment.

We have argued that degradation of clinical use of the term
“depression”, that has facilitated excessive use of antidepressants has
also resulted in a loss of definition between “the illness that we call
depression”, and responses to adversity. The former undoubtedly benefits
from an illness model; the efficacies of drug and psychological treatments
clearly outweigh the costs of labelling and discrimination. That is not so
clearly the case for sub-threshold, sub-syndromal or, in ICD-10 terms,
mild to moderate “depression”. Gilbody and colleagues’ paper recognises
this, and contributes a timely warning against the risk of medicalising
emotional distress in response to the Quality and Outcomes Framework
(QOF). Applying a pathological medical model when natural adaptive
reactions to adversity are operating can be harmful.1

Jan Scott’s editorial deserves comment, as advice upon what primary
care should offer to individuals with depression. Here there is no
distinction between “the illness that we call depression” (which may
benefit from a chronic disease management paradigm) and emotional distress
(which might well be harmed by such an approach). Again, this is despite
the fact that the evidence base so thoroughly reviewed in developing NICE
guidelines for the management of depression does not support an illness
model for so-called mild to moderate, or sub-threshold depression.

It is timely to see Lord Layard’s views in print in the BMJ. The so-
called Layard hypothesis, that it would be economically sound to invest in
psychological therapies because the result would be improved quality of
life, increased revenue income and savings on incapacity benefit is
generating considerable interest and activity amongst psychotherapeutic
and mental health service provider communities. His position is that
cognitive behaviour therapy (CBT) can be effective across a wide spectrum
of anxiety and depressive conditions. We contend that CBT is another term
that has become degraded by over use. The evidence demonstrating efficacy
of CBT in the treatment of depression is limited to the treatment of
moderate to severe depression, and in the treatment of anxiety, to the
defined anxiety disorders; not to anxiety itself.

However the evidence for even this comes from comparative trials with
drug treatment rather than with “practical help and supportive care” which
we suggest is what is required when emotional distress is an adaptive
call. Furthermore such evidence does not necessarily translate directly
into support for the complex machinery of psychological treatment centres,
where effectiveness will depend on assessment, management, treatment,
education, communication and other ‘black box’ factors operating
throughout the pathway.

We have no wish to gainsay the realistic prospect of improvements in
public health and wellbeing that could arise from stronger investment in
psychological therapies. However, benefit could be restricted if the
adopted approaches do not explicitly recognise the potentially harmful
consequences of an illness model. Converging evidence points to the fact
that the active “ingredient” in psychological therapy is non-specific
factors mediated by the overall quality of the relationship between
therapist and client. This further emphasises the importance of
contributions from non-specialists. Both the NICE Depression Guidelines
and the NICE Anxiety Guidelines advocate a stepped care approach. This
amounts to providing therapeutic input of differing levels of intensity
and sophistication, determined by need and response. As a result a
distinction can be maintained between responses to adversity that take the
form of help-seeking from a healthcare setting, which might well be best
met by a short term, nonspecific practical or supportive intervention2 and
the illness that we call depression, which might well benefit from a
formally defined CBT, avoiding the socially harmful effects of identifying
the former as an instance of the latter.

1. Ørner RJ, Siriwardena AN, Dyas JV, Middleton HC, Shaw I, Woodward
L. (2004) The NICE guideline on depression. Research recommendations for
primary care. Primary Care Mental Health;2:137-9.

2. Ørner RJ, Siriwardena AN, Dyas JV. Anxiety and depression: a
model for assessment and therapy in primary care. (2004) Primary Care
Mental Health;2;55-65.

Competing interests:
None declared

Competing interests: No competing interests

09 May 2006
Hugh Middleton
Senior Lecturer, University of Nottingham
Jane Dyas, Roderick Orner, Niro Siriwardena, Ian Shaw, Louise Woodward
Duncan Macmillan House, Porchester Rd., Nottingham NG22 8TX