Inflammation and Depression: A Public Health Perspective

The multifaceted role of low-grade systemic inflammation in depression and physical illnesses like cardiovascular disease highlights complex interactions between the body, brain and mind. While current research on inflammation and depression has largely focused on exploring possible disease mechanisms and therapeutic potential, we seek to broaden the current discussion by introducing a public health perspective. In this Viewpoint, we propose that inflammation and its contributing sources could represent important targets for public health strategies aimed at improving both mental and physical health. We discuss potential universal, selective and indicated primary prevention strategies for inflammation-related depression. We consider potential approaches to secondary prevention, including scope for anti-inflammatory treatment and CRP testing for guiding treatment allocation and prognosis. Preventive strategies discussed here could also be relevant for other inflammation-mediated mental health conditions.     

Depression Program in Primary Health Care

Chile is a middle income country in the process of demographic transition, where mental health problems contribute significantly to the disease burden. In 2001, Chile introduced gradually the Program of Treatment for Depression in Primary Health Care (PTDPHC), which includes a multicomponent care model according to the severity of the medical profile: integral evaluation by a team of professionals, antidepressant drug treatment, individual psychotherapy, psychoeducational group intervention, and monitoring visits. In 10 years of operation, this program has attended more than 1 million adults. We have conducted several evaluations of this program, and our results show that PTDPHC is effective in decreasing depressive symptoms and comorbidity, has positive effects on the patient and their partners, and is independent of the center; the greatest threat to achieving effectiveness is the rate of treatment dropout. In the future, the manager of this policy must meet the following challenges: the continuous training of primary care teams, the incorporation of techniques that have been shown to improve compliance, and the extension of coverage to remote areas, where telepsychiatry could be a good idea.     

Antenatal Depression Strongly Predicts Postnatal Depression in Primary Health Care

Objective: To estimate the association between antenatal and postnatal depression and to examine the role of socioeconomic conditions in the risk of postnatal depression. Methods: A prospective cohort study, conducted between May 2005 and January 2006, with 831 pregnant women recruited from primary care clinics in the public sector in the city of São Paulo, Brazil. The presence of antenatal and postnatal depression was measured with the Self Report Questionnaire (SRQ-20). Sociodemographic and socioeconomic characteristics and obstetric information were obtained through a questionnaire. Crude and adjusted risk ratios (RR), with 95% CI, were calculated using a Poisson regression. Results: The prevalence of postnatal depressive symptoms was 31.2% (95%CI: 27.8-34.8%). Among the 219 mothers who had depressive symptoms, nearly 50% had already shown depressive symptoms during pregnancy. Women who had antenatal depression were 2.4 times more likely to present with postnatal depression than were women who did not have such symptoms during pregnancy. In the multivariate analysis, higher scores for assets (RR: 0.76, 95% CI 0.61-0.96), higher education (RR: 0.75 95%CI 0.59-0.96), daily contact with neighbors (RR: 0.68, 95%CI 0.51-0.90) and antenatal depression (RR: 2.44, 95%CI 1.93-3.08) remained independently associated with postnatal depression. Conclusions: Antenatal and postnatal depression are highly prevalent in the primary care setting.     

Treatment Resistant Depression: Strategies for Primary Care

Depression is commonly diagnosed and treated in primary care. Recent evidence indicates that the majority of depressed patients will not fully recover with an initial antidepressant treatment. This paper reviews commonly used options for treatment after an inadequate initial antidepressant response. The alternatives range widely, and include escalating the dose of the initial antidepressant, switching to an alternative medication, combining two antidepressants with different mechanisms of action (e.g., bupropion + SSRI or mirtazapine + venlafaxine), adding other medications such as lithium or certain atypical antipsychotics (olanzapine, aripiprazole, or quetiapine) to the antidepressant, adding a natural product such as l-methylfolate or s-adenosylmethionine (SAMe), or adding cognitive behavioral psychotherapy. What agent to be used will depend on the comfort level of the primary care practitioner and the availability of Psychiatry referral. However, it is reasonable to take one or more additional steps to attempt to achieve remission.     

National Patterns of Depression Treatment in Primary Care

BACKGROUND: While past studies suggest that primary care physicians underdiagnose and undertreat depression, little is known about recent national patterns of depression treatment. METHOD: Using the 1995 and 1996 National Ambulatory Medical Care Surveys, we analyzed 1322 primary care office visits by patients reported to have depression. Rates of psychotherapy/mental health counseling, antidepressant use, and benzodiazepine use were assessed. Independent predictors of depression therapy were examined using multiple logistic regression. Where instructive, we compared the practices of primary care physicians with those of psychiatrists (2418 depression visits). RESULTS: Primary care physicians reported depression in 7.8% of their office visits. For these depression visits, antidepressants (42%) were the most common form of treatment, followed by psychotherapy/mental health counseling (28%) and benzodiazepines (21%). Among specific antidepressants, selective serotonin reuptake inhibitors were most often prescribed by primary care physicians (26% of depression visits). Rates of antidepressant and benzodiazepine use varied significantly by primary care specialty. In addition, geographic region and health insurance status influenced the likelihood of receiving benzodiazepines. In their depression visits, psychiatrists reported psychotherapy/mental health counseling (88%) most frequently, followed by antidepressants (64%) and benzodiazepines (25%). CONCLUSION: The predominant use of selective serotonin reuptake inhibitors suggests that primary care physicians have begun to adopt new therapeutic strategies for depression. The modest rate of antidepressant therapy for a clinical population specifically identified by primary care physicians as having depression may indicate undertreatment of depression in primary care settings. Furthermore, high rates of benzodiazepine use are inconsistent with treatment guidelines, and variations in treatment patterns suggest that nonclinical factors influence depression management.     

Escitalopram: A New SSRI for the Treatment of Depression in Primary Care

Escitalopram is the S-enantiomer of the racemic compound citalopram, a selective serotonin reuptake inhibitor (SSRI) widely used for the treatment of depression. This review describes the current body of pharmacologic and clinical evidence supporting the use of escitalopram for the treatment of depression and anxiety. Preclinical studies have confirmed that it is primarily this molecule that provides the inhibition of serotonin reuptake responsible for the antidepressant effect of citalopram, with minimal-to-nonexistent affinity for other receptor sites. Clinical trials of escitalopram in depressed patients indicate that escitalopram, 10 mg/day, is as effective as 40 mg/day of its parent compound, citalopram, with an excellent safety and tolerability profile. Because of its increased selectivity, escitalopram represents a refinement in SSRI therapy for symptoms of depression and anxiety. This article also explores the implications of a more selective SSRI on the management of depressed patients in the primary care clinical practice.     

Patient Self-Management in the Primary Care Treatment of Depression

Efforts to improve primary care treatment of depression incorporate elements of the chronic illness care model, including patient self-management strategies. Case studies, focus groups and the literature suggest six key components of depression self-management programs: (1) implement behavioral change interventions, (2) plan for crisis and relapse prevention, (3) re-establish personal meaning, (4) attend to patients’ experience, context and community, (5) build a patient–clinician partnership and (6) create an integrated, self-management support structure. Successful implementation of these components is facilitated by (1) the care system’s collective and empathic understanding of the disease itself; (2) sufficient time; (3) adequate funding and (4) robust clinical information systems.     

Enhancement of Treatment Response in Depression in the Primary Care Setting

This Academic Highlights section of The Primary Care Companion to The Journal of Clinical Psychiatry presents the highlights of the teleconference "Enhancement of Treatment Response in Depression" held May 18, 2004, and supported by an unrestricted educational grant from Cephalon, Inc. This meeting report was prepared by Physicians Postgraduate Press, Inc.     

Screening for Depression and High Utilization of Health Care Resources Among Patients in Primary Care

The study aims to evaluate the prevalence of depression and the severity of depressive symptoms among primary care patients, who are high utilizers (HU) of health care resources. A cross-sectional, two-stage design was applied to screen for depression using the Brief Psychiatric Health Questionnaire and the Diagnostic Expert System for Psychiatric Disorders. A total of 38 primary care physicians accredited to practice in Berlin and Potsdam in Germany participated in the study. A total of 1,775 patients participated, 507 were identified as HU, 182 (36 %) of these were depressed compared to 81 (11 %) of the typical utilizers (p < 0.001). The depression score was higher and acute suicidality was more prevalent in HU than in typical utilizers (p < 0.001). Our results suggest that HU represent a population with a high prevalence of depression in primary care and should be considered for routine depression screening.     

Depression Care Management for Chinese Americans in Primary Care: A Feasibility Pilot Study

This study describes a culturally relevant intervention using a collaborative depression care model to integrate mental health and primary care services for depressed low income Chinese-Americans at a community health center. A total of 6,065 patients were screened for depression. Of the 341 who screened positive, 57 participated and were randomly assigned to receive either enhanced physician care with care management (32) or enhanced physician care only (25). All enrolled participants were assessed at baseline and 4 monthly follow-up visits for depression, physical and mental health functioning, and perceived stigma toward receiving depression care, to determine the impact, if any, of their mental health treatment. Both groups reported significant reduction of depressive symptoms and improved mental health functioning from baseline to follow-up assessments although there was no significant difference between the two groups. Although the study found no advantage to adding the care management component in the treatment of depression, screening and assertive treatment of immigrant Chinese Americans who tend to underutilize mental health services is important and consistent with the increased adoption of team based care models in patient centered medical homes. High refusal rates for enrollment in the study have implications for future study designs for this group.     

Mental Health in Primary Health Care

Children and families across the world face a multitude of ever-changing challenges that affect their sense of emotional well-being. Dilemmas for children in the first world include competition, consumerism, individualism, narcissism, family breakdown contributing to children as consumers, the erosion of collective (social) responsibility, dislocation, alienation, inequality, relative poverty, and crime. Dilemmas for children in the third world include regional wars and conflict, ecological catastrophe (man-made and natural) contributing to material poverty, lack of state resources (e.g., medical), migration, fragmentation of communities, disease, malnutrition, and crime. Each society has its own mechanisms to promote the natural resilience of children and families in the face of each individual, family, and society's unique challenges. The era of globalization has resulted in the global exchange of not only goods but also ideas and values, resulting in new challenges. Aggressive free market global economic systems contribute to the creation of new dangers. Child psychiatry has unwittingly contributed to reifying children's mental health, helping to obscure the real-life situations that create mental distress. The development of universalized therapeutic approaches has inadvertently replicated colonial dynamics by imposing Western notions of self, childhood, and family onto non-Western populations. Globalization also brings new opportunities for new identities, fusions, and creative solutions. The implications of this perspective for theory, research, and clinical practice in child and adolescent mental health are explored.     

The State of Readiness of Lagos State Primary Health Care Physicians to Embrace the Care of Depression in Nigeria

Globally there is a huge treatment gap for common mental disorders such as depression. Key to improving access to treatment will be the attitudes held towards depression by those physicians who work in Primary Care. This study aimed to explore Lagos State’s Primary Care Physicians’ attitudes towards depression and their views regarding their current working practices. A survey of 41 (82 %) Primary Care Physicians in Lagos State who, after written consent, completed the Depression Attitude Questionnaire which assessed their knowledge and attitude towards the causes, consequences and treatment of depression. The largest part of the sample (37.5 %) estimated that between 5 and 10 % of the patients they saw over a 3 months period would have depression while one in four perceived rates of depression seen to be between 31 and 40 %. Close to half (40 %) of them felt that fewer than 5 % of these depressed patients they saw would need antidepressants and a large part (82.9 %) of them agreed that becoming depressed is a way that people with poor stamina deal with life difficulties. About half (41.6 %) of them believed it was not rewarding to look after depressed patients. Our study suggests that the current knowledge, attitudes and practices of most Lagos State primary health care physicians may be a barrier to patients with depression accessing appropriate care.     

Treatment Adequacy and Adherence as Predictors of Depression Response in Primary Care

ObjectivePrimary care is the de facto mental health system in the United States where physicians treat large numbers of depressed older adults with antidepressant medication. This study aimed to examine whether antidepressant dosage adequacy and patient adherence are associated with depression response among middle-aged and older adults prescribed with antidepressants by their primary care provider.DesignA secondary analysis was conducted on a sample drawn from a randomized controlled trial comparing Treatment as Usual to Treatment Initiation Program, an adherence intervention. Treatment Initiation Program improved adherence but not depression compared to Treatment as Usual (Sirey et al., 2017). For this analysis, we examined dosing adequacy and adherence at 6 and 12 weeks as predictors of depression response in both groups at 12 and 24 weeks.SettingPrimary care practices.ParticipantsOne hundred eighty-seven older adults with depression prescribed an antidepressant for depression by their primary care provider.MeasurementsDepression response was defined as 50% reduction on the Hamilton Rating Scale for Depression. Adherence was defined as taking 80% of doses at follow-up interviews (6 and 12 weeks). Patient-reported dosage and duration of antidepressant therapy was collected using the Composite Antidepressant Score (adequacy score of >3) at follow-up.ResultsGreater adherence, but not receipt of adequate dosage, was associated with higher likelihood of treatment response at both 12 (Odds ratio (OR) = 2.63; 95% Confidence Interval (CI), 1.19–5.84) and 24 weeks (OR = 3.09; 95% CI, 1.46–6.55).ConclusionAs physicians prescribe antidepressants to the diverse group of adults seen in primary care, special attention to patients’ views and approach to adherence may improve depression outcomes.