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One of the biggest obstacles that primary care physicians face in addressing psychiatric illness in our setting is some old and incorrect assumptions about the types of illnesses we confront each day. Not the least of these assumptions is the persistent belief that most mood disorders in primary care are acute and mild. This is simply not the case. The natural history of a unipolar major depression typically contains a 9- to 12-month prodrome of fatigue and insomnia, with progressive impairment by anhedonia and depressed mood as the episode becomes more syndromal. The typical duration of a major depression is said to be 9 to 18 months. However, as many as 30% of patients fail to completely recover spontaneously, and these residual symptoms of depression place patients at risk for future reoccurrence of major depression and lingering dysfunction that is often "normalized" by patients who cannot remember what a truly normal mood is like. Such chronic and recurrent illnesses tend to collect in our practices. This familiar pattern of waxing and waning symptoms with infrequent remissions into an asymptomatic state has been documented by Ormel et al.1 Sadly, the chronicity described by Ormel et al. does not even address the prevalence of bipolar illness as a subset of this mood disorder population.2
We are, then, understandably excited about offering our readership a collection of supplemental readings on chronic depression. This supplement, edited by A. John Rush, M.D., documents the prevalence and cost, both in individual and societal terms, of chronic depression and offers a perspective on long-term management. Drs. David Dunner, Harold Pincus, Madhukar Trivedi, Beverly Kleiber, and Andrew Nierenberg collaborate with Amy Pettit and National Depressive and Manic-Depressive Association Executive Director Lydia Lewis to describe these issues. The supplement also features a proposal for a rational algorithm for the treatment of chronic depression.
"Better" is not "well." So we strive for excellence in patient care. We hope your practice of medicine is enhanced by this information.
J. Sloan Manning, M.D.
Editor in Chief
The Primary Care Companion to the Journal of Clinical Psychiatry