About 20% of mental health outpatient visits are made for depression. The course of depressions with and without treatment is hard to predict. Prognosis (forecasting the course of disease) is one of a physician’s most important judgments.

Depression causes anhedonia (lack of pleasure in life and the original title of Woody Allen’s “Annie Hall”), self reproach, suicidal ideation, and indecisiveness. Some elderly deny feeling sad and are preoccupied with physical problems.

Answers on prognosis can be obtained from a collaborative study of 942 patients seeking treatment for depression, correctly treated or not. It was organized by the National Institute of Mental Health and published in 1990 and 1996. The probability of recovery from a treated depression within one year is 67% (usually manifest at six weeks), at two years it is 81%, at five years 88%, and at ten years 93%. If the patient remains chronically depressed at five years, the probability of recovery by the tenth year is 38%. The recovery rate annually in this subgroup is 9%, a distinct decrease from the first-year response rate of 67%. About 5% of patients received electroconvulsive treatment, perhaps for failure of other treatment or the acuteness of the symptoms. The intensity of treatment at onset did not predict the clinical state at the end of observation.

Attempts were made to identify early people who didn’t respond well. Illness duration before treatment was shorter (7 months) in people who responded well than in people who responded poorly (several years). At the study’s beginning, 18% had been sick for two or more years. The people who responded well were more likely to be married and less likely to be widowed, separated, or divorced.

Why in the modern era of treatment with anti-depressive drugs do chronically ill subjects fail treatment? Possibly patients who don’t follow advice are discouraged or have had adverse effects, making them reluctant to take their medicine. Drug trials may be too brief or antidepressant blood drug levels may not have been checked. There may be poor access to medical care. Chronic sufferers are more likely to be older and have psychotic symptoms (severe disease with loss of contact with reality). Not all investigators agree on these criteria. With increasing age females are more likely to be chronic.

Because major depression causes significant losses such as educational status, employment, annual income, interpersonal relationships, and overall life satisfaction, attempts to improve treatment are important.

It is evident that people with major depressions who fail initially can recover even after a lengthy illness. To avoid hopelessness, patients and their families need assurance that recovery will eventually come. Physicians should advise both optimism and patience. The chronically depressed patient in the community is often unrecognized and poorly treated. Depression occurs in 13% of the elderly (compared to 12% of the general population) and almost 30% of the medically ill elderly. Chronicity is common in women with early onset. It may last up to 10 years or more but it does not continue indefinitely.

Depression is not a weakness, it is not an emotional experience, it is a disease that responds to antidepressive medicines. It affects otherwise normal healthy people. It does no good for someone to “fight this themselves.” It may sometimes be more fruitful to focus on a patient’s life problems after remission from drug treatment. These medicines are not addictive and are not a “cop-out.”

Ian Maclean Smith, M.D.
Emeritus Professor
Department of Internal Medicine
University of Iowa Hospitals and Clinics