background Depression accounts for about 4% of the illness burden worldwide. Despite the availability of effective treatments of depression, there are no indications that the monthly prevalence of depression is decreasing.
aim This article attempts to answer the question of the causes of this paradox, and what can be done about it.
method A critical analysis is made of the literature and other (less formal) sources of information. results Moderately effective treatment could reduce the prevalence of depression by 20-25%. Possible reasons why there seems to be no reduction on prevalence include: an increase in the incidence of first episodes, delay in seeking help and thus delayed treatment, non-compliance with treatment regimens, 'patients' failing to look after themselves properly, inadequate treatment and possibly also rather limited success of long-term treatment. These proximal causes are able to thrive in a climate in which mental health care is insufficiently geared to people's needs and fails to give adequate attention to the chronic and recurrent nature of many forms of depression or to the inability of patients to look after themselves properly. The mental health service in its present form is unable to reduce the gap between the amount of treatment it provides and the results it achieves.
conclusion From this perspective some policy recommendations are made with regard to primary care and the specialised services. These recommendations include the use of the 'stepwise' treatment model, the implementation of care programmes that concentrate on high-quality care, the re-evaluation of the roles of health professional (carer) and patient and the re-distribution of resources on the basis of illness burden and cost-effectiveness.