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ALASTAIR DOBBIN ET AL.
appeared useful in a primary-care setting, where past studies have
experienced problems of recruitment, concordance, and compliance.
The World Health Organization has recently recognized depression as
the fourth leading contributor to the global burden of disease (World
Health Organization [WHO], 2009). It is estimated that at any one time 5%
to 10% of the population of the United Kingdom (UK) experience depres-
sive symptoms and that 60% to 70% of adults at some point in their lives
will experience symptoms of depression or anxiety sufficient to influence
their daily activities (Singleton, Bumpstead, O’Brien, Lee, & Meltzer, 2001).
Depression was the fifth commonest presenting problem recorded at gen-
eral practitioner (GP) consultations in 2005/2006 (Information Services
Division Scotland, 2007). It is also recognized that depression is costly; costs
in England have been estimated at £77 billion each year, taking National
Health Service (NHS) costs, lost productivity, cost of benefits, and reduc-
tions in quality of life (Sainsbury Centre for Mental Health, 2007).
In primary care, therapy with antidepressants is standard for acute epi-
sodes of depression. Daily use of antidepressants in Scotland has grown
from 1.9% of the population (aged 15+) in 1992/1993 to 8.8% by 2007/
2008 (Information Services Division Scotland, 2008). Antidepressants are
effective in the treatment of depression; although the placebo effect has
increasingly been recognized as being powerful. A meta-analysis by the
Cochrane society concluded that “differences between antidepressants
and active placebo are small” (Moncrieff, Wessely, &Hardy, 2002, p. 1). In
2002 a group of researchers analyzed data they had obtained under free-
dom-of-information legislation from the U.S. Food and Drug Administra-
tion for all the trials of the four main Selective Serotonin Reuptake
Inhibitors, which included unplished trials; this analysis revealed that the
difference between medication and placebo was not clinically significant
(Kirsch, Moore, Scoboria, & Nicholls, 2002), indeed “medications must be
interfering with responsiveness in at least some others who would fare
better on placebo” (Kirsch & Antonuccio, 2002, p. 2), a conclusion previ-
ously reached with tricyclic antidepressants (Thomson, 1982).
Current directions in the management of depression promote an
approach that aims to increase capacity for, and promote use of, self-help
psychological interventions, particularly for those experiencing mild to
moderate depression (National Institute for Clinical Excellence: Guide-
line Development Group, 2007). At present, cognitive-behavioral therapy
(CBT) is the most widely available psychological treatment for depres-
sion (Antonuccio & Danton, 1995; Geddes & Butler, 2002). However, it is
often difficult to access, has lengthy waiting times, is relatively costly and
may not be available at all as a direct referral from primary care.
There are recognized precursors to the development of depression,
including previous attacks of depression, childhood anxiety (Reinherz,
Paradis, Giaconia, Stashwick, & Fitzmaurice, 2003), sleep disturbance
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