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Psychiatrie Bulletin (1989), 13, 583
Can depression be prevented?
JANSCOTT,Senior Lecturer in Community
Psychiatry, University of Newcastle
upon Tyne
Prevention is traditionally a controversial issue in
psychiatry. Many would consider it to have no
empirical base and therefore regard the whole idea as
unscientific. However, doctors cannot evade their
obligations to consider exploring important issues of
public health simply because the methodology is
complex. The Social, Community and Rehabilitation
Psychiatry Section of the Royal College has struggled
with the issue of prevention over a number of years.
The deliberations of an earlier working party within
the Section chaired by Dr C. M. Parkes and the con
clusions of more recent meetings convened by Dr
A. C. Brown perhaps yielded more questions than
they have been able to answer. Thus, in an attempt to
widen the debate within the College it was decided
to devote the entire February 1989 Annual General
meeting of the Section to this somewhat neglected
topic. The meeting focused on the role of prevention
with particular reference to its application to depres
sive disorders. Depression provides an interesting
model to examine in this context as it spans the
spectrum of neurosis to psychosis and many different
aetiological theories have been proposed.
The morning session (chaired by Dr D. G. Fowlie,
Aberdeen) was devoted to a discussion of some of
these theories and the possibilities for primary
prevention. Dr Nicol Ferrier (MRC, Newcastle)
examined the functioning of the hypothalamic-
pituitary-adrenal (HPA) axis and tried to offer some
links between biological and cognitive models of
depression. Professor McGuffin (Cardiff) suggested
that the propensity to encounter adversity and
(genetic) vulnerability to depression cluster in certain
families. Professor George Brown (Bedford College)
addressed the social origins of depressive disorders
and discussed prevention in schematic terms. Using
this model he identified four possible intervention
points (preventing crises; avoiding background diffi
culties; preventing developmental problems; and
'post-onset' interventions). Lastly, Dr Jennifer
Newton (a prevention research worker with MIND)
outlined some examples of good practice in preven
tion, e.g. NEWPIN. She then contrasted disease
models with health promotion approaches and
suggested that in order to set up and evaluate inter
ventions based on the former, research needed to
be focused on vulnerable groups. It might then be
possible to identify the types of support that were
likely to be effective in preventing depression despite
the presence of risk factors. The talk also highlighted
the need to mobilise voluntary, community and
natural support networks as well as the use of
innovative primary and secondary care processes to
promote prevention.
The latter half of the day (chaired by Professor
E. S. Paykel, Cambridge), covered secondary and
tertiary prevention. Dr Ian Falloon and colleagues
(from Buckingham) outlined a service model that
offered early intervention to depressed patients and
their families by the placement of mental health pro
fessionals in primary care settings. The efficacy of
cognitive therapy in the treatment of depression was
then discussed by Dr Jan Scott (Newcastle). Finally
Dr Abou-Saleh (Liverpool) systematically outlined
pharmacological approaches to depression.
What did we learn from the day? In the plenary
session (led by Professor E. S. Paykel) it was
suggested that overall we could feel more confident
about our knowledge and ability to treat depressive
disorders, but early intervention required early
detection. There was a need to train and help other
professionals in this area. More importantly, he
pointed out that the crux of the matter was whether
or not there were any good examples within psy
chiatry of primary prevention. It is certainly time for
such approaches to be tried; depressed patients, their
families, and the public at large now expect it
from us. The early addresses had outlined the need
for clinicians to utilise multifactorial models of
depression. Given the heterogeneity of this disorder,
how confident are we at predicting the risk of
developing depression? (Thus allowing us to target a
vulnerable population as suggested by Dr Newton).
A wide ranging discussion with the audience high
lighted concerns that the models of depression put
forward were not as robust as we would like. It is
important that future research tries to integrate psy-
chobiosocial approaches rather than set up compet
ing aetiological theories. The fundamental question
of the role of a psychiatrist in primary prevention
remains unresolved. Perhaps, by necessity, a one day
meeting posed more new questions rather than identi
fying solutions. At the end, Professor Paykel asked a
question of those present - if you were given the task
of advising the health minister on how to spend 10%
of the available resources on primary prevention for
the treatment of depression what would you suggest?
Most of the attenders at the meeting probably mused
on how to tackle this question on the train going
home. If they have now come up with the answers,
could they please let us know!
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