SPHERE: A National Depression Project

In reply: It is with great pleasure that we resume our ongoing correspondence with Phillips concerning the medical and psychological status of patients who present with non-specific somatic complaints such as chronic fatigue.1 As we have reported previously,2 we have been strong advocates of both the need to develop appropriate instruments for measuring neuropsychiatric states characterised by non-specific somatic symptoms and to promote effective medical and psychological management of patients with these disabling conditions.3

In their letter, Phillips and colleagues fail to grasp the essential issue. To describe a condition as a neuropsychiatric state (or mental disorder) does not necessarily lead to simplistic and entirely unhelpful assumptions about "medical" versus "psychological" causes or treatments. Phillips et al attempt to promote once again the notion of "biological" (ie, acceptable) versus "psychological" (ie, unacceptable) theories of the causation of chronic fatigue syndrome. Such an approach is not only intellectually sterile and inconsistent with the past decade of intensive research by a wide range of medical and psychological research teams,4 but also profoundly unhelpful to people affected by these disabling disorders.3

In recent years, the very significant health burden of common mental disorders such as depression, anxiety, alcohol or other substance misuse, and neurasthenia (prolonged fatigue states lasting longer than three months) has been well documented in the Australian community5 and in the primary care setting.6 Phillips and colleagues appear to have no knowledge of the basic epidemiological fact that mental disorders are two to three times more common in primary and other medical care settings than in community studies (hence the total rate of disorder in our study is about twice that detected in the Australian National Survey of Mental Health and Well-being). Contrary to their implications, the total rates reported in our general practice study are entirely consistent with the largest multinational study of primary care ever conducted.7 That study indicated that a third of all primary care patients have mental disorders and another third have mental health difficulties (with or without concurrent medical disorders) requiring specific psychological assessment.

The significance of our study is that it has brought the extent of common mental health needs (including depression, anxiety, alcohol or other substance-misuse and somatoform disorders) to the attention of the Australian medical profession. What is now required is a concerted and integrated response — not a return to dualistic notions of illness that have for so long hampered the provision of effective pharmacological and non-pharmacological treatments to patients with mental disorders who present for medical care.