Chronic Illness (2005) 1, 101–106
C E
Is depression a chronic illness? For the motion
LINDA GASK
University of Manchester, Division of Primary Care, Rusholme Health Centre, Walmer Street,
Manchester M14 5NP, UK
GROWTH OF A DEPRESSION
‘INDUSTRY’
At the beginning of the 1990s there was a
renewed air of optimism about the outcome
for people who suffered from depression.
The message of the Defeat Depression
Campaign in the UK and the Depression,
Awareness, Recognition and Treatment
(DART) programme in the USA was that
depression was both a common and treat-
able illness,1 as long as it could be recognized
and effectively treated. General practitioners
(GPs) were castigated for ‘missing’ it, and
the general public were urged to seek help.
Unfortunately for the credibility of these
campaigns, they coincided with the launch
and promotion of a new group of antidepres-
sants, the selective serotonin reuptake
inhibitors (SSRIs). Funding from the phar-
maceutical companies was suddenly avail-
able to promote public health messages
about depression in a way that it never had
been before. I personally took advantage of
this, in my work with the Defeat Depression
Campaign, to produce educational materials
for primary care. Nevertheless, the over-
whelming message of the 1990s was that
depression could be cured by popping a pill.
Prozac became the most widely prescribed
antidepressant in history. Rates for the pre-
scription of SSRIs dramatically increased.2
Celebrities ‘came out’ as taking the tablets. If
Reprint requests to: Linda Gask.
Email: Linda.Gask@manchester.ac.uk; fax: +44 161
256 1070.
© W. S. Maney & Son Ltd 2005
a patient failed to recover, the assumption
was often that there must be something else
wrong with them (perhaps a personality
disorder). However, clinicians (Professor
Parker eminent among them) recognized
the concept of treatment-resistant depres-
sion and were beginning to conclude that the
view promoted by the drug industry was a far
too simplistic way of looking at the problem:
Biological psychiatry, managed care, industry
sponsored research and advertising, and societal
pressures have led us to expect termination of treat-
ment soon after a short-term intervention. Antide-
pressant efficacy trials that declare success after
eight weeks and that selectively exclude severely
depressed patients and those with complex co
morbid conditions — that is, patients from the real
world in which we practice — are a source of
frustratingly simplistic advertising copy.3
DEPRESSION AS A CHRONIC
ILLNESS
A chronic illness is, by definition, one that
lasts for a long period of time. The course of
a chronic illness can also be marked by
relapse or recurrence of acute symptoms. I
am not going to refer to depression as a ‘dis-
ease’ (although some biologically minded
psychiatrists call it one), as the search for the
definitive biological marker (or markers —
both genetic and neurobiological) is still in
progress.4 But it does qualify as a syndrome,
a collection of symptoms that frequently
occur together in a recognizable pattern
(with some variations). And, in that it causes
disability and loss of ability to function,
it can also be an ‘illness’ according to our
DOI: 10.1179/174239505X44817
102 GASK
general acceptance of the meaning of that
term.
In an edition of the British Medical Journal
devoted to chronic illness, Andrews5 suc-
cinctly argued what others6,7 had been think-
ing for some time. Depression is a complex,
heterogeneous disorder that remits and
recurs, and is a condition from which some
people take a very long time to recover. In
his argument, Andrews drew from various
sources of evidence, including his own
research with Kiloh,8 a 15-year follow-up of
depressed patients admitted to a new general
hospital psychiatric unit in 1970. They
found that only one-fifth recovered and
remained continuously well, three-fifths
recovered but had further episodes, and one-
fifth either recovered or committed suicide.
Andrews noted that an English follow-up
study, again of a hospital sample, showed
similar results.9 In a specialist care setting in
the USA, the multicentre NIMH Collabora-
tive Depression Study of 431 people, begun
in 1978, provided important data. In a re-
port that covered only episodes beginning
during follow-up and that therefore allow
more precise determination of onset and
remission, Coryell et al.10 reported that 40%
recovered within 3 months, 60% within
6 months, and 80% within 1 year. However,
symptom levels changed frequently over
time, and over 12 years, patients in the study
on average had symptoms in 59% of weeks
but met full criteria for depression in 15% of
weeks.11
These, however, are studies of people seen
by specialist services who would be expected
to have a poorer prognosis. What about
studies in primary and community care? In
the Australian mental health survey,12 fewer
than half the people with depressive episodes
at some time during the year had symptoms
that met criteria for depression during the
month of the interview. However, the people
who did meet criteria for depression during
the previous year dated the onset of their first
episode an average of 5.4 years earlier (range
1–54 years), and nearly half (44%) reported
a previous episode within 12 months of their
latest episode. Only 39% had met criteria for
a full remission between the two episodes.
The US National Comorbidity Survey13
showed that three-quarters of people aged
15–54 years who had ever met criteria for
depression had had more than one episode.
Their mean age was 34 years, and they
reported an average of 11 prior episodes
lasting from 2 to 69 weeks.
The largest primary care study of depres-
sion was conducted by the World Health
Organization in 15 cities across the world in
the early 1990s. Goldberg et al. reported that
two-thirds of patients whose illnesses were
recognized and treated with drugs still had a
diagnosis of mental illness at 1-year follow-
up, and in nearly half the diagnosis was still
depression.14 In the community, depression
is a disorder that can persist, remit and
recur, and recurrence is more likely to occur
when full remission has not been achieved
and there are residual symptoms15 — a
familiar picture to those who work or do
research in primary care settings.
Although reduction of symptoms has been
the goal of treatment, it is only in the last few
years that attempts have been made to estab-
lish standardized definitions and operational
criteria for treatment outcomes. Indeed,
until the early 1990s, outcome terms, defini-
tions and criteria reported in the literature
were notably inconsistent.16 In 1991, Frank
et al.17 proposed definitions for outcomes
in an effort to facilitate the creation of a
uniform terminology that would assist com-
munication between clinicians and enable
useful comparison of results from different
clinical trials. Frank’s terminology is import-
ant, in that it helps us delineate the different
outcomes of depression more precisely and
understand the true effects of treatment on
the course and outcome of the disorder
(Table 1).
A standard textbook figure for an
adequate response rate in a trial of an anti-
depressant is approximately 70%, but the
actual remission rate is much lower (prob-
ably 35%–45%),18 which is not much above
the very substantial placebo response rate
 IS DEPRESSION A CHRONIC ILLNESS?
TABLE 1. Definitions of outcomes in depression17

Patient no longer fully symptomatic but evidence of
more than minimal symptoms

Patient no longer meets syndromal criteria and has no
or minimal symptoms

Returns to fully symptomatic state that occurs during
remission; re-emergence of current episode

Extended period of remission; indicates end of current
episode

Appearance of new episode of major depression; occurs
only during recovery
reported in depression. Some people un-
doubtedly undergo ‘spontaneous’ remission,
while others experience a positive effect of
simply being treated (the placebo response
proper). Most episodes of depression spon-
taneously remit even after prolonged periods
of time, which means that it can be difficult
to determine what is the natural course of
the disorder, and what is the effect of treat-
ment. The evidence for continuation therapy
preventing relapse after an episode of
depression appears to be stronger than the
evidence for maintenance therapy prevent-
ing recurrence in the longer term.19 Effective
psychological treatments for depression
(cognitive–behavioural therapy, interper-
sonal therapy and problem-solving) exist but
are still not widely available in the commu-
nity (I would go so far as to say that the
recent UK National Institute of Clinical
Excellence (NICE)20 guidelines on treat-
ment advising greater use of psychological
treatments are simply unrealistic for most
primary and many specialist care profession-
als, as there are insufficient well-trained
therapists). However, there is evidence that
in individuals with depressive symptoms that
are resistant to standard drug treatments,
adjuvant cognitive therapy is more costly
but more effective than intensive clinical
treatment alone in preventing relapse.21
103
As a psychiatrist, I would certainly agree
with the observation that some people seen
in a specialist setting who have been labelled
as having ‘treatment-resistant’ depression
may in fact have received inadequate treat-
ment for too short a time. The conclusion
that many researchers in primary care have
come to over the last few years has been
that many people suffering from depression
in the community are still not receiving
effective treatment. This is a difficult and
at times controversial message, given the
general antipathy towards antidepressant
medication fuelled by media reports about
the SSRIs22 and the probable overpre-
scription of drugs to those with mild depres-
sion, who are indeed unlikely to benefit
from them. However, what is proposed is
not necessarily more treatment with drugs,
but a more coordinated approach to the
whole treatment process. The treatment of
depression in primary care is essentially
reactive. As with many other problems, the
patient is expected to consult again when
they deem it to be necessary. In a study in
which I collaborated some years ago in
Manchester,23 we interviewed people who
were being treated for depression by their
GPs. Even though these patients had been
selected for us to interview by their own
GPs, the overwhelming impression we
gained from listening to these 27 men and
women was of relapsing and remitting dis-
ability, unmet need and a reluctance to
‘waste the time’ of the doctor. Many of these
people did not believe that it was possible to
feel any better:
I don’t like feeling depressed, because it makes you
feel inadequate. You feel like you are one of those
weak, weak people, just a worthless person ... I just
think what’s the point in going back to see? He can’t
do anything. Nobody can do anything. (GP
patient)23
Proactive models of care,24 also used for
chronic physical illnesses such as diabetes
and heart failure, have been successfully
applied to depression.25 These combine a
range of interventions, such as reorganiza-
tion of care to include active case manage-
ment (assertive follow-up) of people with
104 GASK
depression in primary care, education for
staff, clinical practice guidelines, computer
systems that track whether patients have
been seen, and improved links with com-
munity resources and agencies. Providing
care in this way improves outcomes, but at
greater cost. With colleagues in York and
Manchester, I am currently exploring how
case management and assertive follow-up of
depression might be adapted to the UK.
Professionals may fear that patients find this
intrusive or worry that a ‘depression register’
is potentially stigmatizing. There is a strong
belief in some circles that people with mental
health problems should be ‘left’ to seek
help when they are ready to accept that
they have a problem. This view has major
shortcomings:
A model of practice in which patients seek help only
when they deem it necessary is not appropriate for
an episodic but lifelong condition that affects hope
and volition, reduces compliance, and predisposes
to suicide.5
Despite the progress that we have made in
treating depression in the last half-century,
depression is an increasingly important
cause of disability in the world. This is the
new public health message.26
LESSONS FROM HISTORY
Should this message of pessimism surprise
us? We have lived through a period of great
optimism about the outcome of depression,
and a time too when more and more people
were ‘discovered’ to have depression (but
perhaps not the most severe form) and
received the ‘miraculous wonder drugs’ of
the late twentieth century.
Perhaps the discovery of the antidepres-
sants 50 years ago led to a period of false
optimism.
Depression has been recognized since
ancient times. In the seventeenth century,
Burton produced his treatise The Anatomy
of Melancholy,27 but he included within the
remit of melancholy a variety of other disor-
ders (including probable organic disease) as
well as what we would today recognize as the
severe form of depression called melancho-
lia. Freud also significantly contributed to
the literature on depression with Mourning
and Melancholia,28 but it was Emil Kraepelin
who demarcated the geography of psychi-
atric diagnosis by distinguishing the two
major syndromes of dementia praecox (more
or less equivalent to schizophrenia) and
manic-depressive insanity (incorporating
what we would now call both bipolar and
unipolar depression).
Manic-depressive insanity ... includes on the one
hand the whole domain of so-called periodic and
circular insanity, on the other hand simple mania,
the greater part of the morbid states termed melan-
cholia ... Lastly we include here certain slight and
slightest colourings of mood, some of them
periodic, some of them continuously morbid, which
on the one hand are to be regarded as the rudiment
of most severe disorders and on the other hand pass
over without sharp boundary into the domain of
personal predisposition.29
Kraepelin formulated the first systematic
description of the natural course of depres-
sion. On the basis of his longitudinal study
of 899 patients in Munich in the late nine-
teenth century, he asserted that depression
was a chronic and recurrent disease. He
noted how episodes recurred with increasing
frequency over time and that the duration
of these episodes, although highly variable
between individuals, tended to be fairly con-
sistent within individuals, usually showing
a gradual increase over time. Although the
‘average attack’ lasted 6–8 months, episodes
lasting 2–4 years were ‘not at all rare’.
Reviews by Robins and Guze30 and Scott31
of the outcome literature, which mainly, but
not exclusively, dates from the era before
modern treatment, revealed a wide variation
of chronic course (defined here as a period
without recovery for 2 years) between stud-
ies (1%–28%), but the median figure was
approximately 15%. Most of the patients in
these studies had been hospitalized.
A historical perspective causes us to once
again consider what depression actually is.
Is it one entity (Kraepelin did not distinguish
bipolar from unipolar depression), more
 IS DEPRESSION A CHRONIC ILLNESS?
than one (the old ‘endogenous-reactive’ split
that I was taught at medical school) or
several different entities, as Professor Parker
believes, with different causes but some
similarities and differences in clinical pre-
sentation?32 We are still unable to answer
this question. As Healy comments,33 the dis-
covery of the first antidepressants was not
simply important because these drugs might
help people. The interest in psychotropic
drugs was as important in the European
psychiatry of the 1950s for what they might
reveal about the nature of disease or the
workings of the mind. When the first
changes were noted with antidepressant
drugs, Healy considers that:
What was to be seen was not an antidepressant
effect so much as the outlines of a disease — whose
existence had been proposed before but which was
now being revealed by a pharmacological scalpel.
(p. 56)33
What was discovered was a ‘disease’ that
responded to antidepressants: one type of
depression.
The research into depression over the last
half-century has largely been dominated by
pharmacology. Few outcome studies were
published in the 1960s and 1970s. In this
period of therapeutic optimism, people with
depression who did not respond to antide-
pressants were labelled as having ‘depressive
personality’. When SSRIs began to be pro-
moted for ‘dysthymia’, which is difficult to
distinguish from depressive personality, this
became recognized as an illness in its own
right. Yet by the late 1980s, even before the
start of the great depression campaigns, what
Paykel34 calls the ‘age of innocence’ was
really over. The results of the NIMH study
simply confirm what was known before; for
many people, but not all, what we now
commonly call depression is a chronic and
disabling ‘illness’. The problems we face
now are those of predicting chronicity,35
engaging and retaining people in effective
therapy for a problem that still carries signifi-
cant stigma, particularly in the developing
world, and finding more effective treatments
105
for ‘resistant’ depression. We are very poor
at predicting what will work for whom, and
in understanding why.
CONCLUSION: A PERSONAL VIEW
While I admire Professor Parker’s semantic
arguments, and would indeed agree that
there is probably no single disease entity
called ‘depression’, I would argue that there
is a commonly recognized syndrome that is
called ‘depression’. In many of those who
suffer from it, this follows a relapsing and
remitting course. I am one of these people.
In the last 25 years, I have had both psycho-
logical and pharmacological treatment for
this illness. Despite continuing medication, I
know that, when the conditions in my life are
right for it (and decidedly wrong for me), it
will return. I have mixed feelings about the
term currently fashionable in mental health
circles in the UK used to describe the knowl-
edge of the service user: ‘expert by experi-
ence’. I think it is possible to be an expert
in the shades and pattern of one’s own illness
very well, but not necessarily, simply
because of that, become an expert on the
problems of another. That also requires
specific talent, and sometimes, scholarship
too. Solomon36 has recently provided both,
combining an accessible but impressive
treatise on the illness with an account of his
own, and others’, very personal battles
with chronic depression. This summarizes
perfectly for me the nature of the problem:
I have for the moment managed to contain the
disablement that depression causes, but the depres-
sion itself lives forever in the cipher of my brain. It is
part of me. To wage war on depression is to fight
against oneself, and it is important to know that in
advance of the battles.36 (p. 38)
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