Evolution of the management of depression in Spain from the psychiatrist'sperspective. A comparative analysis: 1997 vs 1982

The main problem of depression is not only the high prevalence of the disor der but also its serious consequences on the patient's quality of life and the associated social costs in terms of health care resource utilization an d productivity losses. In recent years, there has been a considerable impro vement in the knowledge of depression from the pathogenic, clinical and the rapeutic perspectives. The present study analyzes whether such advances are reflected in a positive evolution of the treatment of depression in Spain. To this effect we have contrasted the results of two socio-sanitary studie s published in this country: the White Book editions of 1982 and 1997 (WB82 and WB97, respectively). From the methodological perspective, the physicia n selection criteria employed were very uniform (structured questionnaires delivered to 128 (WB82) and 300 (WB97) randomly selected psychiatrists). Th e origin of patients consulting for specialized care has varied over this 1 5-year period. In effect, WB82 patients were essentially referred by friend s (87.5%) and from the primary care setting (44.546), whereas in the WB97 s tudy referral from primary care predominated (50.1%), followed by the patie nt's personal decision (24.80%). In turn, 40.7% and 51.7% of the psychiatri sts in WB97 respectively considered the diagnostic and therapeutic means av ailable in primary care to be insufficient. The priorities for improving pa tient quality of life, as reflected by both editions of the study, were the training of primary care physicians and the adequate provision of means in the mental health care centers. On the other hand, fewer problems for esta blishing a correct diagnosis were referred in the 1997 edition of the study (28.7%) than in 1982 (48.4%). In this sense, the main problem reported in WB82 was the lack of specialized training, whereas the masking of depressio n by some other disease process or symptoms was the main problem in WB97 (6 7.6% vs 21.1% according to WB82). The main symptoms upon which the diagnosi s of depression are based do not seem to have evolved much in the past 15 y ears. The most frequently cited manifestations were a worsening of mood, lo ss of interest and leisure capacity, sleep alterations and diminished vital ity. A comparative analysis of the therapeutic resources used was not possi ble, for prior to 1982 the only drugs available to physicians were the clas sical tricyclic agents and some MAO inhibitors; the selective serotonin reu ptake inhibitors (SSRls) - possibly the greatest advance in the treatment o f depression in these 15 years - had not yet been introduced. Nevertheless, it should be pointed out that 98% of the psychiatrists consulted in WB97 c onsidered pharmacologic treatment to be the most widely adopted form of man agement once depression has been diagnosed. (C) 2000 Editions scientifiques et medicales Elsevier SAS.