Evaluating the first 1000 patients referred to a specialist depression clinic: a case for tertiary referral...

We report on the assessment and outcome of the first 1000 patients referred to a tertiary referral depression clinic established to assess the utility of diagnostic sub-typing on clinical course of illness.

Diagnostic, treatment recommendations, prognostic judgments and 12-week outcome data were examined.

Nearly 40% of those with a primary mood disorder were diagnosed with bipolar disorder, of whom three-quarters received such a diagnosis for the first time. Alternative diagnoses or formulations were provided for 68% of the total sample, with the therapeutic paradigm altered for the majority (86%) of patients. Improvement rates were indicative of a higher level of improvement in those diagnosed with bipolar disorder (some 70%) compared to those with unipolar disorders (some 60%). Overall, however, rates of 'full remission' were low, being 2% and up to 12% for bipolar and unipolar patients respectively and perhaps reflecting the tertiary nature of the assessing clinical facility. Baseline clinician predictions were in the order of 60% accuracy in predicting outcome, irrespective of diagnostic grouping.

Anticipation factors (e.g. attending a specialist tertiary referral service) may have contributed non-specifically to outcome. Use of clinician-derived diagnoses rather than strict DSM-IV criteria limits comparisons to other studies.

The high rates of a first-time bipolar diagnosis suggest that detection and diagnosis of this condition continues to be problematic. Low remission rates underline the chronic nature of many mood disorders, and the need for ongoing management given the high risk of relapse. Our findings offer support for the importance of identifying bipolar disorder and distinguishing depressive sub-types in order to shape more targeted treatments, a task that might be advanced by the establishment of more tertiary referral services.