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In any analysis of depression and anxiety these conditions can be viewed from several different perspectives. In this chapter we restrict our analysis to four different perspectives: biological, interactional, flow and symptom. The selection of any of the four has a number of implications in terms of the recommended type of treatment, treatment goals and the ways in which it is determined whether or not these goals have been achieved.

The four perspectives are often combined. However, it is necessary to look at the perspectives individually if our task is to analyse how prescribers and patients combine the different perspectives.

There has been intensive debate about the new antidepressants. Arguments and counter arguments reflect different ethical values regarding depression and anxiety. For those who have a restrictive attitude to the use of drugs, personal difficulties like divorce or the death of a family member should be handled by psychosocial coping strategies. The main counter argument is that the new antidepressants can allow formerly inhibited people to exercise power in social areas. Also, there is a value conflict on a theoretical and philosophical level. The materialists, like most of those who subscribe to a biological perspective, argue that mental processes can be reduced to brain processes. Chemical substances affect the brain and so the mental processes can also be changed. This lends a positive attitude to the use of psychotropics for depression and anxiety. On the other hand, interactionists argue that traumatic events, e.g. during childhood, can be memorized in the cognitive system and can also affect the body, e.g. causing symptoms of depression. For interactionists, psychotropics are much less important because the drug is normally not assumed to influence the individual's governing self.

General practitioners (GPs) detect only about half of their patients who have a depressive disorder as identified by a clinical symptom scale. However, they tend to diagnose correctly almost all of the patients with psychological symptoms. It is probably difficult to teach GPs to detect depressed patients who present with sleeping problems. If this view is accepted there is a great need for clinical trials involving the kind of depressed patient whom GPs encounter. In such trials different GP communication strategies alone or in combination with pharmacological treatment have to be compared to find which strategy is most effective in reducing symptoms of depression and anxiety.

Our knowledge of those factors that determine the prognosis for a patient suffering from clinical depression or anxiety is so rudimentary that reliable pharmacoeconomic calculations which aim to compare pharmacological therapy with non-pharmacological therapy cannot be made.

To conclude:

• Therapists ought to provide their patients with information about different perspectives on depression and anxiety. It is unethical for a therapist to restrict herself to only one perspective when talking with a patient.

• In research different perspectives on depression and anxiety ought to be combined. We need to know when and how to use pharmacological and sociopsychological treatments in primary care.

• We need to develop and evaluate effective communication strategies for primary health care professionals. At present little help is available to such professionals in selecting communication strategies for their patients with depression and anxiety.

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