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Managing depression in general practice in Pakistan: do we need to re-invent the wheel?

Depressive illnesses constitute a major portion of workload of a family physician in the UK (16%) 1 and North America (23.5%) 2 . Major depressive disorder has been found to be present in nearly 13% of patients aged over 15 attending general practitioners (GPs) for a new inception of illness 3 Comparative data is not available for Pakistan. However 4 two studies that looked into pathways to care in Rawalpindi and Lahore 5 suggest that around 25% of patients seen in a psychiatric service are first seen by a primaiy health care physician. Other studies done at general practice level 6 and a hospital based non-speciality clinic 7 report a widely varying prevalence figure of 5.4-38.4% for anxiety and depressive syndromes. These syndromes, which form the bulk of psychiatric morbidity in general practice, had a prevalence figureofmorethan 30% in two recent community surveys, one in Chitral, a remote rural area in North Pakistan 8 and the other in Azam Basti, a Katchi Abadi in Karachi (Unpublished data). Epidemiological studies from the UK and USA show that the prevalence of major depression in general population is around 5% 9,10 . Extrapolation of this data would suggest that there are more than 42 million anxious and depressed patients amongst Pakistan’s projected population of 140 million 11 . Atleast 7 million of these suffer from major depressive disorder. This is further corroborated by the data on consumption of benzodiazepines and antidepressants in Pakistan. Approximately, 11 million units of benzodiazepine compounds and over 2 million units of antidepressants were dispensed in the year upto June 1996. Considering that many depressed patients are inappropriately treated with benzodiazepines, this suggests a large number of patients already recognized and being treated with medication. With the total number of psychiatrists estimated at 200, a vast majority of these patients inevitably will be seen and treated by the GPs. It is therefore, important that initiatives being taken to enhance GPs’ skills to manage depressive illness must