outcome of major depression in primary care:

O r i c i n a lD a D e r s The effectsof detectionand treatment on the outcomeof major depressionin primary care: a naturalistic studv in 15 cities D...
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O r i c i n a lD a D e r s

The effectsof detectionand treatment on the outcomeof major depressionin primary care: a naturalistic studv in 15 cities D A V I DG O L D B E R G

the poor prognosis of depression, measures to improve compliance with treatment would apoear to be indicated.

MARTIN PRIVETT B E D I R H A NU S T U N GREG SIMON M I C H A E LL I N D E N SUMMARY Background. Thisstudy repofts the responsesof patients with confirmed depressive l/inesses to different treatmentsin the WHO Mental Disordersin GeneralHealthCare study,conducted in 15 citiesaroundthe world. Aim. To discover how depressionsrecognizedby the doctor compare with unrecognizeddepressions,both in terms of the initial illnessesand their outcomes,and to compare the outcomes of those depressianstreated with antidepressantswith those treatedwith daytimesedatives. Method. The design of the study was naturalistic,in that physicians were free to treat patientshoweverthey wished Pattents with confirmed depressivel/lnesseswere assigned to four groups.treatmentwith an antidepressant,treatmentwith a daytime sedative (usuallya benzodiazepine);patients recognized as having depression by the physician but were not offered drug treatment,and patients unrecognizedas having depression by their physician Flesuffs. Both groups receiving drugs had illnessesof equal severity,were demographicallysrmilarto one another,and had similarprevioushistoriesof depression.Thosereceivingantidepressantshad significantlyfewer overall symptomsand fewer suicidalthoughtsthan thosetreatedwith sedatives.By the end of one year, differencesbetweenthe groups had disappeared; patientsnot given drugs had milder illnessesbut did significantly better than thase receivingdrugs,both in terms of symptoms lost and their diagnosticstatus. Unrecognizeddepressions were less severethan recognizeddepressions,and had a similar coLtrseover the year. Conclusions. Patientsreceivingantidepressantswerebetterin terms of overall symptoms and suicidal thaugllts than those treatedwith sedativesat three months,but thisadvantagedoes not persist.Depressronemergesas a chronicdisorderat oneyear follow-up * about 609,oof those treated with drugs, and 50?,"of the milder depressions,still meet criteriafor caseness The study does not support the view that failure to recognize depressionhas serious adverseconsequences,but, in view of

prollssor ol' ps1'chia1r.1', Sir Dat,id Cioldberg.FRcf,.IrR.,ps).:h. lnstitute ol [ ) s l c l r i a t r l ' l., o n d o n .N , {l ) r i ! e t t . I u s ( s, l a t i s t i c i ( r na.n d B U s t u n .p r o j e r ' t t l i l e c t o r .\ ' l c n t a l H e a l t h D i v i s i o n .W o r l d H e r l t h O l g a n i s a l i o n(,- i e n e v a ( i Simon. rto. i'ti,lt.psvchiirtrist,(iroup I'.lcalth(io-opcrativeol PuScl S o u n d ,S e a t t l e l.. l S A . N ' lL i n d e n .r , l r \, t D .p r o l . c s s oorf p s y c h i a t r l .F r c c t l n i r e l s i t \ o 1B e r l i n . ( . ) c l n r a n y . S u b n r i t t e c5l : J a n u a r 1l 9 9 8 : f i n a l a c c c p t a n c e8:. l n l y 1 9 9 8 . .t. Brili.slr.lrtttrtrttlrtf Gencrut Pn rclir-n,r and, having recogrriz-ed it. for failing to treal it cucrgcl.icalll' enough.2H()\\'c\er. thc significanccof unrccognizcd dcprcssionin prirnalv care is cquir'ocal.and studies:rt single centrcsr'ahave failed to lind irn associationbetscen recrrgnition and outcolrc. perlrapsbccauserecognition does not imply opt.imaltrcatment.One tlS strrd)srandornizcddcprcssedpatients 'r.rsual 'rnulti-tirceted to care' or cnhancedor clre' (N'lC).The latter involved gleater frequencl.'o1'visits. t"r,ou'ith a psychiatrist.In those rvith nrajor dcprcssion,I\4(l ploduccd qrcatcr cornpliancc u'ilh treatrnent, u'ith paticntsratinq anti.leand grcatcrsetist-action pressantsas r)x)l'ehelpful antl resultlngin greatt:rsvrr)ptonrreriucticu. Ht>ueler.in minor depression, N'lOprrxluccdbettercompiiancebut not bcttt'roulccuncsor sertisfaction. .l-hc presentpapcr studics lhe natural history o1'crrnfirnrcd dt-pressionsthat u'ere unclctectc'dby thr: doctor, as u'ell as cL)ntrzrstingthr' courseof those cpisoclesof ciepressiontreatedusinq 'l rl'ith thosc tre:rtcdusins sedatir es. hc studt' u'as antidepressants naturatistic,in that do!'torsivere l'rec to trcat pirticntshoucvcr thev ni"hrd. I'he design ensuredthzrtthc d!'pressiveillnesses scen \\,ercrepresentativc o1'tht>scoccurrirrgin qcncralpracticc, irnd doctorsdid not knoq'rihcthcr ()r not a paticntthcv had sccn had bet'n idr-ntiflt'clbv the reseuch intervit-il'as e caseof depressive illness.Irr spitet>t'el idenceof elficacy in controlledclinical trials,"x tht:rr' is lack ol' iulirrrn:ttion on efficicnct'l thc qr-restitx heing rvhcther,under routine clinical treatrncntcrrnditions,anliof tltcse'disordeprc'ssar)ts can be shorvnto influence the cr.lurscd e r s . S o r n er e c e n t s t u d i e s h a v e f a i l e c lt o s h o r r 'a r l i f f c r e n c e b e t u , e c na n t i d e p r c s s a n tasn d p l : r c e b < > s . esrh( i' l e o t h c r s h a r e and olhcrs still shou'n cqr.ralcffccts rl'ith benzodiazcpincs,ll-r3 herveshoun that psychological treatrnelltsarc cclurrllveflec ti\,e.1'll:(bntrolleJ studies.thcrel-rrre, need to be suppl!'rncnt\r!l b y c p i d c r n i o l o g i c i lsl t u d i c s< r nt h c p r o v i s i o r ta n r l ( ) u t c o r r c\ , i treatrnent.In thc presentstudr'.(iPs lrequcntll' r!-porl.d cr)ufl sellingas one of the lreiltnrentsgiven to the patientseitheron its o\\/nor in cornhinationq,ith dlug tlc:ilmcut.bur the inr tstigrrtols -l'hosc patients had no control over \\ihat $as mcant bv this tcnn. 'no u'ho did not reccive a prescription t'ere therc-forecallt'd ',r'hether drugs', or rlot thev r.r'crealso reportedas hat'irrgreeeir,eci counselling. 'fhc ainr of lhe prcscntstudr,u'asto r utptomr on the CIDI, and lt'w'els\:rnptomson thc Gllt]. l,ength of prcviouscpisocle\\'as {hc sarnc for all rccognizcd patients(over 90"1'ol the recognizedgroups rc-portedpreri,.rus episodeslastinglonger than one rnonth),but rvaslr'ssIor unrec,.rgnizcd patients(significantlrlcucr 18.i..5',/.: l.: = 22.8:d"i'.= 2: P = 0.001 h:id such cpisodcs't.Unrecogniz-edpalicnls yt'ctc .rlsr't youngerand had their s1'mptonrs for less tinre than rectrguizcd 'I'hey patients. also had less sclere illnessesthan recogniz-etl paticntsq,ith ltN,er OII)l svrnptonrs('l'able 2). lou'er ()llQ scoles ('l-ablc 3), lon'er scoresrelating to suicide ('l'able -5),and ioit,cr disabilitl-scoresat l:aseline(7.7 i'crsus9.6: t = 2.1: P = 0.035). I)atientssaid the1.t(x)kthe drugs li>r \\,idelv r,nn'ing lengthsol tirne:for anticleplessants,2l {25.31n)tclohthernfor lessthan orrc rnonth.:rnd lhc nean lcnqth o1-tirne rr,as l{).7 q'eckst and lol l&il

D GolcJberg. M Privett"B Ustun,er rl/

Original papers

Table 1. Baselinecharacteristics of live groupsof depressedpatients,comparedusingchi-squaredand Student'st-test.(NS = not significant.) Group (n = B5) Antidepressants Sedativesin = 711 No pschoactive drugs(n = 161) Unrecognized depression(n = 323) Antidepressants versussedatives(1 versus2) Drugversusno drug{1+2versus3)

Mean

Male

(")

Married (T")

Timesincefirst onset(years)

Proportionwith previousepisode{%)

42.6 43.2 393 38.1 NS

20.0 169 29.2 24.8 NS c2= 4.9

48.2 54.9 56.8 585 NS NS

12.4 13.1 8,4

492 39.2 36.9 38.3 NS NS

r - , Aa

D-nnaAa

P = 9.9660 Fecognizedversusunrecognized (1+2+3versus4)

t-rqa P = 6 gg4t'

NS i-QQ

P = 9.gg1t' NS

NS

NS Plnorc likely,to still tre sLri'l'erius front deprcssion.l'hc facr at the one-\,eartollou,-up - althoughthoscnot fr)llo$'ce up l\'ere that almost half of thc-unrccognizc.dcases l{8.Jal.) rlcre srill in no n,ervdilferent front those u'hr.lseresults u,e report herc. eithel casesof depressionor c.rsesof anolher mcntal disordcr, l''inalll', tht'rc ncrc largc ccntrc clifle'rcnccsin t.hcdrugs prcscrihcd suggeststhat cflitrts to iurpr,tvcthe abilitl of'doctOrst-odcrcct for depression-In sornecentres,antidepressants n.ere harcllyever clepressive illness are r.vorthwhile, although the qenerzrllr,, goocl uscd,u'hilc in othcrs.cia_1timc scdzrtilcs u crc avt:idcd. oulc()lncJor ihe rlholc group suggcststhat this cantri>! bc thoui:ht A g a i n s t t h e s c s h o r t c o n r i u g st,h e r e a r e s o r n eu n d o u b t e d a maior Dloblem. British .loumal of (ieneral Praclice, December 1998

llt4J

D Goldberg.M Privett.B Ustun,er r,l/ Drttgs ,-ersus ttct drug,s I)eprcssivepaticnts \r'ho wcrc not trcatcd n,ith drugs h:id lor.vcr (iHQ scoresand feuer depressives)'lnptc)msreported on the (llDI than thosegivcn drues.'l'hey also had sirnilarnumhersof disabilitr,davs.Hoq'eler. ovtr thc.tbllorving1'earthe changcsin the groupsu'ere sirnilar.and the analvseso1'covariance fbileclt shor.r'that thosc r.r'ilhoutdnrgs u,ergat any disadvantilgc. J'his in n() \\',t)' n)eansthat drugs irre ullr)ecessitrv, but w'e ha\,e seenthat [hcv appcar to be being given to pnticntsu,ith the most sevcrcillncsscs.both irt terms of'thcir curren( statusand thcir prcvious 'l'he experienceoI i]lness. linding thal patierrtsr.r,ithless severe illncsseshad ir bcttcr outcolne should causeno surnrise.thc more important point is that there appL-ared to bc no long-tt'nn penalties for failinu to prescribeps1,'cht>iropics for lhose q'ith iess sevcreillne:sscs. A nt i tl ep rt: ssu t t.\ ver s trs dq t' t i m e sedat i ves 'l-he clataindicate that those dc'pressionstreirtedl'ith rrntid!-pressantshad 1'e*cl gc:neralps1,'chiatric svrnpturs, erndscorcd lcss on iterns dealins rl,i1hsuic'idalideas at thrce months I'ollori'-up, rtheu contparedu'ith those trcated sedatives.At one )'ear. "lith difl'ercncesbctrvecnpaticnts trc:r1cd*'ith thc tr,o classcsof drug $'L-reno longer significant. Hou'evt'r, our findings need to be consicleredin the context of the str,rdldesign - ue icientified patienl.son an'inlentiorl io trcat'biisis.and c

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