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

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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

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Length of Follow-up of Depression

In one study⁴⁴ the length of the follow-up from the onset of depression was not clear because it did not mention when the depressive episodes occurred. In all other studies the follow-up began with a depressive episode. One study started the follow-up at first episodes only.¹³ That is the only study in which a time relation between the initial diagnosis and recurrences is presented longitudinally. One other study started at initial episodes in the practice³⁸; all others start at index and recurrent episodes, but the proportions are not clear.

Recurrence or Depression at Follow-up

There were differences in levels of depression included in the outcome results Table 1. The rates of recurrence presented in the community studies ranged between 26% and 47%, and the rates of depression at follow-up were between 9% and 44%. Recurrence rates in the family practice studies ranged from 35% to 40%. The recurrence rate of 35% was calculated retrospectively, relying on the symptoms mentioned on the case records. The recurrence rate of 40% was found by extracting data from a morbidity registry and checking those data against symptoms on the patient records.¹³ Both studies also presented the number of recurrences. In one study 27% of the followed-up patients had 2 episodes; 6%, 3; and 3%, 4 or more³⁸; in the other the percentages were 16% with 2, 12% with 3, and 12% with 4 or more.¹³

Treatment

The authors of 4 studies^38-40,42 reported on treatment. None described the nature and length of treatment clearly, and treatment was not related to recurrence or depression at follow-up.

Mortality

Data for mortality were given in 4 studies^13,39-41 (range of rates=14%-44%). The higher mortality rates refer to the elderly. In 2 studies mortality was similar to the expected rates (compared with a control group in one¹³ and with the National Mortality Statistics in the other³⁹); in another study⁴¹ the rates were significantly higher than in a control group of nondepressed individuals; and in the last study¹³ the results of a comparison were not discussed. Data on suicide attempts and suicide can be found in only one study.¹³

Health Status

Two studies reported on disability or self-perceived physical health, but none of the studies used any of the well-known health status measurement instruments. One study³⁹ reported on disability levels (with a modified version of the American Resources and Services) There was significantly more moderate to severe impairment among the depressed than among the recovered cases, as rated by a clinician; also, it is not clear whether this rating refers to the initial assessment or the follow-up. In the other study⁴⁰ 46% of the elderly patients reported poor health status, but it is not clear which instrument was used; no relation was found between outcome and perceived health status.

Total Rates of Recurrence or Depression at Follow-up

Table 2 shows the total rates of recurrence or depression at follow-up, adding up the results of minor and major depression when possible. The recurrence rates of the populations in which no specific age group was followed-up ranged from 30% to 40%. These studies had indications for higher recurrence rates in the younger age groups. The community studies of depression in the elderly and young adults reported outcome as depression at follow-up. The rates of depression at follow-up in 2 of the studies of the elderly^39,41 were relatively high. One of these studies⁴¹ only reported on major depression at follow-up. This was also the case in the study with young adults.⁴²

Discussion

Studies of the long-term outcome of depression in the community and in primary care are scarce and difficult to compare, and methodologic shortcomings hamper their generalizability.

Our data suggest that overall recurrence rates in the community and in family practice vary between 30% and 40%. The relationship between treatment and long-term outcome remains unclear, because none of the studies were controlled trials for treatment or looked into this matter adequately. This also applies to the patient’s qualitative experience. Almost all studies exclusively report physician-diagnosed recurrence or positive scores on diagnostic instruments of depression at follow-up.

Recurrence rates of 30% to 40% indicate that the prognosis for depression in community and family practice is not as poor as in psychiatry. In psychiatric settings much higher recurrence rates are found, with percentages of up to almost 90% depending on the length of follow-up and the setting.^9,10,37 Prognosis seems to be related to age, with young adults and the elderly having poorer prognoses. In the study on young adults, between 30% and 40% of the patients had a major depressive disorder at follow-up, but those results did not include rates of minor depression. They also did not include recurrences between the follow-up interviews, and thus it is likely that recurrence rates were higher. Higher recurrence rates were also found in the younger age groups in 2 of the community studies.^43,44 All the studies performed exclusively with the elderly reported depression at follow-up and gave a poor prognosis.^39-41 This was not confirmed in the 2 community studies involving various ages and one general practice study.^13,43,44 The higher rates in studies on the elderly might be explained by the use of diagnostic instruments more sensitive to detect depression specifically in that age group. Another explanation might be that differences were not found because of the relatively small number of elderly persons present in the other studies.