In terms of years of life lived with a disability (YLD), of the ten leading causes of disability worldwide in 1990, five were psychiatric conditions: major depressive disorder, alcohol abuse, bipolar disorder, schizophrenia, and obsessive compulsive disorder. Depression alone was responsible for one in ten YLDs worldwide.

As the report suggests, ́the burden of psychiatric conditions has been heavily underestimatedî. Altogether, psychiatric and neurological conditions accounted for 28% of all YLDs. While the burden was greatest in developed countries, the pattern was similar in developing countries as well. Perhaps more significantly, projections to 2020 rank major depressive disorder as second behind ischaemic heart disease in the 15 leading causes of disease burden worldwide.

In the Australian context it is estimated that at least 15% of the population will suffer from significant depression at some stage of life, and at any one time about 3-5% will have significant symptoms. In general practice, 5% of patients have major depression and another 5% have a less severe form of this illness (Mitchell:1998). The depression seen in general practice often coexists with physical disorder, or may present with physical rather than psychological complaints.

Depressed patients experience more impairment in quality of life than patients with common medical disorders, and they are also higher consumers of health care (Lloyd 1995). In direct monetary terms, it is estimated that in 1993-94, $521 million was spent in health system costs associated with depression in Australia (Mathers:1998). However, the true burden in terms of personal suffering and reduced quality of life, is difficult to quantify. Depression impacts not only on the individual, but also on their family, friends colleagues and society in general.

The recently published Commonwealth Department of Health and Aged Care National Health Priorities Report (1999) on depression provides an excellent profile of prevalence, management and future initiatives to deal with the problem. As the report suggests, interventions to deal with depression are possible across the entire continuum of health care, from promotion, prevention and early intervention through to treatment and maintenance care. While the effectiveness of many prevention and promotion activities is still to be demonstrated, the recognition of depressive symptoms along with co-morbid conditions is of vital importance, not only in relation to major depressive disorder, but also attempted and completed suicide. While the intervention of specialist mental health services may be necessary in more complex cases, GPs are in a central position to recognise and treat early depressive symptoms and disorders.

Barriers to treatment

A recent national survey of public preferences revealed that the views of most respondents regarding treatment for depression differed from those of most clinicians (Jorm et al 1999a). GPs and counsellors were rated more highly as sources of help than psychiatrists and psychologists. Many standard psychiatric treatments such as antidepressants, ECT and admission to a psychiatric ward of a hospital were more often rated as harmful than helpful, while some non-standard treatments were rated highly (eg. increased physical or social activity, relaxation and stress management, and reading about people with similar problems). Even vitamins, herbal remedies and special diets were rated more highly than antidepressants.

This mismatch of public and professional views may have several sources. Many people are unaware of depressive symptoms, are afraid of the potential stigma of being labelled as depressed, and hope that their symptoms will 'pass'. Frequently, consumers of mental health services are unaware of the choice of interventions available, and the different types of treatment likely to be offered by GPs, psychiatrists, psychologists, and counsellors.

Many current research studies in this field now suggest that both antidepressant medication and psychological interventions can produce effective outcomes when used together or separately. While the choice of treatment should be an informed collaborative process between providers and consumers, the costs of psychological therapies that can be long term are prohibitive for many people. As a consequence, the burden of care often rests with GPs. Despite recent changes to Medicare, the time taken to provide the full range of treatments for a complex depressive disorder is still not adequately reimbursed to GPs.

Following the first national workshop on depression held in Canberra in late 1997, a framework for a three year plan of action (1999 - 2001) to improve health care practices and health outcomes for depression was established. The national depression action plan involves the development of strategies in the areas of promotion, prevention, early intervention, management and treatment, community education and data needs. Several initiatives have already been started, including the development of guidelines for the treatment of depression in young people.

Other areas of concern identified at the workshop for further research include:

• The link between depression and suicide in older men.
• Depression in older people in residential care.
• Potential psychosocial treatments and their evaluation.
• Integrated care models best suited to different types of depression.
• The efficacy of self-help treatments, such as support groups and St John's wort.
• Treatments for dysthymia and cyclothymia.
• Types of psychotherapies best suited to depressive disorders across the lifespan.

Tim Armstrong is the NRDGP's mental health project officer.

Copies of the Health Priorities Report on Depression are available from the Department of Health Care Publications Unit in Canberra. Tel: (02) 6289 5811 or through Tim Armstrong at the NRDGP.

References available on request.

This page was last built on 21/03/2003. It was originally posted on 28/2/2000; 8:55:42 PM.