1. Depression: An overview Most cases are managed in primary care Role of secondary care largely applies to severe and complex cases Secondary care would be swamped and unable to cope if referral threshold decreased Dysthymia Major depressive disorder – 1-week prevalence rate 2% 1 1. McManus S, et al (2007) Adult psychiatric morbidity in England, 2007: results of a household survey. Leeds:

2. Prevalence of depression in England (2007) Prevalence of depressive episode in last week Adult Psychiatric Morbidity in England 2007 NHS information centre for health and social care 2009 Depression is common – approximately 2% of men and 3% of women in England are suffering from depression in a given week

3. Health care services used for depressive episode 1 1.Adult Psychiatric Morbidity in England 2007 NHS information centre for health and social care 2009 2.Ostler K et al. B J Psychiatry 2001;178: 12-17 7.2% of consecutive adult attendees in general practice had a depressive disorder. 2

4. Major Depressive Disorder: Definition Characterised by single or recurrent major depressive episodes (MDEs) 1 MDE: >2 weeks involving 5 or more of 9 symptoms – depressed mood – loss of interest or pleasure in nearly most activities – appetite or weight change – sleep disturbances – agitation or retardation – tiredness – poor concentration – feelings of worthlessness, hopelessness or inappropriate guilt – suicidal ideation 1. DSM-IV 4th Revision of the American Psychiatric Association’s Diagnostic and Statistics Manual (American Psychiatric Association 1994).

5. MDD: Course and Outcome 1 in 5 people suffer depression during their life 1 1/3 recover within 3 months High risk of chronicity 2 Wide range of costs – Impaired functioning – Secondary morbidity – Mortality Approx 50% of patients who experience 1 st episode will relapse within 5 years 3 1 Depression Alliance. One in five factsheet. Available online at http://www.depressionalliance.org/publications/da_one_in_five.pdf.http://www.depressionalliance.org/publications/da_one_in_five.pdf Accessed on 07 September 2010 2 Spijker J (2002) Brit J Psych 181;208-213 3 Mueller et al. (1999) Am J Psychiatry 156 (7): 1000

6. Keller MB, Boland RJ. Biol Psychiatry. 1998;44(5):348-360. % of Patients Expected to Experience Recurrence Within 5 Years from Recovery of Previous Episode Recurrence Becomes More Likely With Each Episode of Depression First Episode Second Episode  Third Episode ≈50% ≈70% >90% 020406080100

7. Depression - Major Cause of Disability Worldwide: DALYs (2000 and 2020) DALYs=disability-adjusted life years. 1. WHO. The World Health Report 2001: Mental Health: New Understanding, New Hope; 2001. 2. Murray CJL, Lopez AD, eds. The Global Burden of Disease; 1996. Rank 2Perinatal conditionsUnipolar major depression 3HIV/AIDSRoad traffic accidents 4Unipolar major depressionCerebrovascular disease 5Diarrheal diseasesChronic obstructive pulmonary disease 2000 1 2020 (Estimated)2 Lower respiratory infectionsIschaemic heart disease1

8. Goals of treatment 1.Kupfer DJ. J Clin Psychiatry 1991;52 (5, Suppl): 28–34 2.Frank E et al. Arch Gen Psychiatry 1991;48:851-855 Remission, recovery, relapse, and recurrence were first defined by a working group in 1991. 2

9. Definitions of response and remission Frank E et al. Arch Gen Psychiatry 1991;48:851-855 Response and partial remission were defined as an improvement of sufficient magnitude that the individual is no longer fully symptomatic (i.e. no longer meets syndromal criteria for MDD) but continues to evidence more than minimal symptoms. Response is commonly operationalised as a 50% reduction in HAMD or other symptom scale score.

10. Definitions of response and remission Frank E et al. Arch Gen Psychiatry 1991;48:851-855 Remission was defined as a period during which improvement of significant magnitude is observed that the individual is asymptomatic i.e. no longer meets syndromal criteria for MDD and has no more than residual symptoms. Remission was operationalised as a HAMD-17 score of 2 weeks and < 6 months. Recovery occurs when remission exists for > 6 months.