Long-Term Follow-up of Depression Among Patients in the Community and in Family Practice Settings

,

Original Research

Long-Term Follow-up of Depression Among Patients in the Community and in Family Practice Settings

J Fam Pract. 2000 December;49(12):1113-1120

References

1. Froom J, Aoyama H, Hermoni D, et al. Depressive disorders in three primary care populations: United States, Israel, Japan. Fam Pract 1995;12:274-78

2. Ormel J, VonKorff M, Ustun TB, et al. Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 1994;272:1741-48

3. Robins LN. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984;41:949-58

4. Williams JW, Kerber CA, Mulrow CD, et al. Depressive disorders in primary care: prevalence, functional disability, and identification. J Gen Intern Med 1995;10:7-12

5. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA 1989;262:914-19

6. Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992;14:237-47

7. Coryell W, Turvey C, Endicott J, et al. Bipolar I affective disorder: predictors of outcome after 15 years. J Affect Disord 1998;50:109-16

8. Paykel ES. Historical overview of outcome of depression. Br J Psychiatry Suppl 1994;26:6-8

9. Angst J, Preisig M. Course of a clinical cohort of unipolar, bipolar and schizoaffective patients: results of a prospective study from 1959 to 1985. Schweiz Archiv Neurol Psychiatr 1995;146:5-16

10. Piccinelli M, Wilkinson G. Outcome of depression in psychiatric settings. Br J Psychiatry 1994;164:297-304

11. Lavori PW, Keller MB, Mueller TI, et al. Recurrence after recovery in unipolar MDD: an observational follow-up study of clinical predictors and somatic treatment as a mediating factor. Int J Methods Psychiatric Res 1994;4:211-29

12. Blacker CV, Clare AW. Depressive disorder in primary care. Br J Psychiatry 1987;150:737-51

13. van Weel-Baumgarten E, van den Bosch W, van den Hoogen H, et al. Ten year follow-up of depression after diagnosis in general practice. Br J Gen Pract 1998;48:1643-46

14. Watts CA. Depressive disorders in the community: the scene in Great Britain, 1965. J Clin Psychiatry 1984;45:70-77

15. Klinkman MS, Schwenk TL, Coyne JC. Depression in primary care—more like asthma than appendicitis: the Michigan Depression Project. Can J Psychiatry 1997;42:966-73.

16. Lin EH, Simon GE, Katon WJ, et al. Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. Am J Psychiatry 1999;156:643-45

17. Ormel J, Oldehinkel T, Brilman E, et al. Outcome of depression and anxiety in primary care: a three-wave 3 1/2-year study of psychopathology and disability. Arch Gen Psychiatry 1993;50:759-66

18. Kupfer DJ. Long-term treatment of depression. J Clin Psychiatry 1991;52 (suppl):28-34.

19. Prien RF. Efficacy of continuation drug therapy of depression and anxiety: issues and methodologies. J Clin Psychopharmacol 1990;10:86S-90S.

20. Tan RS, Barlow RJ, Abel C, et al. The effect of low dose lofepramine in depressed elderly patients in general medical wards. Br J Clin Pharmacol 1994;37:321-24

21. Thompson C, Thompson CM. The prescribing of antidepressants in general practice: II. A placebo-controlled trial of low-dose dothiepin. Human Psychopharma 1989;191-204.

22. Wernicke JF, Dunlop SR, Dornseif BE, et al. Low-dose fluoxetine therapy for depression. Psychopharmacol Bull 1988;24:183-88

23. Paykel ES, Freeling P, Hollyman JA. Are tricyclic antidepressants useful for mild depression? A placebo controlled trial. Pharmacopsychiatry 1988;21:15-18

24. Hollyman JA, Freeling P, Paykel ES, et al. Double-blind placebo-controlled trial of amitriptyline among depressed patients in general practice. J R Coll Gen Pract 1988;38:393-97

25. Mynors WL, Gath D. Predictors of treatment outcome for major depression in primary care. Psychol Med 1997;27:731-36

26. Scott AI, Freeman CP. Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks. BMJ 1992;304:883-87

27. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996;53:913-19

28. Pincus T, Stein CM. Why randomized controlled clinical trials do not depict accurately long-term outcomes in rheumatoid arthritis: some explanations and suggestions for future studies. Clin Exp Rheumatol 1997;15 (suppl):S27-38.

29. Wolfe F, Hawley DJ, Cathey MA. Clinical and health status measures over time: prognosis and outcome assessment in rheumatoid arthritis. J Rheumatol 1991;18:1290-97.

30. de Abajo FJ, Rodriguez LA, Montero D. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study. BMJ 1999;319:1106-09

31. Po AL. Antidepressants and upper gastrointestinal bleeding. BMJ 1999;319:1081-82

32. Mackay FR, Dunn NR, Martin RM, et al. Newer antidepressants: a comparison of tolerability in general practice. Br J Gen Pract 1999;49:892-96

33. Sampson E, Warner JP. Serotonin syndrome: potentially fatal but difficult to recognize. Br J Gen Pract 1999;49:867-68

34. Tondo L, Laddomada P, Serra G, et al. Rapid cyclers and antidepressants. Int Pharmacopsychiatry 1981;16:119-23

35. Classification committee of WONCA. ICHPPC-2-defined (International classification of Health Problems in Primary Care). 3rd ed. Oxford, England: Oxford University Press; 1983.

36. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition. Washington, DC: American Psychiatric Association; 1994.

37. Van Londen L, Molenaar RP, Goekoop JG, et al. Three- to 5-year prospective follow-up of outcome in major depression. Psychol Med 1998;28:731-35

38. Widmer RB, Cadoret RJ. Depression in primary care: changes in pattern of patient visits and complaints during a developing depression. J Fam Pract 1978;7:293-302

39. Kua EH. The depressed elderly Chinese living in the community: a five-year follow-up study. Int J Geriatr Psychiatry 1993;8:427-30

40. Kivela SL, Kongas SP, Kesti E, et al. Five-year prognosis for depression in old age. Int Psychogeriatr 1994;6:69-78

41. Sharma VK, Copeland JR, Dewey ME, et al. Outcome of the depressed elderly living in the community in Liverpool: a 5-year follow-up. Psychol Med 1998;28:1329-37

42. Angst J, Merikangas K. The depressive spectrum: diagnostic classification and course. J Affect Disord 1997;45:31-39

43. Eaton WW, Anthony JC, Gallo J, et al. Natural history of Diagnostic Interview Schedule/DSM-IV major depression: the Baltimore Epidemiologic Catchment Area follow-up. Arch Gen Psychiatry 1997;54:993-99

44. Coryell W, Endicott J, Keller MB. Predictors of relapse into major depressive disorder in a nonclinical population. Am J Psychiatry 1991;148:1353-58

45. Logan WPD, Cushion A. Morbidity statistics from general practice. Vol 1. London, England: Her Majesty’s Stationary Office; 1954.

46. Copeland JR, Dewey ME, Griffiths-Jones HM. A computerized psychiatric diagnostic system and case nomenclature for elderly subjects: GMS and AGECAT. Psychol Med 1986;16:89-99

47. Nagel R, Lynch D, Tamburrino M. Validity of the medical outcomes study depression screener in family practice training centers and community settings. Fam Med 1998;30:362-65

48. Andrews G, Anstey K, Brodaty H, et al. Recall of depressive episode 25 years previously. Psychol Med 1999;29:787-91

49. Wright AF. Should general practitioners be testing for depression? Br J Gen Pract 1994;44:132-35

50. Van Weel C. Validating long term morbidity recording. J Epidemiol Community Health 1995;49 (suppl):29-32.

51. Merikangas KR, Wicki W, Angst J. Heterogeneity of depression: classification of depressive subtypes by longitudinal course. Br J Psychiatry 1994;164:342-48

52. Murphy JM, Olivier DC, Sobol AM, et al. Diagnosis and outcome: depression and anxiety in a general population. Psychol Med 1986;16:117-26

53. Hagnell O, Lanke J, Rorsman B. Suicide and depression in the male part of the Lundby study: changes over time during a 25-year observation period. Neuropsychobiology 1982;8:182-87

54. Lloyd KR, Jenkins R, Mann A. Long-term outcome of patients with neurotic illness in general practice. BMJ 1996;313:26-28

Our inclusion criteria were: original longitudinal follow-up studies in English of adult populations in the community or primary care with at least 25 patients in the follow-up. In the included studies diagnosis of depression was according to: the International Classification of Primary Care or the International Classification of Health Problems in Primary Care (ICHPPC-2) in general practice studies; the Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition, third edition revised, or fourth edition; the research diagnostic criteria (RDC) or immediate predecessor (St Louis); or the International Classification of Diseases (ICD)-9th Revision-Clinical Modification or the ICD-10th Revision.^35,36 As inclusion criteria for outcome of depression we included studies reporting on recurrences, relapses, psychopathology, disability, or quality of life at follow-up. We defined long-term as a follow-up of at least 5 years, because recurrences usually occur within this time frame.^9,13,37 A follow-up of at least 5 years should give an indication of percentages of single-episode depression and recurrence rates, and should provide more of an opportunity for distinguishing recurrence from relapse and no recovery (yet) than a shorter follow-up.

When abstracts met the inclusion criteria or remained unclear, full articles were retrieved for further evaluation. We also retrieved relevant reviews. All of these studies were screened with the ancestry approach. Additionally, a number of experts in the field from the Netherlands, the United Kingdom, and the United States were asked for additional references.

Data Abstraction and Presentation

Because of the wide variety of study designs, we limited ourselves to a qualitative evaluation. We abstracted data about design, setting, diagnostic criteria, number and specific diagnosis of depressive patients in the follow-up, age and sex, length of follow-up, treatment, and outcomes.

We calculated a total rate of recurrence or depression at follow up for all patients still alive and present at the end of the follow-up of each study. For that purpose we combined the rates for minor and major depression. This gave us the opportunity to compare the outcome results of depression diagnosed with family practice criteria with DSM cases and cases meeting RDC.

Results

Selection of Articles

The computer search supplied 421 potentially relevant articles. We selected 56 papers on the basis of that search, the reference lists of 4 review articles, and the suggestions of experts. Eight of those studies met all our inclusion criteria: 6 of these were community studies, and 2 were in primary care. Studies were excluded for 1 or more of the following reasons: no longitudinal follow-up (13), long-term follow-up shorter than 5 years (35), no diagnostic criteria mentioned in the article (4), population not from community or primary care (5) or too small (1), or outcome results of depression were mixed with other diagnoses (2).

Design, Aim, and Outcomes

Table 1 provides an overview of the included studies with outcomes as presented in the original articles. There was only one study from the 1970s³⁸ meeting our criteria; all others were published in the last 10 years.

Initially there had either been a community survey with screening instruments, followed by diagnostic interviews or the whole population had been interviewed to identify cases of depression. Then there had been a follow up with the depressed subjects. In 4 of the 6 community studies the outcome was presented as depression at follow-up,^39-42 and in the other 2 studies as recurrences.^43,44 In 2 studies the results of depression at follow-up were based on 3 follow-up interviews: in the third, fourth, and fifth year after the initial assessment in the first study,⁴¹ and one every 5 years in the other.⁴² Three studies were performed on the elderly,^39-41 one on young adults living in the community,⁴² and 2 in community samples in which all ages were represented.^43,44 In one of these latter studies⁴⁴ the population consisted of family members and relatives of affectively ill probands.

Both family practice studies had a historic cohort design^13,38 and referred to patients recognized with depression in family practice. A cohort of depressed patients had been identified from a morbidity registry¹³ or practice,³⁸ and was followed up longitudinally using the patients’ records (and registry¹³). The follow-up started on the date the diagnosis was made for the first time¹³ or the first time in the practice.³⁸ Outcome in both studies was based on the reference to recurrences on the patients’ records over the entire study period.

The Diagnosis of Depression and Diagnostic Criteria

There was only one study using specific family practice criteria. For that study E-list criteria (the first classification for general practice, developed in the United Kingdom and derived from the ICD) was used initially and was later replaced with ICHPPC-2 criteria.^45,13 In all the other studies DSM,^40,42,43 RDC,^38,42-44 or criteria derived from the RDC for use in elderly populations^39,41 (obtained with GMS-AGECAT, a computerized diagnostic system for elderly subjects derived from the Geriatric Mental State⁴⁶) were used. In the family practice study by Widmer and Cadoret³⁸ the symptoms on the records were incorporated in the RDC retrospectively.