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Tylee and Walters1 make a good case for the development of a chronic disease model for the management of depression in primary care. Some of the figures that they quote deserve further comment. It is of concern that between 30 and 50% of patients treated for depression with anti-depressants in primary care do not show a response, while only 30% achieve remission. It is also of concern that only 10% of patients on antidepressants complete an adequate course. Finally, it is of concern that 76% of patients with residual symptoms relapse and that 12 months after diagnosis, 45% of patients with severe symptoms remain depressed, and 40% of patients have a relapsing remitting course over a decade. These facts clearly lead up to the statement that 40% of patients with depression are eligible for ‘step 4’ secondary care interventions.
It is interesting to see how these statements appear to be born out in practice. We work in a community mental health team with a catchment population of 60 000. Out of these, in 10 months 456 patients were seen in the clinic. Of these, 63 had a diagnosis of recurrent depressive disorder, 12 had psychotic depression, 28 had anxiety and depression, 73 were seen for depressive episodes, and 41 had bipolar affective disorder. Although it is clear that depressive illness makes up the bulk of the morbidity which we treat, there is clearly concern that these figures are unlikely to be equivalent to the 40% of depressed patients of our population who are eligible for secondary care services according to the figures quoted by Tylee, hence Tylee is right that many patients who are in fact eligible for treatment in secondary care are in fact treated in primary care.
How, then, are we to treat these patients adequately? Tylee is correct that a ‘chronic disease management model could be developed based on the ‘step care model’, but this must presuppose several developments. Key to such a model must be:
Some of us have experience of the development of guidelines for the treatment of depression in primary care, and for some, local guideline development has led eventually to national publication.2 We have also been involved in developing standards for the delivery of primary care psychiatry throughout Europe,3 which were commissioned by an umbrella organisation of patient groups in order that patients should know what to expect. However, we have also experience that guidelines do not, in themselves, change practice.
Tylee has himself led the way in developing training for primary care teams in the treatment of depression,4 but, despite this idea having been taken up by National Institute for Mental Health in England in various ‘trailblazer’ courses, we are unaware of any major national change in primary care treatment of depression as a result. This is almost certainly because such work is very labour intensive and commissioners have never, to our knowledge, provided the necessary investment. It must be born in mind that Rutz5 has shown that educational efforts of this sort must be delivered on an ongoing basis, rather than as a ‘one-off’ session.
We have designed a system6 whereby primary and secondary care collaborated together. A special group of experienced community psychiatric nurses were attached to both primary and secondary teams, so that they could provide a constant link between the professionals of both teams, thus providing the ‘consultancy’ to primary care requested by Tylee. Drinkwater7 has shown that such a system in Luton provided care which was valued by both GPs and patients, but this team has ceased to exist because of financial stringency. Consistency is needed for such efforts to be successful.
Finally, it is likely that modern concepts of the depression/bipolar spectrum of illness will lead to a change in the stepped care model of depression itself. It is becoming apparent that depression itself is not one illness, but a number of illnesses within the ‘bipolar spectrum’.8 Such illnesses include both unipolar depression, depression and anxiety, and bipolar illness, including both bipolar I and bipolar II disorder. There are indications emerging that many patients who previously might have been interpreted as ‘recurrent depressive disorder’ or ‘resistant depression’ are in fact cases of bipolar II illness. This will have important implications for the choice of treatment. For example, recent discussions regarding increased suicidality of patients on venlafaxine9,10 have suggested that this would be a medication which is not the best choice for bipolar II patients, because it may well induce mixed affective states.11 Some mood stabilisers may become important choices in the treatment of such patients. In one study of 300 consecutive patients in an office-based private psychiatric clinic in Italy, 26% were diagnosed with bipolar II, less than 1% bipolar I, 28% depression and anxiety, 9% recurrent depression, and only 4% with major depressive episodes.8 If this is the case, we may well be mis-identifying many of our bipolar II patients as being unipolar, thus in part explaining some of the disappointing outcome figures quoted by Tylee. We are currently re-assessing our patients in our community mental health team in order to see if this possibility is true.12
Such issues wil require a greater sophistication from GPs as regards diagnosis and treatment of depression.
Given all these issues, it should be feasible to develop a primary care chronic disease management model for treating depression. Crucial to this remains time which can be given to careful effort in the assessment of patients, adequate follow up, including help from nurses deployed to primary care, and the availability of GPs with a special interest in mental health. Such GPs could perform the intermediate role which office-based private psychiatrists provide in Europe, dealing with the patients which Tylee describes as ‘falling between steps 3 and 4’. Proper training is required for such doctors, which should be jointly developed by the two Colleges of Psychiatrists and General Practitioners.