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EDITORIALS: Andre Tylee and Roger Jones Managing depression in primary care BMJ 2005; 330: 800-801 [Full text]

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The precise diagnosis of depression in primary care can also decrease over concern about treatment

Antonio E Nardi   (11 April 2005)

overstating the case

Christopher F Dowrick   (12 April 2005)

Integrating complementary medicine into the management of depression.

Charlotte Paterson   (14 April 2005)

try honesty

Roelof A. Bijkerk   (14 April 2005)

A pseudoepidemic of depression

Derek A Summerfield   (14 April 2005)

Nothing "pseudo" about my depression

Dr Christopher L. Manning   (18 April 2005)

Early & Effective Intervention in Depression

Mamdouh EL-Adl, None   (4 May 2005)

The precise diagnosis of depression in primary care can also decrease over concern about treatment 11 April 2005
Antonio E Nardi, Associate Professor of Psychiatry Federal Univ Rio de Janeiro, R. Visconde de Piraja, 407/702. Rio de Janeiro. 22410-003. Brazil. Send response to journal: Re: The precise diagnosis of depression in primary care can also decrease over concern about treatment	Depression places a significant economic burden on patients, families, caregivers, employers, and payers worldwide (1). Tylee & Jones (2) pointed that the public confidence in the ability of general practitioners to manage depression has been knocked by current concerns about selective serotonin reuptake inhibitors. They suggested that better support for effective non-pharmacological treatment, and more appropriate use of antidepressants in primary care should help to restore that confidence. The first step for a correct, safe, and efficacious treatment of depression is the early and precise diagnosis. The enhancement in quality of the diagnosis in primary care will also increase the confidence in the overall treatment. The assumption that a normal sadness is a depressive disorder or the opposite posture that a depressive syndrome can be a normal reaction to social or physical problems can develop unrealistic expectation to the treatment or can compromise the precocious intervention for treatment. The diagnosis of depression is based on clinical evaluation and in a large range of differential diagnosis. Depressive mood is the hallmark of all depressions, regardless of their additional specifying features and of their intensity, duration, and variation (3). It is a sustained emotional state that is characterized by sadness, low self-esteem, hopelessness, emptiness, unhappiness, pessimism, and desire for isolation. The main differentiating features of depressive mood from the non-morbid emotional reaction of sadness can be based on the intensity and the depth of the suffering become so unbearable that often the death wish provides a comforting option. The symptoms last long enough to be felt as unaltered affective state. The depressive mood, the cognitive and the somatic symptoms associated pervade all domains of personal life and impact on the individual’s performance. It is well established that depression imposes a significant economic burden on society with direct and indirect costs, quality of life, mortality and morbidity, and individual suffering. Improving the quality of antidepressant treatment most likely increases the overall total costs of depression treatment but can improve the cost effectiveness of treatment. Better rates of usage of adequate antidepressant doses and time duration of treatment, and the employment of evidence based treatment for some subtypes of depression as the melancholic, the psychotic, the seasonal, and the atypical depression may also result in a better effectiveness of treatment, increase confidence in the health professionals and decreasing overestimated concerns. References: 1.Klerman GL, Weissman MM. The course, morbidity, and costs of depression. Arch Gen Psychiatry 1992; 49: 831-834. 2. Tylee A, Jones R. Managing depression in primary care. BMJ 2005; 330: 800-801. 3. Judd LL. The clinical course of unipolar major depressive disorders. Arch Gen Psychiatry 1997; 54: 989-991. Competing interests: None declared
overstating the case 12 April 2005
Christopher F Dowrick, Professor of Primary Medical Care University of Liverpool L69 3GB Send response to journal: Re: overstating the case	Tylee and Jones mount a spirited defence of the primary care management of depression. As a general practitioner with very positive attitudes towards mental health problems, I commend their obvious enthusiasm for this cause. However there are several points in their argument which I think are worthy of challenge. It is disappointing to see a restatement of the old canard that general practitioners are poor at recognising depression. There is now substantial evidence that we can be highly discriminating when it comes to mental health. We are much more likely to make a diagnosis of depression when patients present with severe distress, and less likely to do so when they present milder problems (1). Given that the prognosis of depression is strongly linked to severity, and that mild presentations are much more likely to respond spontaneously, this selective diagnostic behaviour can be seen not as a cardinal error but as as a well-judged response based on a sound working knowledge of natural history (2). Once we have made a diagnosis of depression in primary care, we need to be suitably cautious about the likely benefits of whatever treatments we decide to offer. Tylee and Jones note the plethora of possible interventions which are recommended within the NICE guidelines, but do not alert BMJ readers to the fact that the evidence on which these recommendations are based is rarely of high quality. The efficacy of antidepressant medication is now open to serious doubt: placebo response is increasing over time (3), conventional drug trials have fundamental methodological limitations (4) and their results may be biased through selective reporting. In primary care we frequently bemoan our inability to access systematic psychological treatments such as cognitive behavioural therpay, but here too the evidence for efficacy is at best patchy (5). We should also acknowledge the potentially noxious effects of an overenthusiastic approach to managing depression in primary care. Once embarked on a course of medication, patients worry about losing the sense of 'being normal' (6), and find it difficult to stop. We run the risk of a epidemic of long term unnecessary prescribing, reminiscent of the anxiolytic debacle in the 80s and early 90s. More fundamentally, by focussing our attention on depression as a medical condition, Tylee and Jones foster the assumption that distressed patients are ill and in need of treatment. I prefer to start from a different premise: of encounters with people who (usually and successfully) lead their own lives, but who (occasionally) may value our support when they run into difficulties (7). References (1)Thompson C, Ostler K, Peveler RC, Baker N, Kinmonth AL. Dimensional perspective on the recognition of depressive symptoms in primary care. Br J Psychiatry 2001;179:317-23. (2)Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995;311:1274-6. (3)Walsh BT, Seidman SN, Sysko R, Gould M.Placebo response in studies of major depression. JAMA 2002;287:1840-7. (4) Kirsch I. Are drug and placebo effects in depression additive? Biol Psychiatry 2000;47:733-5. (5)Parker G, Roy K, Eyers K.Cognitive behavior therapy for depression? Choose horses for courses. Am J Psychiatry 2003 160:825-34. (6) Garfield SF, Smith FJ, Francis SA. The paradoxical role of antidepressant medication – returning to normal while losing the sense of being normal. J Mental Health 2003;12:521-35. (7) Dowrick C. Beyond Depression. Oxford, Oxford University Press, 2004. Competing interests: None declared
Integrating complementary medicine into the management of depression. 14 April 2005
Charlotte Paterson, MRC Research Fellow MRC Health Services Research Collaboration, Department of Social Medicine,Bristol University,BS8 2PR Send response to journal: Re: Integrating complementary medicine into the management of depression.	The main message of your editorial on managing depression in primary care (1), that ‘public confidence needs to be restored’, suggests that biomedical models and paternalistic relationships still dominate in this area of health care. This defensive position has the effect of foreclosing discussions about the range of useful treatment options before lay views and beliefs have been carefully considered. Consequently the authors do not discuss the use of complementary therapies such as acupuncture, despite their increasing popularity and evidence base. Looked at afresh, the evidence presented in the editorial suggests that lay opinions should not be discounted but rather, as they are based on a wealth of everyday real-life experience, they should constitute the foundation to our evidence base. For example, the 1995 survey of lay attitudes commissioned by the Royal Colleges of Psychiatrists and General Practitioners that is cited in the editorial (2) found that 78% of people considered antidepressants were addictive and it went on to conclude that ‘Patients should be informed clearly when antidepressants are first prescribed that discontinuing treatment in due course will not be a problem’.Ten years on we are presented with evidence on withdrawal reactions to selective serotonin reuptake inhibitors (SSRIs) that suggests that in this instance lay opinion was closer to the truth than medical assertion. The 1995 survey also reported considerable lay uncertainty about the effectiveness of antidepressants (30% of the public thought that antidepressants were ineffective), an uncertainty that is mirrored in the finding, from systematic reviews of antidepressant drugs, that only about 50% of people who took them showed a positive treatment response (3). A report by the Mental Health Foundation in 1998 (4), describes how many mental health service users appreciated not only ‘talking therapies’ but also a range of alternative and complementary therapies. They often combined them with standard medical regimes, and identified benefits such as ‘a relief from tension’, ‘being treated as a ‘whole person'’, and ‘taking responsibility for my own health’. A number of observational and experimental studies are now building evidence onto this lay foundation. For example 12% of patients presenting to acupuncturists in private practice gave depression as a primary reason for seeking treatment, and after four months their symptoms and wellbeing had improved by 1.5 on a 7 point scale (5). A RCT in North America demonstrated a response rate to acupuncture (45%) that is similar to those found in trials of antidepressants (6). The ‘antidepressant story’ has much to teach us, including the necessity of respecting lay experiences and opinions. Surely the time has come to set up and evaluate integrated mental health services that offer patients the choice of complementary therapies alongside other treatment options. Reference List 1. Tylee A, Jones R. Managing depression in primary care. BMJ 2005;330:800-801. 2. Priest RG, Vize C, Roberts A, Tylee A. Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313:858-859. 3. Cipriani A, Geddes J. Prescription antidepressant drugs versus placebo. Clinical Evidence [online] 2003; http://www.clinicalevidence.com/ceweb/conditions/meh/1003/1003.jsp:(accessed 8.4.05) 4. Wallcraft, J Healing minds. A report on current research, policy and practice concerning the use of complementary and alternative therapies for a wide range of mental health problems. London: Mental Health Foundation, 1998. 5. Chapman R, Norton R, Paterson C. A descriptive outcome study of 291 acupuncture patients. The European Journal of Oriental Medicine 2001;48-53. 6. Allen JJB, Schnyer RN, Hitt SK. The efficacy of acupuncture in the treatment of major depression in women. Psychological Science 1998;9:397-401. Competing interests: None declared
try honesty 14 April 2005
Roelof A. Bijkerk, Human Being Grand Rapids MI, 49505 Send response to journal: Re: try honesty	From the article "Before selective serotonin reuptake inhibitors (SSRIs) became available, general practitioners were legitimately concerned about the side effects of treatment, particularly with the older tricyclic antidepressants.7 Although more caution in prescribing has recently been advocated,w1 w2 SSRIs initially offered a new dawn for depression treatment in general practice, with drugs that were relatively free of side effects. " "Nine out of 10 depressed patients are treated only in primary care,2 3 and up to two thirds of suicide victims contact a general practitioner in the four weeks before the death. " "Public confidence in the ability of general practitioners to manage depression has been knocked by current concerns about SSRIs, exaggerated in the media. Better support for self help, wider provision of effective psychological services, and more appropriate use of antidepressants in primary care, and more urgent attention by NHS planners, should help to restore that confidence. " Is this necessary to point out that when someone states that medications "offered a new dawn for depression treatment in general practice, with drugs that were relatively free of side effects. " , that there is something going on when since "the new dawn" these medications then have been proven to double the rate of suicide in people under 18, are now required to carry warning lables while these incredibly negative side effects which are simply debilitating to society have been going on the whole time (for years), Given that the method of healing the medical establishment offers is unfounded and falsely portrayed as healing (the scientific evidence goes against that anti-depressants would be healing), this would certainly only add to the confusion of the patient looking for healing. If a medical practitioner would simply state that they don't have any drugs proven to actually help, that the problem has only been proven to not be organic, that there are many people who have gone through this who have excellent advice not to feel there is something wrong with you brain and to not give up hope, this would be honest. With what IS going on it more explains why up to two thirds of people who call these establishments end up committing suicide rather than that it is a sign that these establishments need more money to do what causes the problem to begin with. Since the advent of the false biological model for Mental Illness there is a whole "epidemic" of these supposed diseases, diseases which have no biological basis (thus actually fall in the category of "perceptions") and yet are falsely treated as if they do and in the mean time feed the drug companies and create true paranoia against a part of the mind which perhaps is simply emotional or needs rest or any of numerous other true organic needs. It also is a great insult to intelligence to be decieved in such a way........... When "Better support for self help, wider provision of effective psychological services" are called for that should be in the environment of honesty and not followed by a reference to medications which for years have caused numerous problems while they have no scientific basis– thus substitute honest science for paranoia and create organic problems while they have not been proven to tend to any. To simply point this out one is found dissident in the mental health field. Is it really too much to expect honesty!? How many people must die!? Competing interests: When something is proven not to be organic is should be seen as such.
A pseudoepidemic of depression 14 April 2005
Derek A Summerfield, hon sen lect/consultant psychiatrist Institute of Psychiatry/Maudsley Hospital, London SE5 Send response to journal: Re: A pseudoepidemic of depression	Tylee and Jones’ editorial on managing depression in primary care has too narrow a biomedical focus. Firstly, they write as if “depression” always means a free standing biologically based disorder. The history of the concept demonstrates the gradual incorporation of a Western cultural vocabulary of guilt, energy, fatigue and stress. (1) In everyday usage “depression” can be used both figuratively or literally, as denoting a normal or abnormal state, and if abnormal either as individual symptom or as full-blown disorder. Bar a small subset of severe cases, I challenge anyone to rigorously demarcate depression from ordinary unhappiness or misery on a routine basis. So- called biological features are generally said to indicate antidepressants, but poor sleep and concentration, weight loss, reduced motivation and drive, anhedonia etc (as well as suicidal ideas) not uncommonly accompany ordinary misery as well. Tylee and Jones do not justify their assertion that depression still goes unrecognised in primary care. I would differ: there is little evidence of an epidemic of depression (as psychiatric disorder), but we do have an epidemic of antidepressant prescribing. In Britain prescriptions rose from 9 million to 21 million during the 1990's, and in the USA have doubled in only 5 years - mirroring the production and marketing of SSRI antidepressants. This is as much a cultural trend as a medical one, reflecting the rise of a medicalisation and professionalisation of everyday life and its problems across Western societies over the past 50 years in particular. (2) Tylee and Jones must be aware that the evidence base for antidepressants is still remarkably unrobust, particularly for the mild/moderate cases who account for the majority of all prescriptions. (3) Whenever I encounter the term “treatment resistant depression” in the psychiatric literature, I wonder how many of such cases have a true psychiatric condition at all. Antidepressants will not cure human misery. It also remains to be seen whether the assertion that current concerns about SSRI's are “exaggerated“ will prove true. I predict that in coming years we will be hearing a lot more about discontinuation reactions. There is also an international dimension to this issue. The World Health Organisation has claimed that “depression“ is a worldwide epidemic that within two decades will be second only to cardiovascular disease in terms of disease burden. This seems a serious distortion, one which can serve to deflect attention away from what millions of people might cite as the basis of their misery, like poverty and lack of rights. The one clear -cut beneficiary would of course be the pharmaceutical industry, with its vested interest in the biologisation of the human predicament. 1. Jadhav S. Cultural origins of Western depression. International Journal of Social Psychiatry 1996; 42: 269-86. 2. Summerfield D. Cross-cultural Perspectives on the Medicalisation of Human Suffering. In Posttraumatic Stress Disorder. Issues and Controversies (ed G.Rosen) 233-45.Chichester: John Wiley, 2004. 3. Moncrieff J. The anti-depressant debate. British Journal of Psychiatry 2002;180: 193-4. Competing interests: None declared
Nothing "pseudo" about my depression 18 April 2005
Dr Christopher L. Manning, Policy and Services Manager Depression Alliance N1 9BE Send response to journal: Re: Nothing "pseudo" about my depression	Dear Sir, In the current climate of polarised views about depression and its very existence, I shall confine myself to comments about my lived experience and general views about the editorial and subsequent responses. I am grateful for the ringing endorsement of my ability to do so, and the weight that I can now expect to receive in this discussion? ("Looked at afresh, the evidence presented in the editorial suggests that lay opinions should not be discounted but rather, as they are based on a wealth of everyday real-life experience, they should constitute the foundation to our evidence base". Paterson Rapid Response). In defence of Tylee and Jones, they did not re-iterate a personal view that general practitioners are poor at recognising depression, they merely stated the fact that this is often stated. However, it would be hard to argue from many of the experiences of those who use Depression Alliance that our users' experiences necessarily reflect unadulterated joy at having to visit their GPs a number of times years prior to recognition (and acknowledgment), even if they are ordinarily distressed, whether on a "routine basis" (Summerfield Rapid Response) or not. In one study, 14% of patients with depression still had a clinically severe condition, had not received a diagnosis, and might have benefited from treatment, 3 years after presentation (David Kessler, Olive Bennewith, Glyn Lewis, Deborah Sharp, BMJ 2002;325:1016-1017 ). No wonder, some become "treatment resistant"; with figures like that, even arteries get the chance to harden? Dowrick states: "Given that the prognosis of depression is strongly linked to severity, and that mild presentations are much more likely to respond spontaneously, this selective diagnostic behaviour can be seen not as a cardinal error but as as a well-judged response based on a sound working knowledge of natural history". Since we are clearly having an evidence-based discussion on this subject, where is the evidence for that statement? I suspect that this non-cardinal error is perhaps more of the adoption of a default position of zero-ordinal activity? Once again, the charity hears from many whose experience of their GP can be one of indifference to their predicament and a complete absence of the deployment of those tools that can delineate distress from a severe mental illness. The biopsychosocial processes associated with stress, distress, depression and anxiety are increasingly understood, and the possibility of remediation, or indeed palliation, of that state, should not be denied for the sake of theoretical difficulties that professionals might be having over taxonomy. The experience of having one's leg run over by a tractor and the resultant pain and distress are totally comprehensible and "natural", but do we deny people pain-relief and those other interventions that will accelerate healing? These days, I often hear people say: "Antidepressants only treat symptoms, not causes". Frankly, I don't give a flying fluoxetine. I will sort out my life as much as I can with professional help (as required and appropriate: I am middle class and NHS-savvy, you would expect nothing less), using a myriad of interventions (I am fortunate enough to be in that position, many still are not) and am quite content (it's my choice, in fact) to take a medicine to plug any gaps left over. As for withdrawal, there is no craving or tolerance and doctors need to be taught, in aspects of their work, to take more care of people once they have prescribed any medicine, and especially when discontinuing it. Much of what we see is a direct result of a generally indecent haste to medicalise all that moveth and not especially depression. It is also to be regretted that an already beleaguered group of people should be subjected to further confusion. If there has been overegging of the marketing souffle, we have also recently been able to witness some pretty spectacular non-pharma cause-related marketing by those who may be equally guilty of exploiting a vulnerable group in the interests of raising their own profile? I am confident that what I experience is no placebo effect and I have posited before the need for a "taste challenge" for people who think that the effects (side and therapeutic) of any antidepressant are due to the placebo effect. If they are placebo, people would presumably have no problem personally in taking one for a trial period? Further, if people think that TCA antidepressants are also placebos, then try taking "sub- optimal" doses of 50mg amitriptyline for a week or two and let me know how you get on. Further, it is daft to argue that giving medicines to people who don't need them, or the control group in a trial (where they are often receiving far more attention than they would be in a "usual" clinical setting)is the same as treating people who do. In metaphorical and biological terms, this is the same as suggesting that there is no difference in the experience of trying to board an Underground Train when it is empty, as when it is full? Dowrick states: "We should also acknowledge the potentially noxious effects of an overenthusiastic approach to managing depression in primary care", and then, having criticised the medical emphasis of the editorial, goes on to talk purely about the prescribing of drug interventions. I have as much concern about an underenthusiastic approach; that is what pre- occupies the work of Depression Alliance. He states that "Tylee and Jones foster the assumption that distressed patients are ill and in need of treatment. I prefer to start from a different premise: of encounters with people who (usually and successfully) lead their own lives, but who (occasionally) may value our support when they run into difficulties (7)". There is no assumption in the editorial that "distressed patients are ill and in need of treatment", any more than there is a missing "all" before the "distressed". Further, distress can make people ill, and some people become ill, and depressed, perfectly well without pre-existing distress. Those patients who live within Prof. Chris Dowrick's patch are fortunate; he is a champion for +ve mental health. However, he is by no means the national 'norm'. Hopefully, by driving the issue of need for the development of psychological competencies (including warmth, empathy and respect) across the entire NHS Workforce, this time-resistant vessel can be turned around. Of course we should not be medicalising patients who are not ill, as a result of lack of personal competency or systemic capacity, but neither should we be deconstructing the lived reality of many thousands of people who have experience of the "Dementor's Breath". Summerfield states: "Bar a small subset of severe cases, I challenge anyone to rigorously demarcate depression from ordinary unhappiness or misery on a routine basis". As a GP, I saw many hundreds of people, over many years, who were able to make that demarcation, as indeed can I, and as do most of those who seek out the charity. If professionals are unable to make that demarcation, then there are two ways of dealing with it. One is the development of more sensitive instruments and more quality time for patients with appropriately trained professionals and the other is to have depression yourself. I can assure all readers that you will be able to demarcate it with certainty and that theory, RCTs and fine academic discussions about causation, understandability (appropriateness of response given the circumstance) and categorisation will simply melt away in the furnace of your personal, and family/carer suffering. Yours unforeclosedly Dr Chris Manning Competing interests: You all know the well-rehearsed, and increasingly tired, arguments that Depression Alliance accepts money from "the pharmaceutical industry". In fact, we actively seek it (although it remains less than 25% for any given year since 2002), and foster personal and effective relationships with individuals within those organisations and without. DA would do so, even if Govt funding was sufficient to enable our work, which espouses the worth of self-help and mutual support and wholistic approaches to distress, with or without depression. I have had major depression (or should that be distress?) since 1986. I am in recovery, in some part due to taking an SSRI.
Early & Effective Intervention in Depression 4 May 2005
Mamdouh EL-Adl, Psychiatrist Princess Marina Hospital, Northamptonshire Healthcare NHS Trust, Upton, Northampton NN5 6UH, None Send response to journal: Re: Early & Effective Intervention in Depression	Editor I agree with Tylee & Jones in their editorial that inappropriately criticising GPs would only but damage the public confidence in primary care. In my opinion this is likely to adversely affect public confidence in the NHS & healthcare delivery. We all have to work together to restore public confidence in NHS. With the reduction of mental hospital beds over the past few decades, the role of primary care in mental healthcare has increased in size & importance. In a general practice surgery, every third or fourth patient seen has some form of mental disorder (Cox et al, 2000). The important role of Primary Care in treating depression is well recognised. It is estimated that 9 out of 10 depressed persons are treated only in primary care (Goldberg & Huxley, 1992). For years, however, GPs have been criticised for failing to deal adequately with depression (Tylee & Jones, 2005). There are many reasons why depression is under-diagnosed and is undertreated in primary care. I do not believe that GPs are responsible for all these reasons. One professor of psychiatry suggested that all depressed patients requiring drug treatment should be under the care of a psychiatrist (Tylee & Jones, 2005). In my opinion, this is unrealistic and may disagree with the public wish. In 1990s, surveys showed that the public when suffering depression prefer to see their GP rather than a psychiatrist and to receive counselling or psychological therapy rather than drug treatment (Priest et al 1996). However, the resources to offer counselling & psychological therapy are limited in the NHS (Hollinghurst et al, 2005). It is estimated that in 2020, depression will take the second leading cause of morbidity worldwide. The role of primary care in treating depression is likely to grow and it is essential that primary and secondary care do every effort to face this growing challenge. Recently, there has been a growing interest in promoting early intervention in psychosis. Tylee & Jones (2005) state that only 50% of depressed people seek treatment, 50% are detected in primary care, 50% receive treatment & 50% complete treatment. If this is the case, I think our next challenge is: how to work together to promote early & effective intervention in depression? Dr Mamdouh EL-Adl, Psychiatrist MBChB, MSc, MRCPsych Princess Marina Hospital, Upton, Northampton, NN5 6UH Mamdouh.eladl@nht.northants.nhs.uk References: 1. Cox, J., Rayner, C., Tylee, A. & Hancock, C. (2000) WHO Guide to Mental Health in Primary Care. The Royal Society of Medicine Press Limited. Forward pp xi – xii. 2. Goldberg D, Huxley P. (1992) Common Mental Disorders. A biosocial model. London: Routledge. 3. Tylee, A., Jones, R. (2005) Managing depression in primary care. BMJ; 800-801. 4. Priest RG, Vize C, Roberts A, Tylee A (1996). Lay people’s attitudes to treatment: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ; 313:858 – 859 5. Hollinghurst S, Kessler D, Peters TJ, Gunnell D.(2005) Opportunity cost of antidepressant prescribing in England: analysis of routine data. BMJ; 330: 999 – 1000 Competing interests: None declared