Moderate Depression In Primary Care Research Articles

Utilization of healthcare and prescription medicines after non-pharmacological interventions for depression - A 3-year register follow-up of an RCT in primary care

Depression is a common, recurrent disorder. There is a need for readily available treatments with few negative side effects, that demands little resources and that are effective both in the short- and long term.Our aim was to investigate the long-term effectiveness of two different interventions; physical exercise and internet-based cognitive behavioural therapy (internet-CBT), compared to usual care in patients with mild to moderate depression in a Swedish primary care setting.We performed a register-based 3-year follow-up study of participants in the randomized controlled trial REGASSA (n = 940) using healthcare utilization and dispensed medicines as outcomes.We found no difference between the three groups regarding proportion of participants consulting healthcare due to mental illness or pain during follow-up. Regarding number of consultations, there was no difference between the groups, except for consultations related to pain. For this outcome both treatment arms had significantly fewer consultations compared to usual care, during year 2–3, the risk ratio (RR) for physical exercise and internet-CBT was 0.64 (95% CI = 0.43–0.95) and 0.61 (95% CI = 0.41–0.90), respectively.A significantly lower proportion of patients in both treatment arms were dispensed hypnotics and sedatives year 2–3 compared to the usual care arm, RR for both physical exercise and internet-CBT was 0.72 (95% CI = 0.53–0.98). No other differences between the groups were found.In conclusion, considering long-term effects, both physical exercise and internet-CBT, being resource-efficient treatments, could be considered as appropriate additions for patients with mild to moderate depression in primary care settings.Trial registration: The original RCT was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).

Effectiveness of watchful waiting versus antidepressants for patients diagnosed of mild to moderate depression in primary care: A 12-month pragmatic clinical trial (INFAP study)

BackgroundAlthough mild to moderate major depressive disorder (MDD) is one of the main reasons for consulting a general practitioner (GP), there is still no international consensus on the most appropriate therapeutic approach. MethodsThe aim of this study is to evaluate the clinical effectiveness of watchful waiting (WW) compared with the use of antidepressants (ADs) for the treatment of mild to moderate depressive symptoms in 263 primary care (PC) usual-practice patients in a 12-month pragmatic non-randomised controlled trial. Both longitudinal and per-protocol analyses were performed, through a multilevel longitudinal analysis and a sensitivity analysis. ResultsWe observed a statistically significant time x treatment interaction in the severity of depression (Patient Health Questionnaire, PHQ-9) and disability (World Health Organization Disability Assessment Schedule, WHODAS) in favour of the AD group at 6 months but not at 12 months. The effect size of this difference was small. No statistically significant differences were observed between groups in severity of anxiety (Beck Anxiety Inventory, BAI) or health-related quality-of-life (EuroQol-5D, EQ-5D). Sensitivity analysis and per-protocol analysis showed no differences between the two groups in any of the evaluated scales. ConclusionsSuperiority of either treatment (WW and AD) was not demonstrated in patients treated for depression in PC after one year of follow-up.

Comparing watchful waiting with antidepressants for the management of subclinical depression symptoms to mild-moderate depression in primary care: a systematic review.

The benefits of watchful waiting (WW) over antidepressants (ADs) for the treatment of depression in primary care (PC) are unclear. We aimed to systematically review the evidence supporting either WW or ADs for the treatment of subclinical depressive symptoms and mild-moderate depression in a PC setting. This systematic review was registered at PROSPERO (42016036345). Four electronic sources (EMBASE, PubMed, PsycINFO, Web of Knowledge) were systematically searched from inception to November 2016 for controlled trials comparing WW and ADs in PC following established guidelines. The studies had to include adult population with new symptoms of subclinical depression or mild-moderate depression. Patients in the intervention group should receive a WW approach, while patients in the control group underwent treatment with ADs. The abstraction form included information on the setting, characteristics of the study population, total sample size, size of the control and intervention groups and date of the study. Outcome measures and variability were extracted. The scarcity of studies and the considerable clinical and methodological heterogeneity discouraged us from performing a meta-analysis. Three articles were included and qualitatively synthesized. There was no evidence for the superiority of one treatment option over the other, although two of the studies suggested small differences in favour of ADs when less conservative analyses were conducted (per protocol analysis and analysis not adjusted for missingness predictors). Superiority was not demonstrated by either treatment option. More robust evidence is needed to inform recommendations for the management of depressive symptoms in PC.

Adults with mild to moderate depression exhibit more alcohol related problems compared to the general adult population: a cross sectional study.

BackgroundAlcohol use has been shown to interfere with treatment for depression, but consumption habits are not routinely screened in primary care. To date, few studies have compared the alcohol consumption habits of patients with depression to the general population. The purpose of this study was to compare alcohol habits in adults diagnosed with depression in primary care to the general adult population in Sweden.MethodsNine hundred fourty six patients diagnosed with mild to moderate depression, without a primary substance use disorder, in primary care settings located across Sweden completed the Alcohol Use Disorders Identification Test (AUDIT). Consumptions habits and alcohol related problems in the depressed sample were compared to those in the general adult population (n = 663). Analyses were stratified by gender and age.ResultsRatings of alcohol problems and measures of hazardous drinking and binge drinking were significantly higher among patients seeking treatment for depression in primary care compared to the general population. Male patients scored higher on the AUDIT total and AUDIT-C (consumption) subscale than men in the general population. Compared to younger adults (aged 17–27) older depressed adults (aged 28–50 and 51–71) exhibited higher rates of consumption and problems related to alcohol.ConclusionsCompared to the general adult population, consumption and problems related to alcohol use were substantially higher among patients with mild to moderate depression in primary care. Routine screening of alcohol use in primary care is recommended for patients presenting with depression.

Do patients׳ illness beliefs predict depression measures at six months in primary care; a longitudinal study

BackgroundDepressive disorders are prevalent and costly but there is a lack of evidence on how best to select treatments for mild to moderate depression in primary care. Illness beliefs have been shown to affect the outcome from physical illness, but there is limited information on the beliefs of patients who are depressed. AimsTo measure patients׳ beliefs about depression at baseline and determine whether these relate to depression severity at six months. MethodsPrimary care patients with a recently diagnosed episode of depression completed the Beliefs about Depression Questionnaire and depression severity scores at baseline. The primary outcome was the change in depression severity score on the Hospital Anxiety and Depression Scale after six months. Results227/292 (78%) participants completed follow-up questionnaires. Initial severity of depression at baseline, and particular beliefs about the causes, consequences and timeline of depression predicted poorer outcomes, whereas a belief in using exercise or keeping busy to treat depression predicted improved outcomes. Prescription of antidepressants did not appear to mediate these relationships. LimitationsThis was an initial study using a new validated questionnaire and it cannot be predicted whether these results are representative or would be reproduced in other populations. Although participants were primary care patients whose GP (General Practitioner) had coded as having a new incident episode of depression in the preceding six months, 43% of participants stated they had been depressed for more than a year. Sufficient participants were recruited to ensure the study was adequately powered but participation rate was 30%, raising the possibility of response bias. Conclusions and clinical relevanceIllness beliefs may help to predict outcomes in depression and therefore assessing and addressing patients׳ beliefs about their depression may enhance treatment.

Are patient beliefs important in determining adherence to treatment and outcome for depression? Development of the beliefs about depression questionnaire

Depressive disorders are prevalent and costly but there is a lack of evidence on how to best select treatments for mild to moderate depression in primary care. Illness beliefs have been shown to influence the outcome from physical illness and our previous retrospective study suggested that beliefs may influence the duration of antidepressant medication. The development of a short questionnaire to measure beliefs will allow exploration of the relationship between beliefs, adherence to treatment and outcome for depression. A questionnaire was designed based on Leventhal's Common Sense Model of illness beliefs (CSM). Data from previous qualitative and quantitative studies as well as formal inventories were used to inform the content of individual items. The questionnaire was mailed to primary care patients with a recorded history of depression in the previous 2 years. Data were analysed by principal component analysis to determine underlying multidimensional structure and derive a shortened questionnaire. Three hundred and thirty-four respondents completed the questionnaire. Fifteen components (subscales) were derived which corresponded to aspects of the CSM dimensions for cause, control/cure, consequences and timeline. The identity dimension was retained as one subscale. Reliability coefficients determined the items which best represented each subscale; 52 items were retained to derive a new shortened questionnaire. Convergent construct validity was demonstrated by comparison with the generic brief illness perception questionnaire (BIPQ) and divergent construct validity was shown by comparison with the Hospital Anxiety and Depression scale (HADs). The study was adequately powered, but the response rate means that response bias cannot be excluded. Beliefs about depression are multi-faceted, but fit the dimensions of the CSM. The derived shortened questionnaire will be used to determine whether beliefs about depression are predictive of outcome in a future prospective study.

Community pharmacists and depression: the pharmacist as intermediary between patient and physician

Abstract Objectives To describe community pharmacists' experiences and contributions to the management of mild to moderate depression in primary care and to explore their interactions with patients and physicians. Method Qualitative semi-structured interview study with a purposive sample of 20 community pharmacists from a range of backgrounds in one area of England. Pharmacists were asked to describe their involvement in the management of depression from patients' self-diagnosis and self-treatment through to treatment with antidepressants. They were asked to cite examples of the questions that they were asked by patients about depression and its treatment, and about their practice in advising patients with first-time and repeat prescriptions for antidepressants. Attitudes and practice relating to compliance and concordance with antidepressants were explored. Key findings Pharmacists were asked a wide range of questions by patients about antidepressants and depression. Often these questions posed ethical dilemmas for the pharmacists by raising topics that crossed inter-professional boundaries. Pharmacists generally saw their role as encouraging patients to take antidepressant treatment and they reported providing technical information, mainly when the first prescription was dispensed. Most pharmacists worked from a “compliance” model although this appeared to conflict sometimes with their own views about the appropriateness of antidepressant treatment. Pharmacists rarely entered into discussion with patients on their feelings about treatment or their intention to take it. Monitoring of compliance to antidepressants was largely seen as the province of the physician and pharmacists appeared to feel unable to undertake this role effectively. Nevertheless 17 of the pharmacists expressed a wish to extend their role in the management of depression. Conclusions Pharmacists' accounts showed that patients have unmet needs in relation to the management of depression and treatment with antidepressants. Achieving concordance in the tripartite relationship between patient, GP and pharmacist poses considerable challenges. However, our findings suggest that pharmacists could play a larger role as first-line advisers on depression and its treatment if the identified barriers can be overcome.

Estimating probability of sustained recovery from mild to moderate depression in primary care: evidence from the THREAD study

It is important for doctors and patients to know what factors help recovery from depression. Our objectives were to predict the probability of sustained recovery for patients presenting with mild to moderate depression in primary care and to devise a means of estimating this probability on an individual basis. Participants in a randomized controlled trial were identified through general practitioners (GPs) around three academic centres in England. Participants were aged >18 years, with Hamilton Depression Rating Scale (HAMD) scores 12-19 inclusive, and at least one physical symptom on the Bradford Somatic Inventory (BSI). Baseline assessments included demographics, treatment preference, life events and difficulties and health and social care use. The outcome was sustained recovery, defined as HAMD score <8 at both 12 and 26 week follow-up. We produced a predictive model of outcome using logistic regression clustered by GP and created a probability tree to demonstrate estimated probability of recovery at the individual level. Of 220 participants, 74% provided HAMD scores at 12 and 26 weeks. A total of 39 (24%) achieved sustained recovery, associated with being female, married/cohabiting, having a low BSI score and receiving preferred treatment. A linear predictor gives individual probabilities for sustained recovery given specific characteristics and probability trees illustrate the range of probabilities and their uncertainties for some important combinations of factors. Sustained recovery from mild to moderate depression in primary care appears more likely for women, people who are married or cohabiting, have few somatic symptoms and receive their preferred treatment.

Protocol for the THREAD (THREshold for AntiDepressants) study: a randomised controlled trial to determine the clinical and cost-effectiveness of antidepressants plus supportive care, versus supportive care alone, for mild to moderate depression in UK general practice.

BackgroundDepression guidelines in the UK recommended a policy of watchful waiting for mild depression due to a lack of evidence for the effectiveness of antidepressant treatment for mild cases. However there has been relatively little research carried out in primary care to help establish the severity threshold at which antidepressant treatment is effective and cost-effective.Methods/DesignThe THREAD (THREshold for AntiDepressants) study is a multi-centre randomised controlled trial designed to determine the clinical and cost effectiveness of a selective serotonin reuptake inhibitor (SSRI) plus general practitioner (GP) supportive care, versus supportive care alone, for mild to moderate depression in primary care. The aim is to recruit 300 patients from three centres (Southampton, London and Liverpool). Depressive symptoms will be assessed at baseline, 12 weeks and 26 weeks, using the 17-item Hamilton Depression Rating Scale (HDRS). Two severity sub-groups of patients will be recruited, with HDRS scores of 12–15, and 16–19. Possible predictors of response will be explored including life events and difficulties and alcohol consumption. Analysis of covariance, controlling for baseline value, severity group and centre will be used to estimate the overall treatment effectiveness (difference in HDRS score) at final follow up. The primary analysis will be by 'intention to treat' using double sided tests. The interaction between severity sub-group and treatment will be tested, and if appropriate, effects within separate severity sub-groups estimated. The economic analysis will compare the two treatment groups in terms of mean costs and cost-effectiveness.DiscussionThe results of this study will give GPs important information to help them determine the severity of depression at which antidepressant treatment is likely to be cost-effective.

Laser Acupuncture for Mild to Moderate Depression in a Primary Care Setting – a Randomised Controlled Trial

Depression is a major public health problem. There is some evidence supporting the effectiveness of needle acupuncture in its treatment. Laser stimulation, regarded here as a modality of acupuncture, is non-invasive and therefore free of infection risk; and it is acceptable to patients with needle phobia. The technique is relatively easily learned by community-based general practitioners. It is also amenable to sham control and therefore double-blinding in clinical trials. A double-blind randomised controlled trial was conducted to test the efficacy of low level laser acupuncture in mild to moderate depression. Thirty patients with depression were randomised to receive either active or inactive laser treatment. The laser unit could be switched to one of two settings. One switch position delivered active laser acupuncture and the other was inactive (sham). In the active mode, 0.5J was delivered to each of six to eight individually tailored acupuncture sites per visit. All patients were treated twice weekly for four weeks then weekly for a further four weeks. The patients and the acupuncturist were both blinded to conditions. Outcome was assessed using the Beck Depression Inventory at baseline, weeks four and eight during treatment, and at 4 and 12 weeks following the treatment. At the end of the treatment period, Beck Depression Inventory scores fell from baseline by 16.1 points in the intervention group and by 6.8 points in the sham control group (P<0.001). The difference showed only a trend four weeks later, but was again significant after 12 weeks (P=0.007). Laser acupuncture was well tolerated with transient fatigue as the most common adverse effect. Laser acupuncture may be worth further investigation as a treatment for mild to moderate depression in primary care.

A new instrument for the exploration of distress

Depressive disorders are prevalent and costly but there is a lack of evidence on how to best select treatments for mild to moderate depression in primary care. Illness beliefs have been shown to influence the outcome from physical illness and our previous retrospective study suggested that beliefs may influence the duration of antidepressant medication. The development of a short questionnaire to measure beliefs will allow exploration of the relationship between beliefs, adherence to treatment and outcome for depression.A questionnaire was designed based on Leventhal's Common Sense Model of illness beliefs (CSM). Data from previous qualitative and quantitative studies as well as formal inventories were used to inform the content of individual items. The questionnaire was mailed to primary care patients with a recorded history of depression in the previous 2 years. Data were analysed by principal component analysis to determine underlying multidimensional structure and derive a shortened questionnaire.Three hundred and thirty-four respondents completed the questionnaire. Fifteen components (subscales) were derived which corresponded to aspects of the CSM dimensions for cause, control/cure, consequences and timeline. The identity dimension was retained as one subscale. Reliability coefficients determined the items which best represented each subscale; 52 items were retained to derive a new shortened questionnaire. Convergent construct validity was demonstrated by comparison with the generic brief illness perception questionnaire (BIPQ) and divergent construct validity was shown by comparison with the Hospital Anxiety and Depression scale (HADs).The study was adequately powered, but the response rate means that response bias cannot be excluded.Beliefs about depression are multi-faceted, but fit the dimensions of the CSM. The derived shortened questionnaire will be used to determine whether beliefs about depression are predictive of outcome in a future prospective study.