Recent developments and controversies in depression

Abstract

It rather makes me despair of the future of psychiatry to see such narrow, reductionist reliance on biological and cognitivist formulations throughout the Seminar by Klaus Ebmeier and colleagues (Jan 14, p 153).1Ebmeier KP Donaghey C Steele JD Recent developments and current controversies in depression.Lancet. 2006; 367: 153-167Summary Full Text Full Text PDF PubMed Scopus (321) Google Scholar First, they give the criteria for depression according to the 10th revision of the International Classification of Diseases (ICD10), but does that settle the question of whether this is always a timeless, free-standing, coherent, universally valid, pathological entity with a life of its own? Ebmeier and colleagues do not even mention possible confounding by everyday misery or unhappiness, as if the discourse on depression was self-evidently a domain apart. This is ridiculous: what is called “depression” and what is called “unhappiness” are determined as much outside the clinic, in open society, as within it. People take adversity to the doctor when once western culture encouraged greater stoicism and self-sufficiency, or when the vicar or a wise old neighbour were on hand to help. Going to the doctor changes the language applied to one's problems, and thus what follows. We are in an age of the medicalisation of unhappiness. Ebmeier and colleagues do not justify their assertion that one in six of the population will have major depressive disorder during their lifetime, and that up to 75% of these will not be known to health services. This is a modern myth: in a WHO study in 15 cities around the world, recognition of “depression” by doctors made no difference. Indeed those who were not recognised as depressed did slightly better than those who were.2Goldberg D Privett M Ustun B et al.The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities.Br J Gen Pract. 1998; 48: 1840-1844PubMed Google Scholar This finding surely suggests circumstance-related distress, not depression as psychiatric disorder. The myth was promoted in the UK in the late 1990s by the Defeat Depression campaign of the Royal Colleges of Psychiatrists and General Practitioners, but, again, was confounded in its own precampaign survey of lay attitudes.3Priest R Vize C Roberts A Roberts M 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: 858-859Crossref PubMed Scopus (339) Google Scholar Ebmeier and colleagues see patients' concerns about antidepressant side-effects (expressed by 78% of the 2003 subjects in the Royal Colleges survey) as reflecting an unnecessary “moral panic”. As discontinuation reactions emerge as a distinct clinical problem, is this conclusion wise? Ebmeier and colleagues' assertion that “their effectiveness…make[s] them the likely choice for most patients” goes well beyond the evidence base, which is distinctly thin—particularly in a primary-care setting where most prescribing takes place.4Moncrieff J The anti-depressant debate.Br J Psychiatry. 2002; 180: 193-194Crossref PubMed Scopus (43) Google Scholar This is to offer false confidence to family doctors who tell the mixed bag of patients gathered under the rubric of “depression” that they need antidepressants to correct a “chemical imbalance”. So too with primary-care practices offering counselling to such patients. They get better at the same rate as those who continue to see their family doctor only.5Friedli K King M Lloyd M et al.Randomised controlled assessment of non-directive psychotherapy versus routine general-practitioner care.Lancet. 1997; 350: 1662-1665Summary Full Text Full Text PDF PubMed Scopus (96) Google Scholar I declare that I have no conflict of interest.