Abstract
BackgroundDepression affects over 400 million people globally. The majority are seen in primary care. Barriers in providing adequate care are not solely related to physicians’ knowledge/skills deficits, but also time constraints, lack of confidence/avoidance, which need to be addressed in mental health-care redesign. We hypothesized that family physician (FP) training in the Adult Mental Health Practice Support Program (AMHPSP) would lead to greater improvements in patient depressive symptom ratings (a priori primary outcome) compared to treatment as usual.MethodsFrom October 2013 to May 2015, in a controlled trial 77 FP practices were stratified on the total number of physicians/practice as well as urban/rural setting, and randomized to the British Columbia AMHPSP⎯a multi-component contact-based training to enhance FPs’ comfort/skills in treating mild-moderate depression (intervention), or no training (control) by an investigator not operationally involved in the trial. FPs with a valid license to practice in NS were eligible. FPs from both groups were asked to identify 3–4 consecutive patients > 18 years old, diagnosis of depression, Patient Health Questionnaire (PHQ-9) score ≥ 10, able to read English, intact cognitive functioning. Exclusion criteria: antidepressants within 5 weeks and psychotherapy within 3 months of enrollment, and clinically judged urgent/emergent medical/psychiatric condition. Patients were assigned to the same arm as their physician. Thirty-six practices recruited patients (intervention n = 23; control n = 13). The study was prematurely terminated at 6 months of enrollment start-date due to concomitant primary health-care transformation by health-system leaders which resulted in increased in-office demands, and recruitment failure. We used the PHQ-9 to assess between-group differences at baseline, 1, 2, 3, and 6 months follow-up. Outcome collectors and assessors were blind to group assignment.ResultsOne hundred-and-twenty-nine patients (intervention n = 72; control n = 57) were analysed. A significant improvement in depression scores among intervention group patients emerged between 3 and 6 months, time by treatment interaction, likelihood ratio test (LR) chi2(3) = 7.96, p = .047.ConclusionsThis novel skill-based program shows promise in translating increased FP comfort and skills managing depressed patients into improved patient clinical outcomes⎯even in absence of mental health specialists availability.Trial registration#NCT01975948.
Highlights
Depression affects over 400 million people globally
In one study conducted in 21 countries, respondents who met DSM-IV criteria for major depressive disorder (MDD) within 12 months before the interview, only 16.5% received minimally adequate treatment as defined by evidenced-based guidelines [i.e. receiving either pharmacotherapy or psychotherapy]
Physicians assigned to intervention group were more likely to work in small practices due to one large practice being randomly assigned to the control group
Summary
Depression affects over 400 million people globally. The majority are seen in primary care. We hypothesized that family physician (FP) training in the Adult Mental Health Practice Support Program (AMHPSP) would lead to greater improvements in patient depressive symptom ratings (a priori primary outcome) compared to treatment as usual. Concurrent with other physical and psychiatric conditions, there is higher morbidity and cost to the healthcare system [7] These facts underscore the need for evidence-based strategies that promote early recognition and treatment, thereby improving patient outcomes [1, 6]. In one study conducted in 21 countries, respondents who met DSM-IV criteria for major depressive disorder (MDD) within 12 months before the interview, only 16.5% received minimally adequate treatment as defined by evidenced-based guidelines [i.e. receiving either pharmacotherapy (for a minimum of 1 month, plus 4 visits with any type of medical doctor) or psychotherapy (for a minimum of 8 visits with any professional including religious or spiritual advisor, social worker or counsellor)]. Studies suggest that cognitive behaviour therapy (CBT) has an enduring effect with lower rates of relapse, that many patients prefer non-drug options, [25] and where clinically appropriate, patient choice of evidence-based options improves outcomes [26]
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