Abstract
BackgroundDepression is common in patients with diabetes type 2 (DM2) and/or coronary heart disease (CHD), with high personal and societal burden and may even be preventable. Recently, a cluster randomized trial of stepped care to prevent depression among patients with DM2 and/or CHD and subthreshold depression in Dutch primary care (Step-Dep) versus usual care showed no effectiveness. This paper presents its process evaluation, exploring in-depth experiences from a patient and practice nurse perspective to further understand the results.MethodsA qualitative study was conducted. Using a purposive sampling strategy, data were collected through semi-structured interviews with 24 participants (15 patients and nine practice nurses). All interviews were audiotaped and transcribed verbatim. Atlas.ti 5.7.1 software was used for coding and structuring of themes. A thematic analysis of the data was performed.ResultsThe process evaluation showed, even through a negative trial, that Step-Dep was perceived as valuable by both patients and practice nurses; perceived effectiveness on improving depressive symptoms varied greatly, but most felt that it had been beneficial for patients’ well-being. Facilitators were: increased awareness of mental health problems in chronic disease management and improved accessibility and decreased experienced stigma of receiving mental health care. The Patient Health Questionnaire 9 (PHQ-9), used to determine depression severity, functioned as a useful starting point for the conversation on mental health and patients gained more insight into their mental health by regularly filling out the PHQ-9. However, patients and practice nurses did not widely support its use for monitoring depressive symptoms or making treatment decisions. Monitoring mental health was deemed important in chronically ill patients by both patients and practice nurses and was suggested to start at the time of diagnosis of a chronic disease. Appointed barriers were that patients were primarily motivated to participate in scientific research rather than their intrinsic need to improve depressive symptoms. Additionally, various practice nurses preferred offering individually based therapy over pre-determined interventions in a protocolled sequence and somatic practice nurses expressed a lack of competence to recognise and treat mental health problems.ConclusionThis study demonstrates both the benefits and unique demands of programs such as Step-Dep. The appointed facilitators and barriers could guide the development of future studies aiming to prevent depression in similar patient groups.
Highlights
Depression is common in patients with diabetes type 2 (DM2) and/or coronary heart disease (CHD), with high personal and societal burden and may even be preventable
We screened all patients with Diabetes mellitus type 2 (DM2) and/or CHD in 27 participating General Practitioner (GP) practices for subthreshold depression, defined as a Patient Health Questionnaire 9 (PHQ-9; range 0–27) score of six or more [18, 19], and no major depressive disorder according to the Mini International Neuropsychiatric Interview (MINI) [20, 21]
Our findings show that the main facilitators were: increased awareness of and insight into mental health in chronic disease management and improved accessibility and decreased experienced stigma of receiving mental health care
Summary
Depression is common in patients with diabetes type 2 (DM2) and/or coronary heart disease (CHD), with high personal and societal burden and may even be preventable. People with chronic physical health problems, like type 2 diabetes mellitus (DM2) and coronary heart disease (CHD), are approximately twice as likely to suffer from major depression as compared to the general adult population. Recent meta-analyses have shown that psychological interventions can reduce the incidence of depression, which in high-risk populations can be as high as 25% annually [4, 5]. Offering these in a stepped care format could be an efficient and cost-effective approach to prevent depression, but the evidence is not unequivocal [6]. While effective in reducing the incidence of major depressive disorder in some elderly or visually impaired populations [9,10,11], it was not superior to usual care in other elderly, diabetic or primary care populations [12,13,14,15]
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