Improvement of care for people suffering from depression: the need for comprehensive education

In the years 1983-1984, the Swedish Committee for Prevention and Treatment of Depressions (PTD) offered an educational programme to all general practioners (GPs) on the Swedish island of Gotland. This education has led to a significant decrease in inpatient care, morbidity, mortality and costs incurred by depressive illness on the island. Unspecific medication decreased and specific antidepressive medication increased. Recent scrutiny of all suicides on Gotland during the 1980s showed that the overall decrease due to the educational programme was mainly in those committed by females with recognized major depression who had been in contact with GPs. This was expected. However, the number of male suicides was almost unaffected by the educational programme nor by the GPs' improved ability to diagnose and treat depressions. We believe that male depressive suicidants may not be reached by the medical health care system. This might be due to mens' alexithymic incapacity to ask for help and/or their atypical depressive symptoms, manifested by aggressive or abusive behaviour that leads to rejection or mis-diagnosis in the health care system. Consequently, there is underdiagnosis and undertreatment of male depressions which may explain the paradoxical fact that men in Sweden and elsewhere are only half as often depressed but commit suicides up to five times more often than females in Sweden. New sex-specific diagnostical and therapeutical tools as well as sex specific research and comprehensive educational programs concerning depression and suicidality are needed.