Depressed Primary Care Patients Research Articles

Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients.

The Patient Health Questionnaire-2 (PHQ-2) depression screener has been praised for its brevity and ability to identify depressed primary care patients. Additionally, it is often used as the first of a two-step screening process for suicide risk. Despite its decent performance as a depression screener, the PHQ-2 cannot be assumed to be an adequate screener for suicide risk. In the present study, we examine the utility of the PHQ-2 for identifying suicidal patients. We examined data from 548 adult primary care patients at a Federally Qualified Health Center in the mid-Southern region of the United States who completed the PHQ-2 as part of the full administration of the Patient Health Questionnaire-9 (PHQ-9). Cross-tabulation analyses revealed 22 of the 157 (14.0%) patients endorsing suicidal ideation fell below the conventional clinical cutoff of 3 on the PHQ-2. Logistic regression analyses indicated a positive screen on the PHQ-2 did not improve explanation of suicidal ideation beyond the base model, and only 3 items from the first 8 PHQ-9 questions (depressed mood, feeling like a failure, and psychomotor retardation/agitation) were significant explanatory variables for suicidal ideation. Providers should consider asking about suicide directly, rather than relying on depression screeners to identify suicidal patients. We also recommend providers pay particular attention to any indication that patients feel like a failure or like they have let their loved ones down, in addition to endorsement of depressed mood. (PsycINFO Database Record

Subjective memory complaints and future depression in primary care patients: A four-year follow-up study.

To investigate the predictive value of subjective memory complaints (SMCs) for having a hospital-based diagnosis of a single depressive episode over a four-year follow-up period. A prospective register-based cohort study in general practice. All 17 practices in Inner city Copenhagen participated in the study. They had 40,865 registered patients, 2934 aged 65 years or older. Information on SMCs and socio-demographics was collected during two months at enrolment in primary care. Diagnoses of single depressive episodes were retrieved from the Danish Psychiatric Central Research Register. Cox proportional hazard regression models were used to examine risk factors for a hospital-based diagnosis of a single depressive episode. 758 patients aged 65 years or older consulted their GP in October and November 2002. According to our definition, 177 (23%) had SMCs at enrolment, 12 (6.9%) of whom received a diagnosis of a single depressive episode within the follow-up period. In three multivariate models, SMCs were significantly associated with single depressive episodes. In the fully controlled model SMCs had a hazard ratio (HR) of 2.59 for receiving a subsequent depression diagnosis. In an older general practice population, SMCs are associated with increased risk of receiving a hospital-based diagnosis of a single depressive episode.

Interventions to Increase Depression Treatment Initiation in Primary Care Patients: a Systematic Review.

Nearly 50% of depressed primary care patients referred to mental health services do not initiate mental health treatment. The most promising interventions for increasing depression treatment initiation in primary care settings remain unclear. We performed a systematic search of publicly available databases from inception through August 2017 to identify interventions designed to increase depression treatment initiation. Two authors independently selected, extracted data, and rated risk of bias from included studies. Eligible studies used a randomized or pre-post design and assessed depression treatment initiation (i.e., ≥ 1 mental health visit or antidepressant fill) among adults, the majority of whom met criteria for depression. Interventions were classified as simple or complex and sub-classified into intervention strategies that were graded for strength of evidence. Of 9516 articles identified, we included 14 unique studies representing 16 (4 simple and 12 complex) interventions and 8 treatment initiation strategies. We found low to moderate strength of evidence for collaborative/integrated care (3 studies), treatment preference matching (2 studies), and case management (2 studies) strategies. However, there was insufficient evidence to determine the benefit of cultural tailoring (2 studies), motivation (alone, with reminders or with cultural tailoring (5 studies)), education (1 study), and shared decision-making strategies (1 study). Overall, we found moderate strength of evidence for complex interventions (8 of 12 complex interventions demonstrated statistically significant effects on treatment initiation). Collaborative/integrated care, preference treatment matching, and case management strategies had the best evidence for improving depression treatment initiation, but none of the strategies had high strength of evidence. While primary care settings can consider using some of these strategies when referring depressed patients to treatment, our review highlights the need for further rigorous research in this area.

The Association Between Increased Levels of Patient Engagement With an Internet Support Group and Improved Mental Health Outcomes at 6-Month Follow-Up: Post-Hoc Analyses From a Randomized Controlled Trial.

BackgroundWe recently reported that depressed and anxious primary care patients randomized to a moderated internet support group (ISG) plus computerized cognitive behavioral therapy (cCBT) did not experience improvements in depression and anxiety over cCBT alone at 6-month follow-up.ObjectiveThe 1% rule posits that 1% of participants in online communities generate approximately 90% of new user-created content. The aims of this study were to apply the 1% rule to categorize patient engagement with the ISG and identify whether any patient subgroups benefitted from ISG use.MethodsWe categorized the 302 patients randomized to the ISG as: superusers (3/302, 1.0%), top contributors (30/302, 9.9%), contributors (108/302, 35.8%), observers (87/302, 28.8%) and those who never logged in (74/302, 24.5%). We then applied linear mixed models to examine associations between engagement and 6-month changes in health-related quality of life (HRQoL; Short Form Health Survey Mental Health Component, SF-12 MCS) and depression and anxiety symptoms (Patient-Reported Outcomes Measurement Information System, PROMIS).ResultsAt baseline, participant mean age was 42.6 years, 81.1% (245/302) were female, and mean Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder scale (GAD-7), and SF-12 MCS scores were 13.4, 12.6, and 31.7, respectively. Of the 75.5% (228/302) who logged in, 61.8 % (141/228) created ≥1 post (median 1, interquartile range, IQR 0-5); superusers created 42.3 % (630/1488) of posts (median 246, IQR 78-306), top contributors created 34.6% (515/1488; median 11, IQR 10-18), and contributors created 23.1 % (343/1488; median 3, IQR 1-5). Compared to participants who never logged in, the combined superuser + top contributor subgroup (n=33) reported 6-month improvements in anxiety (PROMIS: –11.6 vs –7.8; P=.04) and HRQoL (SF-12 MCS: 16.1 vs 10.1; P=.01) but not in depression. No other subgroup reported significant symptom improvements.ConclusionsPatient engagement with the ISG was more broadly distributed than predicted by the 1% rule. The 11% of participants with the highest engagement levels reported significant improvements in anxiety and HRQoL.Trial RegistrationClinicalTrials.gov NCT01482806; https://clinicaltrials.gov/ct2/show/NCT01482806 (Archived by WebCite at http://www.webcitation.org/708Bjlge9).

Computerized cognitive behavior therapy for patients with mild to moderately severe depression in primary care: A pragmatic cluster randomized controlled trial (@ktiv)

BackgroundSelf-guided computerized cognitive behavior therapy (cCBT) has the potential to be a feasible alternative to current first-step treatment approaches for depression. Yet, research regarding the effectiveness and acceptability of self-guided cCBT as an adjunct element of GP care is controversial. MethodsPrimary care patients with symptoms of mild to moderately severe depression (N = 647) were recruited from 112 GP practices within a cluster randomized controlled trial. GPs were randomized to groups that provided either cCBT (internet intervention) plus treatment as usual (TAU) or TAU alone. Primary outcomes were self-reported depression severity according to the Beck Depression Inventory (BDI-II) and Patient Health Questionnaire (PHQ-9). Intention to treat (ITT) and per protocol (PP) analysis was performed. ResultsITT analyses showed significant between group differences in depressive symptoms for BDI-II in favor of the intervention group, corresponding to a small effect size (6 weeks: d = 0.36, 95% CI 0.19 to 0.53, P < .001; 6 months: d = 0.41, 95% 0.22 to 0.59, P < .001). The number needed to treat (NNT) at six months was 6.2. PHQ-9 analyses was solely significant at six months (d = 0.26, 95% CI 0.08 to 0.44, P < .05, NNT = 9.2). PP analyses highly agree with these findings. LimitationsThe initial response rate with regard to the recruitment of GP practices for the trial was low. ConclusionsThe results suggest that cCBT is effective in reducing depressive symptoms in mildly to moderately severe depressed primary care patients. Efforts should be made to raise awareness about the potential of such freely accessible treatment options among GPs and patients.

A qualitative study on older primary care patients\u2019 perspectives on depression and its treatments - potential barriers to and opportunities for managing depression

BackgroundDepression is one of the most common mental disorders in old age and is associated with various negative health consequences for the affected individual. Studies suggest that patients’ views on depression have an impact on help-seeking behaviour and treatment. It is thus important to investigate the patient’s perspective in order to ascertain optimum management of depression in late life. However, studies on depression and its treatment exploring the perspectives of primary care patients 75 years or older, are rare.MethodsQualitative data was collected in semi-structured interviews with 12 primary care patients 75 years of age or older with symptoms of depression. Data was analysed using qualitative content analysis.ResultsThe study’s results show the multifaceted views on and treatment of depression in primary care patients 75 years of age or older. Some patients seemed well informed about depression and believed in the efficacy of different treatments, such as medications or psychotherapy. However, some individuals had misconceptions about depression and its treatments. Patients mentioned that they would rather avoid talking about depression within their social network, in part of fear of negative reactions. Furthermore, participants believed that other people had little understanding for people with depression. Patients had different views on the relevance of the general practitioner’s (GP) role in treating depression; some patients believed that the GP had little importance in the treatment of depression.ConclusionsThis study identified positive views of primary care patients 75 years of age or older towards depression as well as views that might hinder optimal treatments. Exemplary implications for an improved management of depression are: educating older adults about depression via age-specific information and having professionals encourage patients in believing that depression is a recognised disorder.

One-year follow-up of a randomized controlled trial of sertraline and cognitive behavior group therapy in depressed primary care patients (MIND study)

BackgroundThe long-term course of symptoms in patients with mild-to-moderate depression is not well understood. A 12-month-follow-up analysis was performed on those participants from a randomized controlled 10-week trial (RCT, MIND-study), who had received either treatment with an antidepressant (sertraline) or a psychotherapeutic intervention (group cognitive-behavioral therapy (CBT)). MethodsThe longitudinal interval follow-up evaluation (LIFE) was applied to 77 patients with mild-to moderate depression. The primary outcome was the number of weeks in the one-year follow-up period spent completely recovered from all depressive symptoms. Functional outcome was measured with the Global Assessment of Functioning (GAF) scale. Further outcomes were relapse and remission rates based on weekly psychiatric rating scales (PSR) and the number of weeks in the follow-up period during which patients had a depressive disorder or subthreshold symptoms of depression. ResultsPatients with acute treatment (10 weeks) with SSRI and those with acute treatment with CBT (also 10 weeks) did not differ significantly concerning the number of weeks in the follow-up period in which they were completely recovered (primary outcome) (SSRI: 31.6 weeks (standard deviation (SD): 23.7), CBT: 27.8 weeks (SD: 24.3)). Sertraline was superior to CBT regarding GAF scores by trend (p = 0.06). LimitationsThe generalizability of the findings is limited by the moderate sample size and missing values (LIFE). ConclusionsSertraline and group CBT have similar anti-depressive effects in the long-term course of mild-to-moderate depression. Regarding long-term global functioning, sertraline seems to be slightly superior to CBT.

Knowledge and Preferences Regarding Antidepressant Medication Among Depressed Latino Patients in Primary Care.

US Latinos are less likely to utilize mental health services than non-Latino whites and to take antidepressant medications. This mixed-method study followed a subset (N = 28) of a research sample of depressed Latino immigrant primary care patients, who took depression medication, with a telephone interview to study their knowledge about and experiences with antidepressant medications. Most (82%) reported taking medication for 2 months or more, and 75% reported feeling better, whereas more than half reported side effects. Most (61%) agreed that antidepressants are generally safe and helpful in treating depression (68%); however, many believed they could be addictive (39%). Fifty percent of patients who discontinued their medication did not inform their providers. Twelve of the 28 patients also participated in focus groups about interactions with providers and made suggestions for conveying information about antidepressants. Patients suggested videos as a format to disseminate medication information because they do not require written comprehension. Other patient recommendations are presented.

The overlap of sleep disturbance and depression in primary care patients treated with buprenorphine

ABSTRACTBackground: Sleep disturbance is common among patients receiving long-term opioid therapies, such as methadone maintenance. However, little is known about sleep disturbances in patients receiving medication treatment with buprenorphine. We sought to determine the frequency of subjective sleep disturbance in a sample of patients receiving medication treatment and to examine clinical factors related to sleep disturbance. Methods: Participants were 328 persons receiving buprenorphine at 3 primary care sites. Sleep difficulty was assessed 2 questions adapted from the Patient Health Questionnaire-9 (PHQ-9) item assessing sleep. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD)-10 and PHQ-2. In addition, information was gathered on participant demographics and treatment characteristics. Demographics, buprenorphine treatment history, and depressive symptoms were compared for those with and without self-reported sleep difficulty. Logistic regression was used to estimate the adjusted association of sleep disturbance with these correlates. Results: Seventy-one percent of persons receiving medication treatment with buprenorphine in the present study reported sleep difficulty. Persons reporting sleep disturbance reported shorter time in buprenorphine treatment and more depressed mood compared with those without sleep difficulty (p < .01). Men were significantly less likely to report disturbed sleep than women (odds ratio [OR] = 0.57, 95% confidence interval [CI]: 0.33, 0.98). Sleep disturbance was not associated significantly with age, ethnicity, educational attainment, or buprenorphine dose. Conclusions: Sleep disturbance is common in patients receiving medication treatment with buprenorphine and is associated with more depressive symptoms as well as a shorter duration of medication treatment. Future research, using subjective and objective sleep measures, is warranted to understand whether sleep disturbance is mitigated by longer buprenorphine treatment and whether difficulty sleeping predicts buprenorphine discontinuation among patients seeking treatment for opioid dependence.

Effects of internet-based cognitive behavioural therapy and physical exercise on sick leave and employment in primary care patients with depression: two subgroup analyses

ObjectivesDepression can negatively impact work capacity, but treatment effects on sick leave and employment are unclear. This study evaluates if internet-based cognitive behavioural therapy (ICBT) or physical exercise (PE), with...

Non-pharmacological treatment for depressed older patients in primary care: A systematic review and meta-analysis.

BackgroundLate-life depression is most often treated in primary care, and it usually coincides with chronic somatic diseases. Given that antidepressants contribute to polypharmacy in these patients, and potentially to interactions with other drugs, non-pharmacological treatments are essential. In this systematic review and meta-analysis, we aimed to present an overview of the non-pharmacological treatments available in primary care for late-life depression.MethodThe databases of PubMed, PsychINFO, and the Cochrane Central Register of Controlled Trials were systematically searched in January 2017 with combinations of MeSH-terms and free text words for “general practice,” “older adults,” “depression,” and “non-pharmacological treatment”. All studies with empirical data concerning adults aged 60 years or older were included, and the results were stratified by primary care, and community setting. We narratively reviewed the results and performed a meta-analysis on cognitive behavioral therapy in the primary care setting.ResultsWe included 11 studies conducted in primary care, which covered the following five treatment modalities: cognitive behavioral therapy, exercise, problem-solving therapy, behavioral activation, and bright-light therapy. Overall, the meta-analysis showed a small effect for cognitive behavioral therapy, with one study also showing that bright-light therapy was effective. Another 18 studies, which evaluated potential non-pharmacological interventions in the community suitable for implementation, indicated that bibliotherapy, life-review, problem-solving therapy, and cognitive behavioral therapy were effective at short-term follow-up.DiscussionWe conclude that the effects of several treatments are promising, but need to be replicated before they can be implemented more widely in primary care. Although more treatment modalities were effective in a community setting, more research is needed to investigate whether these treatments are also applicable in primary care.Trial registrationPROSPERO CRD42016038442.

Factors associated with general practitioners\u2019 awareness of depression in primary care patients with heart failure: baseline-results from the observational RECODE-HF study

BackgroundDepression is more prevalent in patients with heart failure (HF) than in those without, but its detection is complicated by the symptom overlap between the two diseases. General practitioners (GPs) are the first point of contact for patients with HF. Therefore, this study aims to investigate GPs’ awareness of depression in their HF patients and factors associated with this awareness.MethodsIn this cross-sectional, observational study 3224 primary care patients with HF were screened for depressive symptomatology using an algorithm based on the Hospital Anxiety and Depression Scale, the 9-item subscale on Depression of the Patient Health Questionnaire, and selected items from the PROMIS Depression and Anxiety scales. The 272 GPs of all patients involved in the study were interviewed by telephone regarding their patients’ somatic and psychological comorbidities. The awareness rates of depressive symptomatology by the patients’ GPs are analyzed using descriptive statistics. Logistic regression analyses are applied to investigate the patient- and GP-based factors associated with the GPs’ awareness of depressive symptomatology.ResultsGPs were aware of their patients’ depressive symptomatology in 35% of all cases. Factors associated with the awareness of depressive symptomatology were: higher patient education levels, a history of depression known to the GP, GP-consultations due to emotional distress within the last 6 months, a higher frequency of GP-contacts within the last 6 months, a higher New York Heart Association (NYHA) classification and more severe depressive symptomatology. The GPs’ characteristics, including further education in psychology/psychiatry, were not associated with GP awareness.ConclusionsMany aspects, including the definition of awareness and the practical issues in primary care, may contribute to the unexpectedly low awareness rates of depressive symptomatology in HF patients in primary care. Awareness rates might increase, if GPs encouraged their patients to talk about emotional distress, held detailed medical interviews including a patient’s history of depression and payed special attention to HF patients with low education levels. However, it remains to be investigated whether GPs’ judgement of depressive symptomatology is a better or worse indicator for the future prognosis and quality of life of HF patients than psychiatry based diagnostic criteria.

Brief cognitive behavioral therapy for insomnia delivered to depressed veterans receiving primary care services: A pilot study

BackgroundDepression and insomnia are treatable, often co-occur and are common among primary care patients. Treatments designed for primary care must be brief, effective and ideally have the potential to address multiple symptoms. A brief form of cognitive behavioral therapy for insomnia (CBT-I) was piloted among depressed primary care patients with insomnia some of whom endorsed suicidal ideation. MethodsVeterans Affairs primary care patients were randomized to either CBT-I or sleep hygiene. CBT-I consisted of two, 20–40min in-person sessions and two 15–20min telephone sessions; SH consisted of one in-person and one telephone session. Participants were assessed at baseline, post-treatment, and a 3 month follow-up. ResultsCompared to SH (n=14), brief CBT-I (n=13) had large effects on insomnia severity, sleep efficiency, number of awakenings, and time awake after sleep onset with between group effect sizes ranging from .75 to 1.09 at post-treatment and .66–.89 at follow-up, though significance was not maintained at follow-up. Although both groups experienced significant reductions in depression severity, statistically significant group by time interactions were not observed for depression. LimitationsNotable limitations include the small sample size, having excluded patients with the most severe suicide risk, and the absence of objective testing to detect presence of sleep disorders other than insomnia. ConclusionsThe effects observed for insomnia outcomes, corroborate support for using CBT-I in depressed patients and extend this support to a brief from of CBT-I structured for delivery in primary care. Whether a brief form of CBT-I delivered to patients in primary care who endorse suicidal ideation would have a significant effect on depressive symptoms and/or suicidal ideation remains to be tested in a fully powered trial.

Bidirectionality Between Sleep Symptoms and Core Depressive Symptoms and Their Long-Term Course in Major Depression.

To investigate the bidirectional dynamic relationship between sleep symptoms and core depressive symptoms and to identify subgroups differing with respect to their course. The weekly state of depressive symptoms in depressed primary care patients (N = 267) was assessed retrospectively every 3 months for 3 consecutive years. The bidirectional relationship between sleep and core symptoms was estimated by means of manifest Markov modeling. Data-driven subgroups were estimated with parallel processes-latent class growth analyses to identify differences in courses of sleep and core symptoms. In total, core symptoms were associated with next-week development (odds = 1.42; 95% confidence interval [CI] = 1.20-1.67; p < .001) and remission of sleep symptoms (odds = 0.86; 95% CI 0.75 to 0.99, p = .033).Evidence was also found for a reverse pathway such that sleep symptoms were associated with the development (odds = 1.26; 95% CI = 1.05-1.50; p = .012) and remission of core symptoms (odds = 0.87; 95% CI = 0.76-0.99; p = .038). Three classes with different 3-year courses were derived. In class 1, the likelihood that core symptoms remitted was reduced if sleep symptoms were present, and symptoms remained present over 3 years. In class 2, symptoms were bidirectionally related and remitted over 3 years. In class 3, symptoms were not associated, and sleep symptoms declined less steeply than core depressive symptoms. The results suggest that sleep symptoms should be treated alongside core depressive symptoms in patients with an asynchronic decrease of sleep and core symptoms and in patients that do not respond to treatment to increase the chance of complete remission.

Health-related quality of life of primary care patients with depressive disorders

BackgroundDepressive disorders are known to impair health-related quality of life (HRQoL) both in the short and long term. However, the determinants of long-term HRQoL outcomes in primary care patients with depressive disorders remain unclear.MethodsIn a primary care cohort study of patients with depressive disorders, 82% of 137 patients were prospectively followed up for five years. Psychiatric disorders were diagnosed with SCID-I/P and SCID-II interviews; clinical, psychosocial and socio-economic factors were investigated by rating scales and questionnaires plus medical and psychiatric records. HRQoL was measured with the generic 15D instrument at baseline and five years, and compared with an age-standardized general population sample (n = 3707) at five years.ResultsDepression affected the 15D total score and almost all dimensions at both time points. At the end of follow-up, HRQoL of patients in major depressive episode (MDE) was particularly low, and the association between severity of depression (Beck Depression Inventory, BDI) and HRQoL was very strong (r = −0.804). The most significant predictors for change in HRQoL were changes in BDI and Beck Anxiety Inventory (BAI) scores. The mean 15D score of depressive primary care patients at five years was much worse than in the age-standardized general population, reaching normal range only among patients who were in clinical remission and had virtually no symptoms.ConclusionsAmong depressive primary care patients, presence of current depressive symptoms markedly reduces HRQoL, with symptoms of concurrent anxiety also having a marked impact. For HRQoL to normalize, current depressive and anxiety symptoms must be virtually absent.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

The ten-year course of depression in primary care and long-term effects of psychoeducation, psychiatric consultation and cognitive behavioral therapy

BackgroundWhile the majority of depressed patients are treated in primary care, long-term follow-up data on the naturalistic course of depression and treatment effectiveness in this setting are scarce. This study examined the ten-year course of depression in primary care patients who had participated in a randomized clinical trial aiming at enhancement of depression outcomes. MethodsOf the original sample (n=267), 166 patients participated in the ten-year follow-up; missingness was random. Four treatments were compared: (1) Care As Usual (CAU; n=51); (2) a Psychoeducational Prevention program (PEP; n=68); (3) Psychiatric Consultation followed by PEP (PC+PEP; n=21); and (4) brief Cognitive Behavioral Therapy followed by PEP (CBT+PEP; n=26). During the first three years interviews based on the Composite International Diagnostic Interview (CIDI) were three-monthly applied, the seven years thereafter were assessed with a once applied CIDI and a face-to-face life chart-based interview. ResultsDuring the ten-year follow-up 76.5% of the patients developed a new depressive episode, 83.4% used antidepressants (median usage 3.1 years), median depression diagnosis-free time was 9.0 years, and median residual symptom-free time 3.8 years. Treatments did not significantly differ on these outcomes, only trends appeared for lower depression severity for CBT+PEP, and, along with PEP, a higher proportion of symptom-free time. LimitationsAssessment with the once applied life chart interview (a valid and reliable instrument) is less precise than the three-monthly assessments during the first three years. ConclusionsThe long-term course of depression in primary care is unfavorable, whereas treatment effects over time seem absent or small.

Late-life depression and the association with multimorbidity and polypharmacy: a cross-sectional study.

Late-life depression often coincides with chronic somatic diseases and, consequently, with polypharmacy, which may complicate medical treatment. To determine the associations between patients diagnosed with late-life depression in primary care and multimorbidity and polypharmacy. This cross-sectional observational study was performed using 2012 primary care data. Depressed patients aged ≥60 years were compared to age and gender matched patients diagnosed with other psychological diagnoses and mentally healthy controls. Morbidity and prescription data were combined, and regression analyses were performed for the associations between depression and chronic disease and chronic drug use. We included 4477 patients; 1512 had a record of depression, 1457 of other mental health or psychological diagnoses and 1508 were controls. Depressed patients had a 16% [Prevalence Ratio (PR) 1.16; 95% confidence interval (95% CI) 10%-24%] higher rate of chronic somatic disease and higher odds for multimorbidity (OR 1.55; 95% CI 1.33-1.81) compared with controls. No differences existed between depressed patients and patients with other psychological diagnoses. Compared with controls, depressed patients had a 46% (95% CI 39-53%) higher rate of chronic drug use and higher odds for polypharmacy (OR 2.89; 95% CI 2.41-3.47). Depressed patients also had higher rates of chronic drug use and higher odds for polypharmacy compared with patients with other psychological diagnoses (PR 1.26; OR 1.75; both P < 0.001). Late-life depression in primary care patients is associated with more chronic drug use, even beyond the increased rates of comorbid somatic diseases. General practitioners should consider medication reviews to prevent unnecessary drug-related problems in these patients.

Maintenance pharmacotherapy for recurrent major depressive disorder in primary care: A 5-year follow-up study

BackgroundMost practice guidelines recommend maintenance antidepressant treatment for recurrent major depressive disorder. However, the degree to which such guidance is actually followed in primary health care has remained obscure. We investigated the provision of maintenance antidepressant treatment within a representative primary care five-year cohort study. MethodsIn the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up. A graphic life chart enabling evaluation of the longitudinal course of episodes plus duration of pharmacotherapies was used. In accordance with national guidelines, an indication for maintenance treatment was defined to exist after three or more lifetime major depressive episodes (MDEs); maintenance treatment was to commence four months after onset of full remission. ResultsOf the cohort patients, 34% (46/137) had three or more lifetime MDEs, thus indicating the requirement for maintenance pharmacotherapy. Of these, half (54%, 25/46) received maintenance treatment, for only 29% (489/1670) of the months indicated. ConclusionsIn this cohort of depressed primary care patients, half of patients with indications for maintenance treatment actually received it, and only for a fraction of the time indicated. Antidepressant maintenance treatment for the prevention of recurrences is unlikely to be subject to large-scale actualization as recommended, which may significantly undermine the potential public health benefits of treatment.

Health-related quality of life of primary care patients with depressive disorders

BackgroundDepressive disorders are known to impair health-related quality of life (HRQoL) both in the short and long term. However, the determinants of long-term HRQoL outcomes in primary care patients with depressive disorders remain unclear. MethodsIn a primary care cohort study of patients with depressive disorders, 82% of 137 patients were prospectively followed up for five years. Psychiatric disorders were diagnosed with SCID-I/P and SCID-II interviews; clinical, psychosocial and socio-economic factors were investigated by rating scales and questionnaires plus medical and psychiatric records. HRQoL was measured with the generic 15D instrument at baseline and five years, and compared with an age-standardized general population sample (n=3707) at five years. ResultsDepression affected the 15D total score and almost all dimensions at both time points. At the end of follow-up, HRQoL of patients in major depressive episode (MDE) was particularly low, and the association between severity of depression (Beck Depression Inventory [BDI]) and HRQoL was very strong (r=−0.804). The most significant predictors for change in HRQoL were changes in BDI and Beck Anxiety Inventory (BAI) scores. The mean 15D score of depressive primary care patients at five years was much worse than in the age-standardized general population, reaching normal range only among patients who were in clinical remission and had virtually no symptoms. ConclusionsAmong depressive primary care patients, presence of current depressive symptoms markedly reduces HRQoL, with symptoms of concurrent anxiety also having a marked impact. For HRQoL to normalize, current depressive and anxiety symptoms must be virtually absent.

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.