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. > > ------------------- > Problems/Questions? Send it to Listserv owner: [log in to unmask] > > > To unsubscribe, send the following message in the text section -- NOT the > subject header -- to [log in to unmask] > SIGNOFF SDOH > > DO NOT SEND IT BY HITTING THE REPLY BUTTON. 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