Depression In Primary Health Care Research Articles

Case management to improve major depression in primary health care: a systematic review

Case management to improve major depression in primary health care: a systematic review

Postnatal depression in primary care populations in Nigeria

Objective The purpose of this study is to determine the prevalence and associated factors for postnatal depression in primary health care (PHC) centers of a developing society. Method A two-stage screening procedure involving the 10-item self-report Edinburgh Postnatal Depression Scale (EPDS) and the Present State Examination Schedule was employed. Results The prevalence of postnatal depression in the primary care populations studied was 18.6%. Postnatal depression was found on logistic regression to be independently predicted by younger age (OR, 5.42; 95% CI, 2.61–10.32; P<.05), by being primigravida (OR, 2.73; 95% CI, 1.44–4.24; P<.05), by not having the desired gender for their babies (OR, 2.86; 95% CI, 1.62–5.93; P<.05) and by in-law relationship problems (OR, 3.64; 95% CI, 1.84–7.22; P<.05). The EPDS was shown to be a feasible screening instrument for postnatal depression in the PHC centers (sensitivity, 88.1%; specificity, 84.3%; minimum misclassification rate, 15.0%). Conclusion The EPDS should be incorporated into the maternal and child health care programs of PHC centers in developing countries in order to ensure early detection and appropriate therapeutic intervention in cases of postnatal depression.

Suicidal behaviour among primary-care patients with depressive disorders

Most national suicide prevention strategies set improved detection and management of depression in primary health care into a central position. However, suicidal behaviour among primary-care patients with depressive disorders has been seldom investigated. In the Vantaa Primary Care Depression Study, a total of 1119 primary-care patients in the City of Vantaa, Finland, aged 20 to 69 years, were screened for depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. Depressive disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and the 137 patients with depressive disorder were included in the study. Suicidal behaviour was investigated cross-sectionally and retrospectively in three time-frames: current, current depressive episode, and lifetime. Current suicidal ideation was measured with the Scale for Suicidal Ideation (SSI), and previous ideation and suicide attempts were evaluated based on interviews plus medical and psychiatric records. Within their lifetimes, 37% (51/137) of the patients had seriously considered suicide and 17% (23/137) attempted it. Lifetime suicidal behaviour was independently and strongly predicted by psychiatric treatment history and co-morbid personality disorder, and suicidal behaviour within the current episode was predicted most effectively by severity of depression. Based on these findings and their convergence with studies of completed suicides, prevention of suicidal behaviour in primary care should probably focus more on high-risk subgroups of depressed patients, including those with moderate to severe major depressive disorder, personality disorder or a history of psychiatric care. Recognition of suicidal behaviour should be improved. The complex psychopathology of these patients in primary care needs to be considered in targeting preventive efforts.

Case management to improve major depression in primary health care: a systematic review

Deficits in the care of depression lead to poor medication adherence, which increases the risk of an unfavourable outcome for this care. This review evaluates effects on symptoms and medication adherence of case management in primary health care. A systematic literature search was performed. The quality of the studies was rated according to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria. To conduct a subgroup analysis interventions were classified as either 'standard' or 'complex' case management. Thirteen studies met the inclusion criteria. In a meta-analysis we calculated a standard mean difference/effect size on symptom severity after 6-12 months of -0.40 (95% CI -0.60 to -0.20). Patients in the intervention groups were more likely to achieve remission after 6-12 months [relative risk (RR) 1.39, 95% CI 1.30-1.48]. The relative risk for clinical response was 1.82 (95% CI 1.68-2.05). Patients in intervention groups had better medication adherence than the control group (RR 1.5, 95% CI 1.28-1.86). We found heterogeneous results when assessing effects of different types of intervention. We conclude that case management improves management of major depression in primary health-care settings.

Developing primary mental healthcare for children and adolescents

Governmental initiatives to enhance child and adolescent mental healthcare are giving renewed impetus to work in primary care. This review identifies and discusses critically new findings in this area. Research reviews and new studies continue to highlight the burden of unidentified and hence untreated psychopathology among children attending primary care. Expression of parental concern appears to provide important help in improving recognition. Shared protocols have been developed for primary care use for clinical conditions such as attention deficit hyperactivity disorder, but adherence to protocols is still limited. Randomized controlled trials have shown the feasibility and efficacy of suitably adapted therapeutic interventions for adolescent depression in primary healthcare and in educational settings. Surveys indicate a significant amount of child and adolescent mental health work by social services in countries such as the UK, and attest to the usefulness of protocols to attend to children in foster care. The new role of primary mental health worker has the potential to help support the interface between primary and specialist child and adolescent mental health services. There is increased interest in further clarifying and enhancing the role of primary care child and adolescent mental health services.

Identification of somatic and anxiety symptoms which contribute to the detection of depression in primary health care

Somatic symptoms and anxiety symptoms are often disregarded in the detection of depression in primary care. The present investigation examined to what extent somatic and anxiety symptoms recorded with the Composite International Diagnostic Interview–Primary Health Care Version (CIDI–PHC) can improve the detection of depression as compared to the General Health Questionnaire—12-item version alone. Data from the World Health Organization study on Psychological Problems in General Health Care were used. The study sample consisted of primary care attenders from 15 centres from all over the world who underwent a psychiatric examination with the CIDI–PHC. Medically unexplained somatic symptoms (back pain, feelings of heaviness/lightness in parts of the body, periods of bodily weakness, seizures/convulsions, permanent tiredness, exhaustion after a minimum of effort) and—to a smaller extent—diverse anxiety symptoms (e.g. feelings of anxiousness/nervousness, feelings of tension, difficulties relaxing) significantly contributed to the detection of depression in a logistic regression analysis. The results confirm the observation that in primary care somatic symptoms play an important role in the manifestation of depressive disorders. The items investigated herein could prove beneficial for future depression screening instruments to improve the detection of depressive disorders in primary care.

Identification of items which predict later development of depression in primary health care.

To improve recognition and treatment of depression in primary care it would be advantageous to have criteria for identification of later depression. Only a few studies were performed on primary care samples to examine risk factors for new depressive episodes. These were mostly cross-sectional and did not include psychiatric symptoms as possible predictors. This is the first one-year-follow-up study investigating prospectively psychiatric symptomatology as risk factors for depressive episodes in a primary care sample. An international primary care sample of initially non-depressed subjects (n = 2,445) was examined for the presence of depression (ICD-10) at follow-up. Initial measures addressed presence of psychiatric symptoms according to the CIDI-Primary Health Care Version and sociodemographic variables. Logistic regression analysis was carried out to determine the relationship with the development of new depressive episodes. After one year, 4.4% of primary care patients met ICD-10 criteria for a depressive episode. Logistic regression analysis revealed that symptoms of depression and physical, mainly pain-related symptoms were associated with depression at follow-up. General practitioners therefore should be careful in the consideration of depressive symptoms but also of somatic complaints which might precede depression or mask depressive symptomatology. The present results might be helpful for future development of prediction scales.

Treating Depression in Primary Health Care: Is there a Need for Improvement?

Treating Depression in Primary Health Care: Is there a Need for Improvement?

Depression Scale (DEPS) in schizophrenia.

To explore the applicability of the Depression Scale (DEPS), a screening instrument for detecting depression in primary health care, in schizophrenia. The DEPS was compared with the Calgary Depression Scale (CDS) among 63 patients with schizophrenia. Using the CDS as a gold standard, the positive and negative predictive values of the DEPS for the diagnosis of depression were 41% and 97%, respectively. The correlation between the total CDS scores and the total DEPS scores was 0.73. The DEPS appears to be useful for screening depression among schizophrenic patients, but the positive diagnosis must be confirmed with a clinical interview.

The management of depression in primary health care

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Depressive disorders among somatizing patients in primary health care

Unrecognized, untreated and undertreated depressive disorders incur inordinate human and economic costs, despite the availability of an exclusive array of clinical interventions. The aim of this study was to identify cases of masked depression in primary health care, employing a two-stage design. In the first stage, involving a study of 442 patients, the prevalence of recognized depression was 1.8%. In the second step, 62 patients from stage 1 were investigated further because of their high score on somatization tendency. In total, 41 of the 62 patients were found to have a mood disorder according to DSM-III-R, i.e. a major depressive disorder or dysthymia. Two patients were found to have already had a diagnosis of major depression assigned to them in stage 1, but they were joined by 13 more patients. A further 26 patients were found to be suffering from dysthymia, nine had adjustment disorders with depressed mood, and 12 patients showed no signs of depressed mood. For the group suffering from a current episode of major depression or dysthymia, the prevalence rate increased to 11.7% in the initial total population after stage 2. The diagnostic category with the highest rate of depressed patients was 'musculoskeletal diseases'. Patients with masked depression had higher scores for alexithymia and psychasthenia than depressed patients who were directly diagnosed.

The Hampshire Depression Project: development and piloting of clinical practice guidelines and education about depression in primary health care.

This paper describes the development and piloting of a comprehensive educational programme about recognition and management of depressive illness in primary care. Full evaluation of the effectiveness of the programme is currently underway in a randomized controlled trial, the Hampshire Depression Project (HDP), involving 56 general practices. The programme consists of clinical practice guidelines, practice-based seminars and follow-up sessions. Each part of the programme has been designed to be flexible, clinically oriented and relevant to all members of the multidisciplinary primary care team. The pilot study established the need for a systematic approach to the access of practices and practice teams, and the organization and process of the seminars. Application of this approach was associated with excellent attendance in the main programme.