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Depression in primary care: detection, treatment, and patients’ own perspectives
Umeå University, Faculty of Medicine, Clinical Sciences, Psychiatry.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Depression is a very common disorder that causes great suffering for the patient. Recognizing depressed patients in primary care (PC) settings is a challenge and only about half are identified as depressed by their general practitioner (GP). Among patients receiving antidepressants (AD) about 70 % are improved, but only about 35 % reach remission. Hence, there is a need to identify depressed patients and to develop optimal treatment strategies in PC. Self-rating scales can be helpful in assisting the recognition. Patients’ beliefs about the cause of depression and their attitudes towards treatment options have been found to influence their help-seeking behavior, coping strategies, treatment preferences and adherence. To increase depressed patients’ knowledge about their disorder and to help them reach and stay in remission, the “Contactus program” was launched in Sweden, containing patient education and group counseling, as supplement to the usual care in PC.

Aims To explore patients’ beliefs about causes and improvement factors for depression, and evaluate if the Contactus program could help to improve treatment outcome. Also, to investigate the psychometrics of two commonly used self-rating scales for depression, HADS and PHQ-9.

Methods Treatment outcome among patients participating in the Contactus program (N=205) was compared to a control group (N=114) treated as usual. The outcome was measured by HADS, GAF-self and by questionnaires. Both groups also answered an open-ended question about the cause of their depression at baseline and another question about improvement factors at follow-up after six weeks. To compare HADS and PHQ-9, patients (N=737) visiting their physician because of depression filled in both scales. The scales cut-offs were compared with Cohen’s Kappa, internal consistency was calculated and factor analysis was performed. 

Results Depressed patients participating in the Contactus program had a response rate of 55 % compared to 29 % in the control group (p=0.006). Also, remission was reached among 42 % in the Contactus group and 21 % among the controls (p=0.02). The patient’s subjective evaluation of the outcome after six weeks showed that 72% of the Contactus patients considered themselves improved vs. 47% among controls (p=0.01). The most common described reason for depression was current stress, most often work related, and own personality traits. Very few mentioned biological factors. For improvement, the most commonly mentioned aspects were participation in the Contactus program and AD. When comparing HADS to PHQ-9 their agreement at recommended cut-offs, HADS-D≥11 and PHQ-9≥10, was low (k=0.35). The highest Kappa value (0.56) and also equal prevalence of depression were found at HADS-D≥8 and PHQ≥12. Both scales had a high internal consistency (α=0.9).

Conclusions The results of this thesis indicate that patient education and group counseling are valuable supplements to usual treatment of depression in PC. It is also clear that patients and professionals often have different opinions about the causes of depression, at least concerning biological factors. The patients were generally positive to professional help. The patients’ own beliefs about their illness must be considered when developing new types of interventions and when trying to reach an understanding in the patient-doctor encounter. Finally, there are many self-rating scales for depression. Here two scales were compared and both showed good psychometric properties in terms of internal consistency and factor structure. However their optimal cut-offs were questioned. In conclusion, self-rating scales are useful in identifying depressed patients in PC and might also be apt for measuring treatment outcome. Offering the patient education about their disorder and possibility to share experiences seems to increase response and remission rates, substantially. More studies are needed to explore the effects of educational programs, group interventions, and how patients’ own believes interact with the choice of treatment, adherence and outcome.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2010. , 63 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1308
Keyword [en]
Depression, primary care, patient education, group counselling, patients’ beliefs, treatment, causes, self-rating scales, HADS, PHQ-9
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-30516ISBN: 978-91-7264-891-3 (print)OAI: oai:DiVA.org:umu-30516DiVA: diva2:284426
Public defence
2010-01-29, Sal B, Tandläkarhuset, 9 tr, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2010-01-09 Created: 2010-01-07 Last updated: 2010-01-18Bibliographically approved
List of papers
1. Patient education and group counselling to improve the treatment of depression in primary care: a randomized controlled trial
Open this publication in new window or tab >>Patient education and group counselling to improve the treatment of depression in primary care: a randomized controlled trial
2008 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 105, no 1-3, 235-240 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The Contactus program for depressed patients in primary care, consists of six lectures about depression, each followed by a group discussion. The aim of this study was to investigate if Contactus can improve treatment outcome in comparison to a control group. METHODS: Forty-six primary care centres in Sweden, each randomly allocated either to the Contactus group or to the control group, included depressed patients, 205 in the Contactus group and 114 in the control group. Besides regular treatment of depression, the Contactus group participated in the educational program. At start and after 6 weeks, patients filled in a questionnaire and the self-reports: HADS (Hospital Anxiety and Depression Scale) and GAF-self (Global Assessment of Functioning). RESULTS: After 6 weeks, clinically depressed patients (HAD-depression score >10) had a mean improvement in HAD-D of 4.6 in Contactus vs. 3.0 in controls (p=0.02), and 72% vs. 47% considered themselves to feel better (p=0.01). Increase in GAF score was 11.8 vs. 5.8 (p=0.04), respectively. According to HADS, 55% in Contactus were responders vs. 29% among controls (p=0.006), and 42% vs. 21% (p=0.02) were in remission. LIMITATIONS: Only 40% of the patients in Contactus and 35% among controls were clinically depressed according to the HADS (>10 points) at inclusion. CONCLUSIONS: Patient education and group counselling contributes significantly to better improvement among depressed patients. Group treatment is inexpensive and could be implemented in the routine care of depressed patients in primary care.

Identifiers
urn:nbn:se:umu:diva-30520 (URN)10.1016/j.jad.2007.04.007 (DOI)17509694 (PubMedID)
Available from: 2010-01-07 Created: 2010-01-07 Last updated: 2017-12-12Bibliographically approved
2. Comparison of two self-rating scales to detect depression: HADS and PHQ-9
Open this publication in new window or tab >>Comparison of two self-rating scales to detect depression: HADS and PHQ-9
2009 (English)In: British Journal of General Practice, ISSN 0960-1643, E-ISSN 1478-5242, Vol. 59, no 566, e283-288 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: More than half of patients with depression go undetected. Self-rating scales can be useful in screening for depression, and measuring severity and treatment outcome. AIM: This study compares the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ-9) with regard to their psychometric properties, and investigates their agreement at different cut-off scores. METHOD: Swedish primary care patients and psychiatric outpatients (n = 737) who reported symptoms of depression completed the self-rating scales. Data were collected from 2006 to 2007. Analyses with respect to internal consistency, factor analysis, and agreement (Cohen's kappa) at recommended cut-offs were performed. RESULTS: Both scales had high internal consistency (alpha = 0.9) and stable factor structures. Using severity cut-offs, the PHQ-9 (> or =5) diagnosed about 30% more patients than the HADS depression subscale (HADS-D; > or =8). They recognised the same prevalence of mild and moderate depression, but differed in relation to severe depression. When comparing recommended screening cut-offs, HADS-D > or =11 (33.5% of participants) and PHQ-9 > or =10 (65.9%) agreement was low (kappa = 0.35). Using the lower recommended cut-off in the HADS-D (> or =8), agreement with PHQ-9 > or =10 was moderate (kappa = 0.52). The highest agreement (kappa = 0.56) was found comparing HADS-D > or =8 with PHQ-9 > or =12. This also equalised the prevalence of depression found by the scales. CONCLUSION: The HADS and PHQ-9 are both quick and reliable. The HADS has the advantage of evaluating both depression and anxiety, and the PHQ-9 of being strictly based upon the Diagnostic and Statistical Manual of Mental Disorders. The agreement between the scales at the best suitable cut-off is moderate, although the identified prevalence was similar. This indicates that the scales do not fully identify the same cases. This difference needs to be further explored.

Identifiers
urn:nbn:se:umu:diva-26132 (URN)10.3399/bjgp09X454070 (DOI)19761655 (PubMedID)
Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2017-12-13Bibliographically approved
3. Patients' beliefs about the cause of their depression
Open this publication in new window or tab >>Patients' beliefs about the cause of their depression
2010 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 124, no 1-2, 54-59 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Patients' beliefs about the cause of their depression can affect their help-seeking behavior, treatment preferences, coping strategies and treatment compliance. There are few studies exploring depressed patients' beliefs about the causes and to our knowledge none in a Swedish population. However, previous studies show that the patients more often mention environmental and psychological causes than biological. The aim of this study was to further explore depressed patients' answers to an open-ended question about the etiology of their depression. METHODS: Primary care patients, participating in a study evaluating patient education, were asked an open-ended question about their beliefs about what had caused their depression. Answers were obtained from 303 patients. RESULTS: The analysis of the patients' beliefs emerged into 16 different categories of explanations for depression that could be organized into three larger themes: current life stressors, past life events and constitutional factors. Work-related stress was the most commonly mentioned cause, followed by personality and current family situation. Only 3.6% stated biological reasons. LIMITATIONS: We could only count the frequency of mentioned causes, but no ranking of the importance of these causes. CONCLUSIONS: Primary care patients often gave multi-causal explanations to their depression. Biological explanations were rare. Their beliefs were predominantly current life stressors such as work or family situation and also their own personality. Patients' beliefs about their illness are important in the patient-doctor encounter, when developing new treatment strategies aiming at improved adherence to both psychopharmacological and psychotherapeutic treatments and also in patient education programs.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-30515 (URN)10.1016/j.jad.2009.10.032 (DOI)000278787400007 ()19923007 (PubMedID)
Available from: 2010-01-07 Created: 2010-01-07 Last updated: 2017-12-12Bibliographically approved
4. What made me feel better?: patients’ own explanations for the improvement of their depression
Open this publication in new window or tab >>What made me feel better?: patients’ own explanations for the improvement of their depression
(English)Article in journal (Refereed) Submitted
Abstract [en]

Background: Depression is common among primary care patients and among those recognized the usual treatment often consists of antidepressants and supportive counselling/follow-ups. Previous studies have shown that patients and professionals have different beliefs about treatment which in turn can decrease acceptance of the diagnosis, compliance and treatment outcome.

Methods: Depressed primary care patients (N=184) who considered themselves improved at follow-up answered an open-ended question about what they believed had made them better. Among these 117 patients had, in addition to treatment as usual, participated in an intervention with patient education and group counselling (the Contactus program) while 67 were controls. The groups were comparable at baseline and 82 % were on antidepressants.

Results: In total, the patients mentioned 14 separate improving factors which could be organized to the larger themes external factors, self-management, passing spontaneously and professional help. The most frequently mentioned factors for improvement were the Contactus program (53.0 %), antidepressants (40.2 %) and personal development (27.2 %). Few gender and age differences were seen. The controls who mentioned professional help were more likely to have a better outcome.

Limitations: The construct of the open-ended question did not allow us to analyze the rank order of importance of each improving factor.

Conclusions: The patients were generally positive to professional help such as antidepressants and the Contactus program. Patient education and group counselling seems to be a valuable supplement to treatment of depressed patients in primary care.

Identifiers
urn:nbn:se:umu:diva-30521 (URN)
Available from: 2010-01-07 Created: 2010-01-07 Last updated: 2011-05-17Bibliographically approved

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