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A staged approach to depression diagnosis could improve communication and treatment

April 04, 2017

A staged model of depression, ranging from wellness to distress to disorder, could make it easier for diverse groups to talk about depression and has the potential to improve the study of potential depression treatments, argues Vikram Patel of the London School of Hygiene & Tropical Medicine in London, UK, in an Essay in PLOS Medicine in advance of World Health Day 2017.

Around the world, the vast majority of people with depression don't seek care for their symptoms and don't benefit from new knowledge on how to treat depression. To talk sensibly about depression, Patel writes, "one must explicitly acknowledge that the term itself captures a very heterogeneous group of experiences." In some cases, symptoms lumped into the broad diagnosis of depression can be eased by talking with friends. In other cases, a health professional is needed. Having a binary system for classifying all depression--as either a case or a non-case--complicates not only communication about depression, but also the search for biomarkers that might distinguish people with depression.

Patel proposes a continuum of stages to define depression: wellness--the absence of distressing emotional experiences; distress--mild to moderate distressing experiences of short duration; depressive episode or disorder--set apart by severely distressing experiences lasting at least two to four weeks with impairment of social functioning; and recurrent or refractory depressive episodes--those which don't respond to existing treatments. Patients within each stage would be treated differently, with the large proportion of those who are distressed being offered guided self-care (including internet based interventions),and those with disorders being offered clinical interventions such as psychological treatments or anti-depressant medication.

A key barrier to the new model, Patel admits, is the continuing low rate of detection of depression. An alternative approach to current methods of boosting detection rates and assisting in staging of patients with symptoms, he writes, "may be to incorporate screening of adults in primary care and maternal health platforms, using locally validated symptom measures such as the PHQ-9, as has been recommended by the US Task Force on prevention."

Patel concludes that to advance the discourse about depression in society, "we need to move from a binary classification to a staged model which explicitly recognizes the dimensional nature of this condition. Such a revised framing has potential utility for diverse audiences, including scientists, policy makers, patients and practitioners, and offers a framework for consensus between diverse disciplines, between the clinical and public health communities, and between professionals and civil society, on how to talk sensibly about depression, in one voice."


VP is supported by a Wellcome Trust Principal Research Fellowship. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

VP is a member of the PLOS Medicine Editorial Board.


Patel V (2017) Talking sensibly about depression. PLoS Med 14(4): e1002257. doi:10.1371/journal.pmed.1002257

Author Affiliations:

London School of Hygiene & Tropical Medicine, London, United Kingdom

Public Health Foundation of India, National Capital Region of New Delhi, India

Sangath, Goa, Porvorim, India

Current address: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America



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