The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities

Background This study reports the responses of patients with confirmed depr essive illnesses to different treatments in the WHO Mental Disorders in Gen eral Health Care study, conducted in 15 cities around the world. Aim. To discover how depressions recognized by the doctor compare with unre cognized depressions, both in terms of the initial illnesses and their outc omes, and to compare the outcomes of those depressions treated with antidep ressants with those treated with daytime sedatives. Method. The design of the study was naturalistic, in that physicians were f ree to treat patients however they wished. Patients with confirmed depressi ve illnesses were assigned to four groups: treatment with an antidepressant ; treatment with a daytime sedative (usually a benzodiazepine); patients re cognized as having depression by the physician but were not offered drug tr eatment,. and patients unrecognized as having depression by their physician . Results. Both groups receiving drugs had illnesses of equal severity, were demographically similar to one another, and had similar previous histories of depression. Those receiving antidepressants had significantly fewer over all symptoms and fewer suicidal thoughts than those treated with sedatives. By the end of one year, differences between the groups had disappeared: pa tients not given drugs had milder illnesses but did significantly better th an those receiving drugs, both in terms of symptoms lost and their diagnost ic status. Unrecognized depressions were less severe than recognized depres sions, and had a similar course over the year. Conclusions. Patients receiving antidepressants were better in terms of ove rall symptoms and suicidal thoughts than those treated with sedatives at th ree months, but this advantage does not persist. Depression emerges as a ch ronic disorder at one-year follow-up - about 60% of those treated with drug s, and 50% of the milder depressions, still meet criteria for caseness. The study does nor support the view that failure to recognize depression has s erious adverse consequences, but, in view of the poor prognosis of depressi on, measures to improve compliance with treatment would appear to be indica ted.