The treatment of depression in clinical practice : a public health perspective

Abstract

Depression is a major public health problem with a reported point prevalence of 5%. Depressive illness causes great suffering and disability. Effective treatment with antidepressant drugs has been available for more than 40 years. Although there has been an increase in the use of antidepressant drugs, the prevalence of their reported use among depressed individuals is between 7% and 19.7%. The principal aim of this project was to investigate the evidence for the rational use of antidepressant medication for the treatment of depression in the general population.

Information about the use of antidepressants and other medication was collected from an individual-based prescription database. All the individuals included in the study were selected from this prescription database, and they were representative of the population in Jämtland county, Sweden. Medical records were used to identify indications for and the effect of antidepressant medication. The suicide cases and the controls were obtained from Statistics Sweden and the population census register, respectively.

Psychiatric records were used to obtain information about received psychiatric care. Forensic toxicological analysis of the suicide cases was retrieved from the National Board of Forensic Medicine to determine to what extent the purchased medication was in the blood stream at the time of death. For a screening of depression, a questionnaire was mailed and individuals who screened positive were interviewed face-to-face for a psychiatric diagnosis of depression. The data from the prescription database was compared with the other sources of information.

The incidence of dispensed antidepressant drugs doubled between 1991 and 1996. In 995 and 1996, the majority of dispensations were serotonin reuptake inhibitors (SSRIs). More than onethird did not renew their dispensation regardless type of antidepressant. For the SSRIs, more often than for the tricyclic antidepressants (TCAs), recommended doses were prescribed. Significantly more SSRI than TCA treatments continued for at least 6 months. Depression was the indication for 82% and 23% of the SSRI and TCA treatments, respectively. Twice as many SSRI-as TCA-treated depressive cases were successful. Suicide cases were dispensed drugs twice as often as the controls, and three times more suicides received psychiatric care and half of them were clinically depressed. During the 3 months prior to death 36% of the suicide cases were dispensed a psychotropic and 12% an antidepressant. About one-third of the psychotropic drugs were retrieved in post-mortem toxicology. One-quarter of the 4.5% depressed individuals in the population at study were dispensed antidepressant medication, which is a 1.2% prevalence rate for acute therapy. The prevalence rate of continuation therapy was 1.3%.

In conclusion, almost every 20th individual was currently depressed but not more than one in four was prescribed an antidepressant. Modem antidepressants were mainly prescribed for the treatment of depression at recommended doses and more often, compared to the old antidepressants, provided a successful outcome. Few, if any, suicides were taking a course of antidepressants at the time of death. The increased use of antidepressants has been an improvement which has been of benefit for people afflicted with depression and may have prevented a number of suicides.