Are we living in depressing times that are not NICE?

The recent well advertised problems in the treatment of depression (The Times, February 2008) 1 raise important and difficult issues that will impinge upon the medico-legal interface. Antidepressant medicines, used for decades and considered by clinicians to have been effective, have been now deemed not only to be ineffective but to increase the rate of suicide, particularly, it is said, amongst the young. In the scientific literature not everyone agrees with that and there is the prospect of litigation both for not treating with antidepressants and for treating with antidepressants. This is symptomatic of a more profound trend affecting clinical practice and a paradigm for the same problems arising elsewhere in health care. The problem was exposed when a meta-analysis of studies on treatment of depression appeared to indicate that antidepressants did not make much difference. 2 A meta-analysis essentially pulls together the results of several studies to give an overall larger number of subjects for statistical analysis. Meta-analysis is not without its critics. 3 The analyst has no control over the sample cohort and purity of data in each study and there is a high risk of significant differences. A meta-analysis may be of assistance if no study is of reasonable sample size but caution is needed with its interpretation. In this respect a meta-analysis differs from a review of a number of studies which examines each study and draws conclusions from the differences and similarities in the samples studied, techniques and apparent outcome. With the latter the reader is better placed to use his or her critical judgment on the relationship between each of the studies. Unfortunately there are long standing difficulties in the categorisations of disorders of mood. The result has been a shuffle between groupings for some decades. Depression as a " spectrum " as well as the recent proliferation of " bipolar disorder " is the current order of the day. The latter is now said to have five groups and some of these have several subdivisions. Overall the distinctions are unclear – and it may be that the wood cannot be seen for the trees. A basic view of mood is that normally we have the capacity to become lively and excited when positive events occur – elevated mood – and on the same scale when disadvantageous things happen we become miserable. These mood changes occur frequently and within a range that does not …