The three faces of the antidepressants: a critical commentary on the clinical-economic context of diagnosis.

Depression was infrequently diagnosed before the advent of the antidepressants but has now apparently become a major public health problem. National campaigns are organized aimed at increasing recognition of the condition and at commencing treatment for sufferers. Implicit in these approaches is the premise that treatment will necessarily reduce disability and ultimately lower suicide rates. This is by no means certain. The treatment effect size of many antidepressants is modest, the burden of side effects they produce has never been established, and data on the quality of life during treatment is absent. It remains possible that mild depressive disorders confer a protective effect against suicide and that injudicious or unmonitored treatment may increase that risk. In their concern to help patients, physicians appear to have systematically overlooked the risks they expose patients to as part of their therapeutic effort to minimize the risks posed by the patient's condition. Their propensity to overlook the risks posed by therapy may stem in part from the availability of antidepressant treatments on prescription only. Remedying this situation will require first of all a recognition of the biases that prescription-only status introduces into therapeutics. Current pharmacological and neuroscientific developments have the potential to make alternative health care frameworks possible. Whether these alternatives are adopted will probably depend on the capacity of all interested parties to reform the present arrangements. Future concepts of depressive disorders will probably reflect the regulatory arrangements adopted.