Patients' views of antidepressants: from first experiences to becoming expert

Background

The majority of patients discontinue antidepressant treatment earlier than prescribed. The factors behind this and the influences on patients'' choices about whether to take medication remain poorly understood.

Aim

To explore factors that influence patients'' decisions about taking antidepressant medication.

Design of study

Qualitative interview study.

Setting

Interviews were conducted across three sites: London, East Lancashire, and North East England.

Method

Semi-structured interviews were conducted with a purposive sample of 65 primary care patients who were prescribed antidepressants in the past year for depression or mixed anxiety/depression.

Results

Participants described their first course of antidepressants as typically occurring when they had ‘hit rock bottom’, having exhausted all other possibilities; therefore, there was little sense of a positive choice at this stage. There would typically follow a period of experimentation where it was usual to stop and restart medication, often several times. Ultimately, these recurring cycles lead to participants becoming more expert about their condition and better able to make an informed decision about medication. For younger participants, recovery typically remained a goal, although for older people there was often an acceptance that their condition, and medication use, would be long term.

Conclusion

Participants'' accounts demonstrated how they could become expert at managing their condition through a process of trial and error.     

��I didn't want her to panic��: unvoiced patient agendas in primary care consultations when consulting about antidepressants

Background

Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients'' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants.

Aim

To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients'' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP–patient relationship in which unvoiced agendas occur.

Design of study

Qualitative interview study.

Setting

Primary health care.

Method

Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 ‘pairs’ of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs'' consent), using a patient-held tape recorder.

Results

Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were ‘letting the GP down’ by not being able to report feeling better.

Conclusion

Unvoiced agendas are not necessarily an indication that ‘shared decision making’ is absent but may in some cases represent patients'' attempts to ‘protect’ their GPs.     

Detecting recurrent major depressive disorder within primary care rapidly and reliably using short questionnaire measures

Background

Major depressive disorder (MDD) is often a chronic disorder with relapses usually detected and managed in primary care using a validated depression symptom questionnaire. However, for individuals with recurrent depression the choice of which questionnaire to use and whether a shorter measure could suffice is not established.

Aim

To compare the nine-item Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory, and the Hospital Anxiety and Depression Scale against shorter PHQ-derived measures for detecting episodes of DSM-IV major depression in primary care patients with recurrent MDD.

Design and setting

Diagnostic accuracy study of adults with recurrent depression in primary care predominantly from Wales

Method

Scores on each of the depression questionnaire measures were compared with the results of a semi-structured clinical diagnostic interview using Receiver Operating Characteristic curve analysis for 337 adults with recurrent MDD.

Results

Concurrent questionnaire and interview data were available for 272 participants. The one-month prevalence rate of depression was 22.2%. The area under the curve (AUC) and positive predictive value (PPV) at the derived optimal cut-off value for the three longer questionnaires were comparable (AUC = 0.86–0.90, PPV = 49.4–58.4%) but the AUC for the PHQ-9 was significantly greater than for the PHQ-2. However, by supplementing the PHQ-2 score with items on problems concentrating and feeling slowed down or restless, the AUC (0.91) and the PPV (55.3%) were comparable with those for the PHQ-9.

Conclusion

A novel four-item PHQ-based questionnaire measure of depression performs equivalently to three longer depression questionnaires in identifying depression relapse in patients with recurrent MDD.     

Prevalence of anxiety among women attending a primary care clinic in Malaysia

Background

This is the first study investigating anxiety among women attending a primary care clinic in Malaysia.

Aim

The objective was to determine the factors associated with anxiety among these women.

Design

This cross-sectional study was conducted in a government-funded primary care clinic in Malaysia. Consecutive female patients attending the clinic during the data-collection period were invited to participate in the study.

Method

Participants were given self-administered questionnaires, which included the validated Generalised Anxiety Disorder-7 questionnaire (GAD-7) Malay version to detect anxiety.

Results

Of the 1023 patients who were invited, 895 agreed to participate (response rate 87.5%). The prevalence of anxiety in this study was 7.8%, based on the GAD-7 (score ≥8). Multiple logistic regression analysis found that certain stressful life events and the emotional aspect of domestic violence were significantly associated with anxiety (P<0.05).

Conclusion

The prevalence of anxiety among women in this study is similar to that found in other countries. Factors found to be associated with anxiety, especially issues on domestic violence, need to be addressed and managed appropriately.     

Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network

Background

Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP.

Aim

To investigate whether unexplained symptoms as presented to the GP predict mental disorders.

Design and setting

Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands.

Method

All data about contacts between patients (n = 16 000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined.

Results

All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression.

Conclusion

Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.     

Emotional distress in Angolan patients with several types of tuberculosis

Background

There is growing evidence that emotional distress expressed in terms of anxiety and depression is very high among tuberculosis (TB) patients.

Objectives

This study aims to determine levels of anxiety, depression and emotional distress in patients with several types of TB and to determine the association between social-demographic and economical factors, clinical variables and anxiety, depression and emotional distress.

Methods

A cross-sectional study was performed in a sample of 81 TB patients. A social-demographic and economical questionnaire was used, followed by the hospital anxiety and depression scale.

Results

38.3% and 49.4% of our sample presented significant levels of anxiety and depression. 44.4% of patients had significant levels of emotional distress.Married subjects, a diagnosis of extra-pulmonary TB and multidrug resistant TB were related to higher risk for anxiety. Gender, extra-pulmonary and multidrug resistant TB were associated to depression. Female gender and cases of extra-pulmonary TB presented a 1.5 times risk for emotional distress.

Conclusions

Our study found high rates of anxiety, depression and emotional distress among TB patients. Marital status, gender, type and treatment of TB were related to higher levels of emotional disorder. Mental health services should be an integral part of programs against tuberculosis.     

Recorded quality of care for depression in general practice: an observational study

Background

Depression is a leading cause of disease and disability internationally, and is responsible for many primary care consultations. Little is known about the quality of primary care for depression in the UK.

Aim

To determine the prevalence of good-quality primary care for depression, and to analyse variations in quality by patient and practice characteristics.

Design of study

Retrospective observational study.

Setting

Eighteen general practices in England.

Method

Medical records were examined for 279 patients. The percentage of eligible participants diagnosed with depression who received the care specified by each of six quality indicators in 2002 and 2004 was assessed. Associations between quality achievement and age, sex, patient deprivation score, timepoint, and practice size were estimated using logistic regression.

Results

There was very wide variation in achievement of different indicators (range 1–97%). Achievement was higher for indicators referring to treatment and follow-up than for indicators referring to history taking. Achievement of quality indicators was low overall (37%). Quality did not vary significantly by patient or practice characteristics.

Conclusion

There is substantial scope for improvement in the quality of primary care for depression, if the highest achievement rates could be matched for all indicators. Given the lack of variation by practice characteristics, system-level and educational interventions may be the best ways to improve quality. The equitable distribution of quality by patient deprivation score is an important achievement that may be challenging to maintain as quality improves.     

Psychiatric morbidity in stroke patients attending a neurology clinic in Nigeria

Back ground

Stroke produces a wide range of mental and emotional disorders. Neuropsychiatric complications associated with stroke may have negative effects on the social functioning, overall quality of life and the recovery of motor functioning of stroke survivors.

Objective

To determine the prevalence and nature of psychiatric morbidity among stroke patients attending neurology outpatient clinic of the University of Ilorin Teaching Hospital (UITH), Ilorin-Nigeria.

Methods

All patients with stroke aged 18 years and above at an outpatient neurology clinic in Ilorin, Nigeria were assessed for mental and emotional disorders using the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) over one year (March 2009 to February 2010).

Results

Overall prevalence of psychiatric morbidity was 36.0% (30/83) among 83 patients who constituted the study population. Specific diagnoses recorded were depression (19.2%), generalised anxiety disorder (9.6%), harmful alcohol use (2.4%); dementia, somatoform disorder, phobia and delusional disorder each had a prevalence of 1.2%. Clinical and sociodemographic variables were not significantly associated with psychiatric morbidity.

Conclusion

Psychiatric disorders are often associated with stroke. Identifying and treating stroke patients with these psychiatric co-morbidities could thus help to improve the overall quality of life of these patients.     

Psychological treatment of depression in primary care: a meta-analysis

Background

Although most depressive disorders are treated in primary care and several studies have examined the effects of psychological treatment in primary care, hardly any meta-analytic research has been conducted in which the results of these studies are integrated.

Aim

To integrate the results of randomised controlled trials of psychological treatment of depression in adults in primary care, and to compare these results to psychological treatments in other settings.

Design of study

A meta-analysis of studies examining the effects of psychological treatments of adult depression in primary care.

Setting

Primary care.

Method

An existing database of studies on psychological treatments of adult depression that was built on systematic searches in PubMed, PsychINFO, EMBASE, and Dissertation Abstracts International was used. Randomised trials were included in which the effects of psychological treatments on adult primary care patients with depression were compared to a control condition.

Results

In the 15 included studies, the standardised mean effect size of psychological treatment versus control groups was 0.31 (95% CI = 0.17 to 0.45), which corresponds with a numbers-needed-to-treat (NNT) of 5.75. Studies in which patients were referred by their GP for treatment had significantly higher effect sizes (d = 0.43; NNT = 4.20) than studies in which patients were recruited through systematic screening (d = 0.13, not significantly different from zero; NNT = 13.51).

Conclusions

Although the number of studies was relatively low and the quality varied, psychological treatment of depression was found to be effective in primary care, especially when GPs refer patients with depression for treatment.     

Missed opportunities: mental disorder in children of parents with depression

Background

Emerging evidence suggests that early intervention and prevention programmes for mental health problems in the offspring of parents with depression are important. Such programmes are difficult to implement if children with psychiatric disorder are not identified and are not accessing services, even if their parents are known to primary care.

Aim

To investigate service use in children of parents who have recurrent depression, and factors that influence such contact.

Design and setting

A total of 333 families were recruited, mainly through primary health care, in which at least one parent had received treatment for recurrent depression and had a child aged 9–17 years.

Method

Psychiatric assessments of parents and children were completed using research diagnostic interviews. The service-use interview recorded current (in the 3 months prior to interview) and lifetime contact with health, educational, and social services due to concerns about the child’s emotions or behaviour.

Results

Only 37% of children who met criteria for psychiatric disorder were in contact with any service at the time of interview. A third, who were suicidal or self-harming and had a psychiatric disorder at that time, were not in contact with any service. Lack of parental worry predicted lower service use, with higher rates in children with comorbidity and suicidality.

Conclusion

Most children with a psychiatric disorder in this high-risk sample were not in contact with services. Improving ease of access to services, increasing parental and professional awareness that mental health problems can cluster in families, and improving links between adult and child services may help early detection and intervention strategies for the offspring of parents with depression.     

Lifetime psychopathology among the offspring of Bipolar I parents

BACKGROUND:

Recent studies have demonstrated high rates of psychopathology in the offspring of parents with bipolar disorder. The aim of this study was to identify psychiatric diagnoses in a sample of children of bipolar parents.

METHOD:

This case series comprised 35 children and adolescents aged 6 to 17 years, with a mean age of 12.5±2.9 years (20 males and 15 females), who had at least one parent with bipolar disorder type I. The subjects were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime version (K-SADS-PL). Family psychiatric history and demographics were also evaluated.

RESULTS:

Of the offspring studied, 71.4% had a lifetime diagnosis of at least one psychiatric disorder (28.6% with a mood disorder, 40% with a disruptive behavior disorder and 20% with an anxiety disorder). Pure mood disorders (11.4%) occurred less frequently than mood disorders comorbid with attention deficit hyperactivity disorder (17.1%). Psychopathology was commonly reported in second-degree relatives of the offspring of parents with bipolar disorder (71.4%).

CONCLUSIONS:

Our results support previous findings of an increased risk for developing psychopathology, predominantly mood and disruptive disorders, in the offspring of bipolar individuals. Prospective studies with larger samples are needed to confirm and expand these results.     

Is a Severe Clinical Profile an Effect Modifier in a Web-Based Depression Treatment for Adults With Type 1 or Type 2 Diabetes? Secondary Analyses From a Randomized Controlled Trial

Background

Depression and diabetes are two highly prevalent and co-occurring health problems. Web-based, diabetes-specific cognitive behavioral therapy (CBT) depression treatment is effective in diabetes patients, and has the potential to be cost effective and to have large reach. A remaining question is whether the effectiveness differs between patients with seriously impaired mental health and patients with less severe mental health problems.

Objective

To test whether the effectiveness of an eight-lesson Web-based, diabetes-specific CBT for depression, with minimal therapist support, differs in patients with or without diagnosed major depressive disorder (MDD), diagnosed anxiety disorder, or elevated diabetes-specific emotional distress (DM-distress).

Methods

We used data of 255 patients with diabetes with elevated depression scores, who were recruited via an open access website for participation in a randomized controlled trial, conducted in 2008–2009, comparing a diabetes-specific, Web-based, therapist-supported CBT with a 12-week waiting-list control group. We performed secondary analyses on these data to study whether MDD or anxiety disorder (measured using a telephone-administered diagnostic interview) and elevated DM-distress (online self-reported) are effect modifiers in the treatment of depressive symptoms (online self-reported) with Web-based diabetes-specific CBT.

Results

MDD, anxiety disorder, and elevated DM-distress were not significant effect modifiers in the treatment of self-assessed depressive symptoms with Web-based diabetes-specific CBT.

Conclusions

This Web-based diabetes-specific CBT depression treatment is suitable for use in patients with severe mental health problems and those with a less severe clinical profile.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 24874457; http://www.controlled-trials.com/ISRCTN24874457 (Archived by WebCite at http://www.webcitation.org/63hwdviYr)     

Restless Legs Syndrome in a Community Sample of Korean Adults: Prevalence,Impact on Quality of Life,and Association with DSM-IV Psychiatric Disorders

Study Objectives:

Conflicting reports on prevalence of RLS exist in Asian countries due to differences in sampling strategies and assessment instruments. We assessed the prevalence, correlates, quality of life, and psychiatric comorbidity of RLS in South Korea.

Design/setting:

Cross-sectional nationwide survey.

Participants:

Nationally representative sample of 6,509 Korean adults aged 18–64.

Measurement & Results:

Face-to-face interviews based on the Korean translation of the four features of RLS defined by the International RLS Study Group (IRLSSG), the Korean version of Composite International Diagnostic Interview (K-CIDI), and EuroQol (EQ-5D) were conducted for all participants. The weighted prevalence of RLS in South Korea was 0.9% (men, 0.6%; women, 1.3%). Subjects with RLS had a lower quality of life according to EQ-5D than those without RLS. Adjusted odds ratio for lifetime diagnosis of DSM-IV major depressive disorder (2.57, 95% confidence interval [1.33, 4.96]), panic disorder (18.9 [4.72, 75.9]) and posttraumatic stress disorder (3.76 [1.32, 10.7]) suggest strong association between RLS and DSM-IV depression and anxiety disorders.

Conclusions:

Prevalence of RLS estimated based on the IRLSSG diagnostic criteria is substantially lower in South Korea than in Western countries. Differences in culture and risk factors that affect the expression of RLS may vary across the countries.

Citation:

Cho SJ; Hong JP; Hahm BJ; Jeon HJ; Chang SM; Cho MJ; Lee HB. Restless legs syndrome in a community sample of korean adults: prevalence, impact on quality of life, and association with DSM-IV psychiatric disorders. SLEEP 2009;32(8):1069-1076.     

Efficacy of two interventions on the discontinuation of benzodiazepines in long-term users: 36-month follow-up of a cluster randomised trial in primary care

Background

Primary care interventions that promote cessation of benzodiazepine (BZD) use in long-term users are effective at 1 year, but their efficacy at 3 years is uncertain.

Aim

To assess the 3-year efficacy of two primary care interventions delivered by GPs on cessation of BZD use in long-term users.

Design and setting

Multicentre, three-arm, cluster randomised, controlled trial, with random allocation at the GP level.

Method

Seventy-five GPs and 532 patients were randomly allocated to three groups: usual care (control), structured intervention with stepped-dose reduction and follow-up visits (SIF), or structured intervention with written stepped-dose reduction (SIW). The primary outcome was BZD use at 36 months.

Results

At 36 months, 66/168 patients (39.2%) in the SIW group, 79/191 patients (41.3%) in the SIF group, and 45/173 patients (26.0%) in the control group had discontinued BZD use. The relative risks (RR) adjusted by cluster were 1.51 (95% CI = 1.10 to 2.05; P = 0.009) in the SIW group and 1.59 (95% CI = 1.15 to 2.19; P = 0.005) in the SIF group. A total of 131/188 patients (69.7%) who successfully discontinued BZD use at 12 months remained abstinent at 36 months. The groups showed no significant differences in anxiety, depression, or sleep dissatisfaction at 36 months.

Conclusion

The interventions were effective on cessation of BZD use; most patients who discontinued at 12 months remained abstinent at 3 years. Discontinuation of BZD use did not have a significant effect on anxiety, depression, or sleep quality.     

The association of major depressive episode and personality traits in patients with fibromyalgia

INTRODUCTION:

Personality traits have been associated with primary depression. However, it is not known whether this association takes place in the case of depression comorbid with fibromyalgia.

OBJECTIVE:

The authors investigated the association between a current major depressive episode and temperament traits (e.g., harm avoidance).

METHOD:

A sample of 69 adult female patients with fibromyalgia was assessed with the Temperament and Character Inventory. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview severity of depressive symptomatology with the Beck Depression Inventory, and anxiety symptomatology with the IDATE-state and pain intensity with a visual analog scale.

RESULTS:

A current major depressive episode was diagnosed in 28 (40.5%) of the patients. They presented higher levels of harm avoidance and lower levels of cooperativeness and self-directedness compared with non-depressed patients, which is consistent with the Temperament and Character Inventory profile of subjects with primary depression. However, in contrast to previous results in primary depression, no association between a major depressive episode and self-transcendence was found.

CONCLUSIONS:

The results highlight specific features of depression in fibromyalgia subjects and may prove important for enhancing the diagnosis and prognosis of depression in fibromyalgia patients.     

e-CBT (myCompass), Antidepressant Medication,and Face-to-Face Psychological Treatment for Depression in Australia: A Cost-Effectiveness Comparison

Background

The economic cost of depression is becoming an ever more important determinant for health policy and decision makers. Internet-based interventions with and without therapist support have been found to be effective options for the treatment of mild to moderate depression. With increasing demands on health resources and shortages of mental health care professionals, the integration of cost-effective treatment options such as Internet-based programs into primary health care could increase efficiency in terms of resource use and costs.

Objective

Our aim was to evaluate the cost-effectiveness of an Internet-based intervention (myCompass) for the treatment of mild-to-moderate depression compared to treatment as usual and cognitive behavior therapy in a stepped care model.

Methods

A decision model was constructed using a cost utility framework to show both costs and health outcomes. In accordance with current treatment guidelines, a stepped care model included myCompass as the first low-intervention step in care for a proportion of the model cohort, with participants beginning from a low-intensity intervention to increasing levels of treatment. Model parameters were based on data from the recent randomized controlled trial of myCompass, which showed that the intervention reduced symptoms of depression, anxiety, and stress and improved work and social functioning for people with symptoms in the mild-to-moderate range.

Results

The average net monetary benefit (NMB) was calculated, identifying myCompass as the strategy with the highest net benefit. The mean incremental NMB per individual for the myCompass group was AUD 1165.88 compared to treatment as usual and AUD 522.58 for the cognitive behavioral therapy model.

Conclusions

Internet-based interventions can provide cost-effective access to treatment when provided as part of a stepped care model. Widespread dissemination of Internet-based programs can potentially reduce demands on primary and tertiary services and reduce unmet need.