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Mulder, 2013 Outcome of mood disorders before psychopharmacology: A systematic review.


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"This review provides no support to the belief that pharmacological treatments have resulted in an improvement in the long-term outcome of patients with mood disorders."

 

This paper also contains a short, readable history of how depression has been treated over nearly 100 years.

 

Outcome of mood disorders before psychopharmacology: A systematic review.

Mulder RT, Frampton CM.

 

Aust N Z J Psychiatry. 2013 Nov 27.

 

Abstract at http://www.ncbi.nlm.nih.gov/m/pubmed/24285565

Full text http://anp.sagepub.com/content/48/3/224.full

 

Objectives:This paper systematically reviews all outcome studies of patients with mood disorders treated prior to the widespread use of antidepressants, mood stabilizers, and major tranquillizers. The aim is to estimate recovery and sustained recovery rates and to provide some evidence about the efficacy of modern drug treatments in changing the long-term outcome of mood disorders.

 

Methods:MEDLINE and PSYCHINFO searches for studies on mood disorders published prior to 1970 were performed. Most studies were obtained by hand searching and extensive cross referencing. Information was independently extracted by the two authors.Results:A total of 29 relevant articles were obtained. The studies reviewed over 14,000 patients in total. Patients were mainly inpatients with a predominance of females. The majority of patients suffered from depression. The cohorts were followed up for 1-30 years. The median rate of recovery was 69% (range 17-91%). The time to recovery was generally several months. The median rate of recovering and remaining well was 51% (range 21-67%).

 

Conclusions:The median rate of recovery is less than modern cohorts and the time to recovery longer. However, the rate of recovering and remaining well appears high compared to modern cohorts, although this result may reflect methodological issues. This review provides no support to the belief that pharmacological treatments have resulted in an improvement in the long-term outcome of patients with mood disorders.

 

 

From the paper:

....

Discussion

This paper systematically reviews all English language studies on the outcome of over 14,000 patients diagnosed with manic-depressive psychosis prior to the use of psychotropic drugs. The majority of these patients would now be considered to be suffering from major depression with a significant minority having bipolar disorder. Most studies reported on inpatient samples.

 

A majority of patients recover from their mood disorder. We estimate that a median of 69% of patients recover or are much improved over the follow-up period. However the time to recovery is highly variable and difficult to estimate in most studies. It is reasonable to state that the time to recovery is usually several months. Huston and Locher (1948) reported a mean of 21.1 months; Malzberg (1957) reported 15.7 months in males and 12 months in females. Brodwall (1947) noted that episodes of melancholia lasted 3–21 months while pure depression lasted 6–15 months. These estimates are consistent with other historical studies of inpatient length of stay.

 

Evenson et al. (1994) reported a mean length of stay for major affective illness of around 16 months in the late 19th century.

 

Healy et al. (2001) reported median lengths of stay of 9 months and 7 months for manic-depression and depression, respectively, in 1896. Both studies noted the contrast between lengths of stay a century later.

 

Evenson et al. (1994) reported a mean length of stay of 48 days in the 1970s, while Healy et al. (2001) reported stays of 6.5 days for manic-depression and 3.5 days for depression in 1996.

 

The study by Ravn (1966) on endogenous depression reports that the mean length of hospital stay prior to 1937 was 313.4 days compared with around 70 days after the introduction of ECT and medications. Similarly Lenzi et al. (2008) reported that in the no-treatment era (prior to ECT), the mean length of single episode ranged between 7 and 14 months (although this was based on only three studies: Kraepelin (1921); Pollock (1931); Rennie (1942). They concluded that the length of episode had decreased from 1 year to 1 month.

 

No study specifies treatment prior to the study by Smith et al. (1943), which included patients who received ECT. The seven studies where ECT was used reported a median recovery rate of 76%, which is slightly higher than the overall recovery rate. The median rate of recovering and remaining well was 48% compared with 51% overall. The two studies which contrasted cohorts receiving ECT with earlier cohorts who had no access to ECT reported no differences in recovery rates or suicide rates (Huston and Locher, 1948; Karagulla, 1950). One reported a reduction in the length of admission for those receiving ECT (Huston and Locher, 1948), while the other reported a higher rate of relapse for this group (Karagulla, 1950). The mean differences in outcome are surprising given the general acceptance of the efficacy of ECT. It is little wonder that Karagulla concluded that although the “statistical evidence in this survey does not provide that ECT increases recovery rate, decreases duration, and prevents recurrence in depressive states, clinical observations testifying to its value cannot be disregarded” (p. 1091).

 

We estimate that the proportion of patients who recover and remain well ranges from 21 to 67% with a median of 51%. On the face of it, this figure appears optimistic. Recent estimates suggest that a lesser proportion of depressed patients recover and remain well. Brodaty et al. (2001) summarized modern era long-term studies and reported that major depression is now viewed as a chronic illness with repeat episodes of around 75%, readmission rates of 35–62%, and chronicity in 5–25%. Mulder (2004) reported that depending on the sample studied, 80–90% of patients recover, but 70–80% of these patients relapse and 10–20% do not recover at all. Overall, 20–25% of patients have a sustained recovery following an episode of major depression.

While surprising, our findings are consistent with the very few studies comparing the long-term outcome of mood disorders in the predrug and modern era. Ravn (1966) noted “strikingly few” readmissions among patients treated in a specific hospital prior to 1937 compared to those treated with ECT and drugs.

 

Lenzi et al. (2008) using a small number of studies contrasted the “no-treatment era” with the “psychopharmacological era” and noted that the number of mood episodes has dramatically increased. Epidemiological studies have also reported that the use of drugs has not been associated with an improvement in the long-term outcome of mood disorders. Dickson and Kendell (1986) observed that between 1970 and 1981, when the use of lithium increased 10-fold, the rate of admissions for mania in Edinburgh trebled. Patten (2004) reported that increases in antidepressant use have been accompanied by an increased prevalence and duration of depressive episodes.

 

....

Conclusion

This review shows that the long-term outcome for patients with mood disorders in the predrug era was reasonably positive. Most patients recovered and the majority seemed to remain well after their recovery. Comparisons with modern drug-treated cohorts are difficult due to methodological limitations. Nevertheless there are some consistent findings. The length of mood episode has decreased significantly from around 1 year to 1 month or less. Death rates, other than those due to suicide, have also reduced significantly. In contrast, the recurrence of mood episodes appears to have significantly increased. These data, to paraphrase Dickson and Kendell (1986), provide no comfort for those, including ourselves, who have believed that drugs provide an effective prophylactic treatment for at least a substantial minority of patients with affective disorders.

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Updated -- full free text is now available.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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