Graeme:  As you know, there is controversy about the origins of depression,
which is probably an aspect of several genetically and environmentally
mediated dysfunctions.

Several aspects of depression would lend themselves to a "chronic disease
management model", as Jennifer inquires.

First, treatment makes a difference.  Under the right circumstances, both
cognitive psychotherapy and drug treatment can help.  They can help even
more when used together.

Second, relapse is common.  Some relapses may occur because of recurring
adverse events.  Others may occur because the brain's capacity to remove
cortisol and other stress hormones becomes imperfect.  Too much psychic
stress may overwhelm the body's short-term and long-term mechanisms for
biochemical coping.  Many people recover completely from major depressive
disorder, but many more do not -- and the resulting disability is immense.
(I believe I've seen a WHO statement that depression causes more lost
workdays than any other single disabling condition.)

Third, whether you subscribe to a purely biochemical model or a purely
psychosocial model, the patient's environment interacts with the patient's
innate attitudes and medical treatment to create the patient's experience --
and it does so over a period of time.

One respected writer on the chronicity and treatability of depression is
John F. Greden, MD, at the University of Michigan Department of Psychiatry.
I can fax a three-page summary of his 2000 lecture, "What if We Really Cared
About Depression?", within North America on request.  (It was distributed as
an Audio-Digest program in 2001, but is no longer available for purchase.)
Consider checking "Diagnosing and treating depression earlier and preventing
recurrences: still neglected after all these years."  (Curr Psychiatry Rep.
2004 Dec;6(6):401-2.)  That's one of the more recent references found in a
PubMed search for Dr. Greden's publications.

Chapter 13 of _Comprehensive Textbook of Psychiatry_ (Lippincott, Williams &
Wilkins, 2005) discusses diagnostic and treatment strategies for
depressive-spectrum disorders.  It appears to me to cite historical and
current theories in a well-balanced way -- but the writing is a bit dry.

***

To answer Jennifer's question very briefly:

On the medical side, there are myriad examples.  The best I know is the
"Diabetes Collaborative" approach as outlined and taught by the Institute
for Healthcare Improvement (http://www.ihi.org).  Most of them stay within
the "healthcare system" paradigm, rather than challenging broader social
conditions.  But some programs have experimented with the boundaries of what
the "healthcare system" can do to affect the social conditions.

On the mental health side, I am not as familiar.  My impression is that the
application of chronic disease models to mental health may be less well
developed than that for chronic physical diseases.  But that may just
reflect my own orientation and practice history.  I'd start with resources
such as www.ihi.org and the MacColl Institute for healthcare innovation at
Group Health Cooperative in Seattle.

Be prepared for a difficult time when researching the application of chronic
disease models to depression, because there appear to be fewer funding
sources for system innovation in mental health.  However, the
less-publicized field may have equal or greater opportunities to make a
difference in the public's health.

I won't be able to participate in prolonged discussion on this topic, but
I'd welcome the insights of others and I'd like to know the results of
Jennifer's inquiries.

Best wishes!

Dave Cundiff, MD, MPH
Olympia, Washington, USA

***

On 6/9/05 1:31 PM, "Graeme Bacque" <[log in to unmask]> wrote:

> Jennifer Boyko wrote:
> 
>> I am wondering if anyone knows of any examples of primary medical care
>> settings that have applied a chronic disease management model (for lack of a
>> better term) to address a particular health issue (e.g. depression,
>> diabetes).  Within the setting, which might be a community health centre or
>> family medical practice, this would mean having an information system in
>> place e.g. electronic medical record, evidence based practice,
>> reo-orientation of services, self-care supports, as well as efforts to
>> improve community health through involvement in policies that create
>> supportive envioronments, address determinants of health and enable community
>> devleopment.  
>>  
>> 
> 'Depression' is a situational-based state of mind, not a 'chronic
> disease'. Lumping it in with medical conditions such as diabetes is
> ridiculous.
> 
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