Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 2000 Jun 10;320(7249):1602.

Diagnosing and treating depression

Treatment is often challenging

Ward Tolbert Smith 1
PMCID: PMC1127381

Editor—On reading Kendrick's article,1 I was reminded of the notion that individuals seek out a field of medicine that suits the workings of their brain and personality. Surgeons tend to be results oriented, enjoy solving concrete problems with concrete answers, and need closure (no pun intended). Internists have a high tolerance for “not knowing,” living with uncertainty, and allowing problems to stay open, dynamic, a work in progress. Chronic disease is recognised as the human condition. Family practitioners are willing to tackle any problem to the best of their ability, and they can live with the idea that they need to learn more and more to improve their skills. They tend to find the time to upgrade their knowledge in seminars, journals, and other forms of courses. They are typically not deeply versed in any particular field, psychiatry included.

Depression is a complex illness. Without the sense of “psychological mindedness” that often directs a person into the mental health fields, it is difficult to grasp the full picture of the syndrome of depression. Treatment is often challenging and not as simple as might be implied by the few hours of instruction delivered to the willing participants in the trial.

The choice of standard antidepressant in the trial is certainly open to some criticism: tricyclics have retreated to an occasional choice in the new world of psychopharmacological agents. We now expect full remission of the syndrome of depression and should seldom settle for less. Psychotherapy as an additional treatment modality has been shown to be a useful tool in the treatment plan and should not be overlooked or relegated to the history books.

Unfortunately, the proper treatment requires considerable training and experience and a great deal of time—commodities in short supply in the world of the primary care physician. Lest I seem negative and overly critical, I believe that primary care physicians can have a more effective role in the treatment of depression, but I do not think that the training approach meets the requirements for developing that role effectively.

References

BMJ. 2000 Jun 10;320(7249):1602.

Educating family physicians to recognise depression

Graham Worrall 1,2, John Angel 1,2

Editor—We read Kendrick's editorial with interest,1-1 as we recently conducted and reported a randomised trial of an educational strategy to improve family physicians' detection and management of depression.1-2 Using patients' clinical state as a measure of outcome, we found at six months a modest but beneficial effect of the educational strategy on patients with depression. Furthermore, after 18 months, the depression rating scores of patients from the control group deteriorated slightly, whereas those of patients from the intervention group remained stable.1-3 Doctors who received the intervention had a higher rate of diagnosing depression and a higher rate of referral to psychiatrists and other health professionals than did family doctors who were in the control group. A higher proportion of patients whose doctors had received the intervention remained on their antidepressant drugs for the duration of the study.

Although we agree with Kendrick that the spectrum and course of depression in primary care is different from the “major depressive disorder” that is targeted by the clinical practice guidelines, we are more optimistic than he, as our trial seemed to have a better outcome than many of the trials he described. Perhaps the prescribing pattern of family doctors is different in Canada; we found that 133 of 147 patients who were diagnosed as suffering from depression were treated with antidepressant medication and that 120 (90%) took selective serotonin reuptake inhibitors. We think that educational sessions for small groups of family doctors and close liaison with psychiatric colleagues can greatly improve the recognition of depression and the care of people with depression.

References

  • 1-1.Kendrick T. Why can't GPs follow guidelines on depression? BMJ. 2000;320:200–201. doi: 10.1136/bmj.320.7229.200. . (22 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Worrall G, Angel J, Chaulk P, Clarke C, Robbins M. Effectiveness of an educational strategy to improve family physicians' detection and management of depresssion: a randomized controlled trial. Can Med Assoc J. 1999;161:37–40. [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Worrall G, Elgar F, Robbins M. Improving management of depression [letter] Can Med Assoc J. 2000;162:316. [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Jun 10;320(7249):1602.

Can primary care improve care for depressed patients?

Michael McCullagh 1, Sally Gardner 1

Editor—Kendrick questions the evidence base for guidelines on depression because Thomson and colleagues found that educational interventions did not improve outcomes in depression.2-1,2-2 However, Wells et al found that quality improvement programmes in a managed care setting in the United States can improve the care of patients with depression.2-3 Perhaps it is how we try to change practice that is at issue here and not the dynamic evidence base of guidelines. Primary care practitioners need to know whether there is anything they can do now to help depressed patients.

Kendrick noted that “most patients do not continue treatment for the recommended duration and that this may explain the consistent finding that recognition of depression and drug treatment in primary care is not associated with a better outcome.” This implies that if compliance with treatment could be improved then outcomes would improve. We believe that a more systematic multidisciplinary model can achieve this.

In our typical urban practice a nurse runs a clinic for patients with depression. The clinic addresses the needs of patients and their families from a holistic framework and coordinates appropriate referrals to other agencies, including counselling.2-4 The nurse monitors progress and encourages compliance with medication and other treatment. As a result compliance is enhanced and considerable improvements in mood have been shown.

In complex organisations dealing with complex problems, educational interventions on their own are often insufficient to change behaviour.2-5 Although the evidence base needs constant improvement, primary care can get on with introducing systematic organisational changes to support patients' compliance with treatment.

References

  • 2-1.Kendrick T. Why can't GPs follow guidelines on depression? BMJ. 2000;320:200–201. doi: 10.1136/bmj.320.7229.200. . (22 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet. 2000;355:185–191. doi: 10.1016/s0140-6736(99)03171-2. [DOI] [PubMed] [Google Scholar]
  • 2-3.Meredith L, Unützer J, Miranda J, Carney MF, Rubenstein LV. Impact of disseminating quality improvement programs for depression in managed primary care. JAMA. 2000;283:212–220. doi: 10.1001/jama.283.2.212. [DOI] [PubMed] [Google Scholar]
  • 2-4.McCullagh MG, Gardner S. Practice nurses and treatment of depression. Br J Gen Pract. 1998;48:1091–1092. [Google Scholar]
  • 2-5.Allery LA, Owen PA, Robling MR. Why general practitioners and consultants change their clinical practice: a critical incident study. BMJ. 1997;314:870. doi: 10.1136/bmj.314.7084.870. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Jun 10;320(7249):1602.

A holistic approach is recommended

S Llewellyn-Jones 1,2, P Donnelly 1,2

Editor—Kendrick raises several issues that we wish to challenge.3-1 General practice is a specialty of uncertainty and a decision to ascribe “caseness” may be difficult in many patients who visit the surgery. In psychiatry, where continuum models abound for psychosis, affective symptoms, and other behaviour, caseness may also be viewed in varying shades of grey. However, valid and reliable classification systems, such as the ICD-10 (international classification of diseases, 10th revision) and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, help in this respect. Strict criteria emphasising severity, duration of symptoms, and impact on life all help to define what is illness and what is not.

However, evidence shows that even patients with dysthymia can benefit from using antidepressants.3-2 A doctor's willingness to treat can be rewarded with a considerable overall improvement in symptoms, although this may occur in stages. Classifications such as endogenous versus non-endogenous depression are less in vogue; they are less valid and do not predict response to treatment with antidepressants.

A reluctance to initiate treatment in the face of adverse social factors is a troublesome misconception. We should all try to take a holistic view of our patients. The Royal College of General Practitioners emphasises a biopsychosocial model for the formulation of patients' problems. To conceptualise a person's symptoms as being a result of their social difficulties is also reductionist. This is incongruent in a profession traditionally criticised for adopting an isolated biological viewpoint.

Certainly, unresolved social problems can be a perpetuating factor in depression. But for aetiology to prejudice access to treatment is surely wrong. Some patients may start to solve problems more effectively when their depressive symptoms are lessened and they can begin to see ways out of their social quagmire.

We wonder whether the Hampshire study3-3 is not so much an issue of guideline failure as another demonstration of systematic avolition and disillusion with depression management. If we can make our depressed patients even partially better with drug treatment, we should strive to do so with energy and optimism.

References

  • 3-1.Kendrick T. Why can't GPs follow guidelines on depression? BMJ. 2000;320:200–201. doi: 10.1136/bmj.320.7229.200. . (22 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Hellerstein DJ, Yanowitch P, Rosenthal J, Wallner Samstag L, Maurer M, Kasch K, et al. A randomised double-blind study of fluoxetine versus placebo in the treatment of dysthymia. Am J Psychiatry. 1993;150:1169–1175. doi: 10.1176/ajp.150.8.1169. [DOI] [PubMed] [Google Scholar]
  • 3-3.Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Osterler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet. 2000;355:185–191. doi: 10.1016/s0140-6736(99)03171-2. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Jun 10;320(7249):1602.

Learning to look at the illness from both sides

Helen Johnson 1

Editor—Having taken antidepressants for most of the past eight years, I feel qualified to respond to Kendrick's article.4-1

Firstly, depression is not always easy to diagnose, even if major (my main symptom was depersonalisation), and the correct diagnosis may take some time.

Secondly, amitriptyline is foul. It tastes awful, makes you sleepy, and gives you a tendency to pass out at therapeutic doses.

Thirdly, cognitive behavioural therapy helps up to a point, but the times when you really need to use it (because you're falling down a black hole) are the times you can't use it, because you are incapable of meaningful logical thought.

And finally, there is the issue of compliance. Every time you take an anti-depressant, it is a reminder that you are “weird,” that your thought patterns are abnormal, and that to function normally you depend on medication. Because you are desperate to seize on any hope that you have returned to “normal” is it any surprise that medication is stopped sooner than recommended?

References

BMJ. 2000 Jun 10;320(7249):1602.

Author's reply

Tony Kendrick 1

Editor—Tolbert Smith has a point about the difficulty of changing behaviour through relatively brief education, but our current education system cannot deliver much more than this. The Hampshire depression project used an inpractice programme conforming to good educational principles, which was well received by practitioners who were self selected for their interest in depression.5-1 Its conclusions that improvements in recognition and treatment of depression in primary care are unlikely to be achieved through education alone deserve to be taken seriously.

The Canadian trial reported by Worrall and Angel was not directly comparable as the intervention was a combination of education and increased access to a psychiatrist, so the modest benefits found may have resulted from the extra input from the specialist. They reported no notable difference between the intervention and control groups in the proportion of patients who completed six months of antidepressant treatment. Also there was no attempt to measure changes in doctors' sensitivity by comparing their assessment with that of a screening tool, so they could not assess whether there were improvements in doctors' rates of detection of depression—although the doctors in the intervention group reported more cases to the project team, perhaps they may have had more incentive to do so than the doctors in the control group.5-2

I agree with McCullagh and Gardner that there are effective interventions to improve compliance with treatment and outcome for those patients who truly need drugs.5-3 I am interested to hear about their practice clinic and have also suggested recently that practices might set up nurse led clinics to improve management of depression.5-4

Llewellyn-Jones and Donnelly are right that we should not discount the possibility of treating people with drugs in the face of unresolved social problems, and I did not wish to seem nihilistic, but Johnson reminds us that we need to listen to our patients, who are telling us something about the acceptability of treatment. We must be reasonably sure that we are doing good before we press treatment. Given the high prevalence of depressive symptoms among our patients and the high rate of resolution without specific treatment, the most important question is, who is likely to benefit from treatment? We have almost no primary care research on the effectiveness of antidepressant drugs for different levels of severity of depression and in the presence or absence of continuing social difficulties.

Patients in secondary care are as a group more severely depressed, are therefore perhaps more likely to accept drug treatment, and are more likely to need drugs to get better regardless of any changes in their social circumstances. The prevalence of major depression is proportionately much lower in primary care than in secondary care, which means that the positive predictive value (in terms of predicting the need for drug treatment) of meeting the symptom count will also be lower5-5—there will be more false positives in a population that hasn't already been selected for severity of depression by the referral process, and more patients with milder depression who would have less to gain from taking antidepressants and might be more responsive to psychosocial interventions.

The idea that guidelines for assessment and drug treatment developed in secondary care can simply be applied directly to primary care populations is therefore clearly questionable. I remain unsurprised that guideline based education does not lead to improvements in case detection and outcome when the guidelines do not adequately tell us whom to treat.

References

  • 5-1.Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: the Hampshire depression project randomised controlled trial. Lancet. 2000;355:185–191. doi: 10.1016/s0140-6736(99)03171-2. [DOI] [PubMed] [Google Scholar]
  • 5-2.Worrall G, Angel J, Chaulk P, Clarke C, Robbins M. Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial. Can Med Assoc J. 1999;161:37–40. [PMC free article] [PubMed] [Google Scholar]
  • 5-3.Peveler R, George C, Kinmonth A-L, Campbell M, Thompson C. Effect of antidepressant drug counselling and information leaflets on adherence to drug treatment in primary care: randomised controlled trial. BMJ. 1999;319:612–615. doi: 10.1136/bmj.319.7210.612. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-4.Kendrick T. Depression management clinics in general practice? Some aspects lend themselves to the mini-clinic approach. BMJ. 2000;320:527–528. doi: 10.1136/bmj.320.7234.527. . (26 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-5.McWhinney IR. An introduction to family medicine. Oxford: Oxford University Press; 1981. pp. 95–96. [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES