Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO study. Functional status,health service use and treatment of people with depressive symptoms

BACKGROUND: Screening surveys of depressive symptoms were conducted among primary care patients at six sites in different countries. The LIDO Study was designed to assess quality of life and economic correlates of depression and its treatment in culturally diverse primary health care settings. This paper describes: (1) the association between depressive symptoms and functional status, global health-related quality of life (QoL), and use of general health services across different cultural settings; and (2) among subjects with depressive symptoms, the factors associated with recent treatment for depression. METHODS: Subjects aged 18 to 75 were recruited from participating primary care facilities in Be'er Sheva (Israel), Porto Alegre (Brazil), Melbourne (Australia), Barcelona (Spain), St Petersburg (Russian Federation) and Seattle (USA). Depressive symptoms were measured using the CES-D. Also administered were the SF-12, global questions on QoL, selected demographic and social measures, and questions on recent treatment for depression, use of health care services, and lost workdays. RESULTS: A total of 18,489 patients were screened, of whom 37% overall (range 24-55%) scored > or = 16 on the CES-D and 28% (range 17-42%) scored > or = 20. Overall, 13% reported current treatment for depression (range 4 to 23%). Patients with higher depressive symptom scores had worse health, functional status, QoL, and greater use of health services across all sites. Among those with a CES-D score > or = 16, subjects reporting treatment for depression were more likely than those reporting no treatment to be dissatisfied with their health (except in St Petersburg), and to have higher depressive symptom scores. CONCLUSIONS: Higher depressive symptom scores in primary care patients were consistently associated with poorer health, functional status and QoL, and increased health care use, but not with demographic variables. The likelihood of treatment for depression was associated with perceptions of health, as well as severity of the depression.     

The clinical effectiveness of counselling in primary care: a systematic review and meta-analysis

BACKGROUND: Counselling is frequently used in the management of common mental disorders (such as anxiety and depression) in primary care. However, there are concerns over the clinical effectiveness of counselling, both in comparison with usual general practitioner care, and with other treatments such as alternative psychological therapies and antidepressant treatment. This study used systematic review methodology to assess the current evidence-base. METHOD: A systematic literature review located seven trials of relevance, comparing counselling with usual general practitioner care, cognitive-behaviour therapy and antidepressant medication. Data on internal and external validity were examined using a standardized quality rating scheme. Data concerning the impact of counselling on symptoms of anxiety and depression were pooled using meta-analytical procedures. RESULTS: The main analyses showed significantly greater clinical effectiveness of counselling compared with usual general practitioner care in the short-term (standardized mean difference -0.28, 95% CI -0.43 to -0.13, N=741, six trials) but not the long-term (standardized mean difference -0.07, 95% CI -0.26 to 0.12, N=447, four trials). Sensitivity analyses were undertaken to test the robustness of the results. CONCLUSION: Counselling is associated with modest improvement in short-term outcome compared with usual general practitioner care, and thus may be a useful addition to mental health services in primary care.     

Relationship of psychiatric status to Gulf War veterans' health problems.

OBJECTIVE: A growing body of research has shown that there are important links between certain psychiatric disorders and health symptom reporting. Two disorders in particular (posttraumatic stress disorder (PTSD) and major depression) have been the most widely implicated to date, and this association has sometimes been used to explain the occurrence of ill-defined medical problems and increased somatic symptoms in certain groups, most recently Gulf War veterans. METHODS: Structured psychiatric diagnostic interviews were used to examine the presence of major psychiatric (axis I) disorders and their relation to health symptom reporting in a well-characterized, stratified subset of Gulf War veterans and a non-Gulf-deployed veteran comparison group. RESULTS: Rates of most psychiatric disorders were substantially lower than national comorbidity estimates, consistent with prior studies showing heightened physical and emotional well-being among active-duty military personnel. Rates of PTSD and major depression, however, were significantly elevated relative to the veteran comparison group. The diagnosis of PTSD showed a small but significant association with increased health symptom reports. However, nearly two-thirds of Gulf participants reporting moderate to high health symptoms had no axis I psychiatric diagnosis. CONCLUSIONS: Results suggest that rates of psychiatric illness were generally low with the exception of PTSD and major depression. Although PTSD was associated with higher rates of reported health problems, this disorder did not entirely account for symptoms reported by participants. Factors other than psychiatric status may play a role in Gulf War health problems.     

What depressive symptoms are associated with the use of care services? Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

Background: Depression is generally regarded as a serious, incapacitating illness. Although effective treatment strategies are available, timely recognition remains a stumbling block. We investigated the rates of health service uptake among depressed people and the specific depressive symptoms associated with service use, after adjustment for other illness characteristics and sociodemographic variables. Methods: In a representative sample (n=7076) of the Dutch adult population, we identified 1572 subjects with lifetime major or minor depression, using the Composite International Diagnostic Interview. Results: The majority (73%) of subjects with depression had sought specialised mental health care, or to a lesser extent primary care. As expected, those with more severe (vegetative), complex (anxiety-comorbid) or dangerous symptoms (suicidal ideation) were more likely to be treated in the specialised mental health sector. However, subjects with comorbid substance use dependence were less likely to receive care, especially primary care, and those with more education were more likely to receive specialised care, even after adjustment for illness characteristics. Limitations: The use of lifetime measures of depression and service use may have introduced slight recall bias, but it made the assessments less vulnerable to selection bias for chronic cases and to misclassification of subjects with some lifetime treatment experience. Conclusions: Although care for people with depression is readily accessible in the Netherlands, people with less education and people with comorbid substance use dependence remain unnecessarily out of reach of the care services. Primary care services need to be strengthened to enable the broad-scale application of stepped-care strategies.     

Psychosocial and health belief variables associated with frequent attendance in primary care

BACKGROUND: The reasons for high use of primary care, and in particular the role of psychosocial factors, remain unclear. METHODS: We identified and interviewed 236 frequent attenders and 420 normal users, matched by age and sex, of a public Health Centre in Granada, Spain. Users were questioned about mental health (GHQ-28), social support (Duke-UNC-11), family dysfunction (family APGAR) and health beliefs (health belief model, locus of health control and medical care expectations). We also measured a set of individual, social and illness variables. RESULTS: Multiple logistic regression analyses showed that mental health was the main factor associated with frequent attender status (odds ratio = 3.1; 2.4-3.9). The association was stronger than that between frequent attender status and perceived illness, and between the former and reported chronic illness. Family dysfunction and perceived susceptibility to and severity of disease were also significantly but more weakly associated with frequent attender status. Affective support was more strongly associated with FA status than was confidant support, but both associations disappeared when mental health and family function were controlled for. CONCLUSIONS: Our findings document the association of psychosocial factors and primary health care use. We suggest that the effective management of mental health problems from a family-based approach may reduce primary health care high use.     

汶川地震受灾地区灾后社区、乡镇卫生院工作者精神卫生服务能力评估

目的:了解汶川受灾地区社区、乡镇卫生院工作者的精神卫生知识掌握情况及精神卫生服务能力,为精神卫生培训提供依据,为我国精神卫生服务体系建设提供科学参考。方法:选取灾后社区、乡镇卫生工作者心理卫生服务技能培训班学员353名为研究样本,回收有效问卷313份。使用自编精神卫生知识评估问卷和精神卫生服务调查表进行评估。自编精神卫生知识评估问卷包含抑郁症、酒精依赖、精神分裂症(阳性症状为主)、创伤后应激障碍和躯体形式障碍5种精神障碍。结果:受灾地区乡镇、社区卫生院工作者对于社区5种精神障碍准确诊断率最高的案例为抑郁症(77.0%),药物处理中位数得分最高的为酒依赖;非药物处理中位数得分最高的是酒依赖和创伤后应激障碍。培训前1月内报告未接诊过精神障碍患者的社区、乡镇卫生院工作者占53.4%。不知道任何1所精神卫生服务机构的卫生院工作者占35.1%;不知道精神科专科会诊的占37.7%;不能邀请精神科专科会诊的占39.6%。结论:汶川地震后,受灾地区的乡镇、社区卫生院工作者精神卫生知识和技能掌握较少,精神卫生服务能力相对弱。     

Consequences of anxiety in older persons: its effect on disability, well-being and use of health services.

BACKGROUND: Although anxiety is quite prevalent in late life, its impact on disability, well-being, and health care utilization of older persons has not been studied. Older persons are a highly relevant age group for studying the consequences of anxiety, since their increasing numbers put an extra strain on already limited health care resources. METHODS: Data of a large community-based random probability sample (N = 659) of older subjects (55-85 year) in the Netherlands were used to select three groups: subjects with a diagnosed anxiety disorder, subjects with merely anxiety symptoms and a reference group without anxiety. These groups were compared with regard to their functioning, subjective well-being, and use of health care services, while controlling for potentially confounding variables. RESULTS: Anxiety was associated with increased disability and diminished well-being. Older persons with a diagnosed anxiety disorder were equally affected in their functioning as those with merely anxiety symptoms. Although use of health services was increased in anxiety sufferers, their use of appropriate care was generally low. CONCLUSIONS: Anxiety has a clear negative impact on the functioning and well-being of older subjects. The similarity of participants with an anxiety disorder and those having merely anxiety symptoms regarding quality of life variables and health care use was quite striking. Finally, in spite of its grave consequences for the quality of life, appropriate care for anxiety is seldom received. Efforts to improve recognition, disseminate effective treatments in primary care, and referring to specialized care may have positive effects on the management of anxiety in late life.     

Uptake of mental health websites in primary care: Insights from an Australian longitudinal cohort study of depression

Objective

To describe the characteristics of primary care attendees with depressive symptoms who use mental health websites.

Rates and consequences of posttraumatic distress among American Indian adults with type 2 diabetes

This study examined the prevalence of screened posttraumatic stress disorder (PTSD) and associated diabetes-related outcomes. A sample of American Indian adults with type 2 diabetes (n = 218) participated in interviewer-administered surveys. Using a cutoff of 3 on the Primary Care PTSD screener, 21.8 % of participants screened positive for PTSD. PTSD symptoms were negatively associated with self-rated health status and positively associated with past year hospitalization after controlling for several demographic factors, but not after controlling for depressive symptoms. Past month frequency of hyperglycemia symptoms was not related to PTSD symptoms. When grouped by mental health conditions (neither screened PTSD nor depressive symptoms, screened PTSD only, depressive symptoms only, and both), those with both screened PTSD and depressive symptoms reported the highest proportion of any past month hyperglycemia, past year hospitalization, and low self-rated health status. Screened PTSD, especially in those with comorbid depressive symptoms, is an important consideration in diabetes care.     

Changes in PTSD symptomatology and mental health during pregnancy and postpartum

Changes in mental health symptoms throughout pregnancy and postpartum may impact a woman’s experience and adjustment during an important time. However, few studies have investigated these changes throughout the perinatal period, particularly changes in posttraumatic stress disorder (PTSD) symptoms. The purpose of this study was to examine longitudinal changes in PTSD, depression, and anxiety symptomatology during pregnancy and postpartum. Pregnant women of ethnically diverse backgrounds receiving services for prenatal care at an outpatient obstetric-gynecology clinic or private physicians’ office were assessed by interview on symptoms of PTSD, depression, anxiety, and general stress up to four times, including their first, second, and third trimester, and postpartum visits. Overall, during pregnancy there was a declining trend of PTSD symptoms. For anxiety, there was no overall significant change over time; however, anxiety symptoms were individually variable in the rate of change. For both depression and general stress symptoms, there was a declining trend, which was also variable in the individual rate of change among women during their pregnancy. Visual and post hoc analyses also suggest a possible peak in PTSD symptoms in the weeks prior to delivery. While most mental health symptoms may generally decrease during pregnancy, given the individual variability among women in the rate of change in symptoms, screening and monitoring of symptom fluctuations throughout the course of pregnancy may be needed. Further studies are needed to examine potential spiking of symptoms in the perinatal period.     

Direct and indirect links between childhood maltreatment, posttraumatic stress disorder, and women's health

The authors evaluated the relationships among childhood maltreatment, sexual trauma in adulthood, posttraumatic stress disorder (PTSD), and health functioning in women. Female Veterans' Affairs (VA) primary care patients (N = 200) completed self-report measures of childhood maltreatment, adult sexual trauma, PTSD symptoms, and current health functioning. The authors used structural equation modeling to test models of the relationship among these variables. Childhood nonsexual maltreatment and adult sexual assault were positively associated with PTSD. Childhood nonsexual maltreatment (beta = -.20) and PTSD (beta = -.75) were significantly associated with poorer physical and mental health functioning. Adult sexual assault negatively affected health functioning through its association with PTSD. Thus, poor health outcomes associated with childhood maltreatment in women may be conveyed through PTSD. These findings should strengthen efforts directed at identifying and treating PTSD in female victims of childhood maltreatment with the aim of preventing or attenuating poor health outcomes.     

Somatization among older primary care attenders

BACKGROUND: The importance of somatization among older primary care attenders is unclear. We aimed to establish the prevalence, persistence and associations of somatization among older primary care attenders, and the associations of frequent attendance. METHOD: One hundred and forty primary care attenders over 65 years were rated twice, 10 months apart, on measures of somatization, psychiatric status, physical health and attendance. RESULTS: The syndrome of GMS hypochondriacal neurosis had a prevalence of 5% but was transient. Somatized symptoms and attributions were persistent and associated with depression, physical illness and perceived poor social support. Frequent attenders (top third) had higher rates of depression, physical illness and somatic symptoms, and lower perceived support. CONCLUSION: Somatization is common among older primary care attenders and has similar correlates to younger primary care somatizers. Psychological distress among older primary care attenders is associated with frequent attendance. Improved recognition should result in benefits to patients and services.     

Functional status and use of health care services: longitudinal study on the older adult population in Spain

BACKGROUND: Follow-up studies on the association between functional status and use of health care services among the older people are scarce and have studied only a few types of service. OBJECTIVE: To examine prospectively the relationship between limitation in instrumental activities of daily living (IADL) and utilization of a wide variety of health care services among older adults in Spain. METHODS: Prospective study from 2001 to 2003 of a cohort of 2806 persons, representative of the non-institutionalized Spanish population aged 60 years and over. Limitation in IADL was measured in 2001 using the Lawton and Brody's test. Data on the use of health care services were collected in 2003 and classified into home services (home visits by physicians and nurses) and non-home services (visits to primary care physicians, visits to hospital specialists, hospital admissions, emergency care, and influenza vaccination). Analyses were performed with logistic regression and adjusted for the main confounders. RESULTS: Compared to men with no limitation in IADL, a higher percentage of those with limitation in one IADL in 2001 made use of both home (odds ratio [OR] 2.64; 95% confidence interval [95% CI] 1.73-4.03) and non-home services (OR 2.02; 95% CI 1.04-3.93) in the period 2001-2003. Limitation in one IADL among women was associated with a greater utilization of home services (OR 1.50; 95% CI 1.05-2.14) and visits to hospital specialists (OR 1.61; 95% CI 1.21-2.15). In women, however, a greater number of limited IADL at baseline was inversely associated with visits to primary care physicians in the 2-year follow-up (p for linear trend <0.001). CONCLUSION: Population aging will increase the demand for health services in general, and for home services in particular.     

Diabetes, depression, and healthcare utilization among African Americans in primary care

PURPOSE: This study tested for an association between diabetes and depressive symptoms and assessed the effect of co-occurring diabetes and depressive symptoms on healthcare utilization outcomes among African-American patients. PROCEDURE: The sample consisted of 303 adult African-American patients age 40 and over from a primary care clinic serving the low-income population in Nashville, TN. Measures were based on self-reports during a structured interview. Multivariate analyses adjusted for age, gender, socioeconomic status, and comorbid chronic conditions. FINDINGS: African-American patients with and without diabetes did not differ on the presence or severity of depressive symptoms. However, the co-occurrence of major depressive symptoms with diabetes among African Americans was associated with nearly three times more reported emergency room visits and three times more inpatient days, but was only marginally associated with a lower number of physician visits. CONCLUSIONS: In contrast to previous studies with predominantly white samples that found a positive association between diabetes and depression, no association was found in this African-American sample. Nevertheless, the results did concur with research findings based on other samples, in that the co-occurrence of depression with diabetes was associated with more acute care utilization, such as emergency room visits and inpatient hospitalizations. This pattern of utilization may lead to higher healthcare costs among patients with diabetes who are depressed, regardless of race.     

Religious involvement and depressive symptoms in primary care elders

BACKGROUND: Multiple lines of evidence indicate relationships between religious involvement and depression, although the specific nature of the relationships is yet to be clarified. Moreover, there appear to be no well controlled longitudinal studies to date examining this issue in primary care elders. METHOD: The authors assessed the linear and non-linear relationships between three commonly identified types of religious involvement and observer-rated depressive symptoms in 709 primary care elders assessed at baseline and 1-year follow-up. RESULTS: Cross-sectional analyses revealed a curvilinear, U-shaped association between depressive symptoms and organizational religious activity, an inverse linear relationship of depressive symptoms with private religious involvement, and a positive relationship of depressive symptoms with intrinsic religiosity. Longitudinal analyses revealed a U-shaped association between depressive symptoms and private religious involvement, such that those reporting moderate levels of private religiosity at baseline evidenced lower levels of depressive symptoms at 1-year follow-up than those reporting either high or low levels of private religious activity. CONCLUSIONS: The relationships between religious involvement and depression in primary care elders are complex and dependent on the type of religiosity measured. The authors found the strongest evidence for an association of non-organizational, private religious involvement and the severity of depressive symptoms, although further study is warranted using carefully controlled longitudinal designs that test for both linear and curvilinear relationships.     

What is the association between quality of treatment for depression and patient outcomes? A cohort study of adults consulting in primary care

Background

The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The main objective of this study was to examine the association between receiving at least one minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6- and 12-months. Associations with receiving pharmacotherapy and/or psychotherapy and the role of severity of depression were examined.

Methods

This cohort study included 908 adults meeting criteria for previous-year MDE and consulting at one of 65 primary care clinics in Quebec, Canada. Multilevel analyses were performed.

Results

Results show that (i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; (ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and (iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months.

Limitations

Measures are self-reported. Participants were recruited at different stages over the course of their MDE.

Conclusions

This study shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions, but that those with more severe depressive symptoms are more likely to receive adequate treatment and improve across time.     

Posttraumatic stress disorder in primary care with special reference to personality disorder comorbidity

BACKGROUND: Posttraumatic stress disorder (PTSD) is a common and disabling disturbance in primary care. Few studies have been carried out in primary care samples and none have taken into consideration the association between PTSD and personality disorder. AIM: To describe prevalence and risk factors of PTSD and its comorbidity with personality disorder. SETTING: General practice centre in Valencia (Spain). METHOD: Patients who had experienced at least one traumatic event in their lives were selected from a random sample attending a primary healthcare centre in Valencia and blindly assessed by trained professionals. Patients suffering from PTSD were compared with those who were not. PTSD and personality disorder diagnoses were established using CIDI and SCID-II interviews respectively. Sex, age at the time of experiencing trauma, frequency, multiplicity and type of trauma, dissociative symptoms, personality disorder and severity of PTSD were subjected to multivariate analysis to estimate the probability of developing PTSD and its duration. RESULTS: Life prevalence rate was 14% and current prevalence 9%. Dissociative symptoms and personality disorder were significantly associated with PTSD. Cluster analysis based on age, frequency and type of trauma revealed the existence of one subgroup composed mainly of women who had experienced frequent body-contact trauma at an early age, developed severe PTSD and suffer from a variety of personality disorders, particularly paranoid personality disorder. Time to the complete disappearance of symptoms was only explained by the initial severity of PTSD. CONCLUSION: PTSD is a frequent disorder in general practice and it is often associated with personality disorder. Women who experienced high frequency body-contact traumatic events at an early age often suffer from personality disorder and present a particularly severe form of PTSD deserving referral to specialised care.     

General practitioners' knowledge of post-traumatic stress disorder: a controlled study.

BACKGROUND: Post-traumatic stress disorder (PTSD) is common, is associated with substantial morbidity, and is often not recognised in primary care.AIM: To explore whether general practitioners (GPs) have significant gaps in their knowledge of PTSD.Design of study: A controlled study.SETTING: Primary care in two Scottish regions.METHOD: A validated postal questionnaire consisting of clinical vignettes for PTSD, acute stress reaction, and depression was used to gather the data. The primary outcome measures were the proportion describing 'best practice' management of PTSD and the comparison of this with the control condition, the proportion describing 'best practice' management of depression. The secondary outcome measures were comparisons of PTSD and depression by recognition, drug treatment, and referral. RESULTS: Two-thirds (67.5%) of GPs included PTSD in their differential diagnosis for the PTSD vignette, and 86.8% made a referral to secondary care for the PTSD case. A minority of GPs (42.9%) and only 54.1% of a comparison group of psychiatrists specified the drug treatment of choice for PTSD, a selective serotonin reuptake inhibitor. Only 28.3% of GPs had the knowledge to recognise PTSD and prescribe appropriately, compared with 89.8% for depression (P <0.001). Only 10.2% of GPs described best practice for PTSD, compared with 47.7% for depression (P <0.001).CONCLUSION: Lack of knowledge is among the reasons for less than ideal recognition and management of PTSD in primary care. Further research should aim to explore the implementation of PTSD guidelines in primary care.     

The Thought Control Questionnaire--psychometric properties in a clinical sample, and relationships with PTSD and depression

BACKGROUND: Recent developments in research suggest that particular attempts to control thoughts may contribute to the problem of intrusion. An instrument capable of identifying strategies for dealing with unwanted intrusions in clinical populations may be used for differentiating between thought control strategies that may or may not be helpful. METHODS: The Thought Control Questionnaire (TCQ) (Wells & Davies, 1994) developed and validated on a normal sample, was administered to a clinical sample in order to investigate the consistency of the original factor structure and its psychometric properties. The sensitivity of the scale to change associated with recovery was also examined. Relationships between individual differences in thought control strategies and psychiatric symptoms in patients with DSM-IV major depression, and PTSD with or without major depression were investigated. RESULTS: The Scree Test suggested a six-factor solution which was rotated. This solution split the original distraction subscale into separate behavioural and cognitive distraction, otherwise the subscales were almost identical to those obtained in non-clinical subjects. As this split has been shown to be unreliable, further analyses in this study were based on the five-factor version of the TCQ obtained by Wells & Davies (1994). Predictors of recovery and of symptoms in PTSD and depression were explored. CONCLUSIONS: Correlations between the TCQ subscales and other measures suggest that particular thought control strategies may be associated with the symptoms of PTSD and depression. The TCQ scales appear to be sensitive to changes associated with recovery. Significant differences emerged in thought control strategies between depressed and PTSD patients. Hierarchical regression analysis showed distraction, punishment and reappraisal control strategies predicted depression scores in depressed patients while use of distraction predicted intrusions in PTSD.