Assessment of distress and burden in Australian private psychiatric inpatients

OBJECTIVES

The study aimed to examine (i) the extent of the objective and subjective burden of care experienced by carers of individuals attending Australian private psychiatric hospitals, (ii) the degree to which a carer's distress was influenced by the patient's symptoms and the burden of care experienced.

METHODS

A group of 135 inpatient-carer dyads, for inpatients who attended three Australian private psychiatric clinics, completed measures of distress (Depression Anxiety Stress Scales) and caregiver burden (Burden Assessment Scale; BAS) during an inpatient admission to a private psychiatric hospital.

RESULTS

The level of burden reported by carers was comparable with overseas data. Factor analysis was used to identify the key dimensions of the BAS. The chief concerns of carers related to worries about the patient and disruption to activities.

CONCLUSION

The burden experienced by carers needs to be recognized and addressed to ensure that they are able to continue to provide the care and support required by psychiatric inpatients. Present data are discussed in terms of the best way to support the carers of psychiatric inpatients.

PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes

OBJECTIVE

This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment.

METHODS

Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics.

RESULTS

A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression.

CONCLUSIONS

Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.

Routine use of the Beck Scale for Suicide Ideation in a psychiatric emergency department

BACKGROUND

U.S. suicide rates are estimated to be 11 per 100,000 people, and improved screening in emergency departments may reduce suicide rates.

METHOD

This study examined the relationship between clinician rating of suicide ideation and Beck Scale for Suicide Ideation (BSI) scores when clinicians had access to the BSI results and whether BSI scores and/or clinician ratings of suicidality are associated with patient disposition from the psychiatric emergency department.

RESULTS

Of 735 patients, 665 (90%) had documentation of suicide ideation in the chart; 246 (37%) were rated as suicidal; 487 (66%) patients completed the BSI forms; 300 patients (62%) scored positive on the BSI. Logistic regression analysis for BSI scores and clinician ratings of suicidality showed similar results, except clinicians were more likely to rate males as suicidal, while BSI scores did not vary according to sex. Hospitalization occurred more often for patients with mood disorder who had positive BSI scores, while hospitalization occurred more often for patients with a diagnosis of bipolar disorder or schizophrenia who were rated by clinicians as suicidal.

CONCLUSIONS

There were important demographic and diagnostic differences revealed by logistic regression analysis of BSI scores and clinician-rated suicidality, and these differences may be associated with disposition for patients presenting with suicide ideation.

Home clinic programme: an alternative model for private mental health facilities and sufferers of major depression

Depression demands high emotional and social costs to people suffering it while private hospitals and health funds are economically affected in respect to elongated episodes of care and readmission rates. There is a dearth of nurse-led initiatives aimed to reduce length of stay. An innovative model of care is proposed, offering the opportunity for depressed clients to return home earlier from hospital where they will receive the professional guidance and support of mental health registered nurses (RNs) providing contemporary counselling. Clinical links between the home and the hospital would be maintained by the RNs for a specified time frame. The framework of home clinic programme is to discharge clients from hospital into community within specified time frame (maximum 14 days hospitalization) and the clients will be visited by RNs in their homes five times in the first week, twice in the second week and once in the third week to ascertain their emotional and clinical needs and provide biopsychosocial support. The use of this model has potential benefits for mental health consumers, clinicians, services, and funders.

Pathophysiologic aspects of major depression following traumatic brain injury

Mood disorders, particularly major depression, are the most frequent complication of traumatic brain injury. Major depression is present in about 40% of patients hospitalization for a traumatic brain injury. Anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts are frequently associated with major depression, and their coexistence constitutes a marker of a more disabling clinical course. The complex interactions of genetic, developmental, and psychosocial factors determine patients' vulnerability to developing affective disturbances following a traumatic brain injury. Symptoms of depression cluster into the domains of low mood and distorted self-attitude, lack of motivation and anhedonia, subjective cognitive complaints, and hyperactive and disinhibited behavior. It is reasonable to assume that these symptomatic clusters have specific underlying mechanisms that need to be integrated in a comprehensive pathophysiologic model.

Severe mental illness across cultures

OBJECTIVE

International studies have shown that the outcome of illnesses like schizophrenia vary across cultures. The good outcome in developing countries depends upon a number of factors.

METHOD

Using both primary and secondary sources, existing literature was reviewed. Using terms severe mental illness, culture and schizophrenia, Medline, Psychinfo and Embase were searched. Further searches were conducted using secondary searches.

RESULTS

The impact of culture and its components on the individual and their families influences compliance, engagement with services and expectations of treatment. Cultures also impact upon identity and explanatory models of individuals.

CONCLUSION

Severe mental illness is as likely to be affected by culture as other illnesses. Clinicians need to use multi-model assessment and management techniques.

The aftermath: aspects of recovery described by perpetrators of maternal filicide committed in the context of severe mental illness

Mentally abnormal maternal filicide is a rare and horrifying event. Clinicians are unlikely to develop broad experience with this and there is little information available about recovery. This paper presents a range of descriptions of recovery experiences derived from a qualitative study of mentally abnormal maternal filicide perpetrators. Transcripts from a qualitative, semi-structured interview study of six women who committed filicide in the context of major mental illness were reviewed. Descriptions related to rehabilitation issues were grouped and themes extracted. The women described patchy but horrific memories they avoided thinking and talking about. They described intense self-judgement and self-hate. They valued ongoing relationships with surviving children and were distressed by perceptions that they might be a danger to other children. Managing illness was not described as a major challenge. Acknowledgement of illness was described as important in coming to terms with what they had done. Surviving children and relationships with family and other support networks were described as important in their rehabilitation. We conclude that optimizing treatment and rehabilitation for mental illness, supporting the woman to acknowledge the role of illness in the offence, maximizing support from personal networks, and enabling her to regain some aspect of the mother role may be more efficacious than debriefing with respect to the offence.

Occupational Functioning Scale (OFS)--an instrument for assessment of work ability in psychiatric disorders

The aim was to present the content of the newly developed observer rating scale of work ability--The Occupational Functioning Scale (OFS)--and its basic psychometric properties. Psychiatric disorders cause functional impairment in several domains, including occupational functioning. The assessment of work-related functioning is often neglected in psychiatric research, partly due to a lack of reliable and valid instruments. The validity of OFS was evaluated by comparing it with other work ability measures (SAS-work, Work Ability Index, sickness absence) and to non-work-ability related measures [Inventory of Interpersonal Problems (IIP), Symptom Check List - General Symptomatic Index (SCL-90-GSI)] in 150 patients with depressive or anxiety disorders. Reliability was determined by 39 videotaped interviews rated by four judges. OFS showed excellent inter-rater reliability (intraclass correlation = 0.91) and good criterion validity by being more strongly related to other scales of occupational functioning (mid R:rmid R: = 0.39-0.47) than to measures of general distress (SCL-90-GSI) and interpersonal problems (IIP)(mid R:rmid R: = 0.26 and 0.12). OFS is a simple, reliable and clinically meaningful instrument for assessment of work ability in depressive and anxiety disorders.

One-Year Follow-Up Study of Suicide Attempters Treated for Drug Dependence

A large proportion of patients treated for substance dependencies have attempted suicide. Scarce empirical evidence exists regarding their prognosis. Data from the Drug Abuse Treatment Outcome Survey were analyzed to determine the course of depression and substance dependence of 416 suicide attempters one year after discharge. The likelihood of recovery from drug dependence did not differ between patients who did or did not attempt suicide. Among suicide attempters who recovered from substance dependence, the frequency of Major Depression Disorder was significantly lower compared to admission, but its prevalence was nearly three times higher than that found in the general community.

[Major depressive disorders and psychiatric emergencies: a naturalistic study on crisis intervention relevance]

OBJECTIVE

This retrospective study aimed to evaluate the impact of introducing crisis intervention patterns in the emergency unit of a general hospital on the number of admissions and outpatient follow-ups for patients with major depressive disorder.

METHOD

The study included all patients with major depressive disorder (DSM-IV criteria) who visited the psychiatric emergency unit in a general hospital during two 8-month periods: before (425 patients) and after (436 patients) crisis interventions were introduced.

RESULTS

After crisis interventions were introduced, the voluntary admission rate decreased significantly (from 17.9% to 12.4%), while the number of outpatient follow-ups increased (from 82.1% to 86.2%). Borderline personality disorder was associated with a significant reduction of the admission rate (27.8% against 38.2%), while the admission rate for patients with depressive disorder with psychotic features did not decline after crisis interventions. Crisis interventions were more effective on women.

CONCLUSIONS

These outcomes suggest the relevance of crisis intervention in psychiatric emergency settings to improve the management of patients with major depressive disorder. Crisis intervention fosters outpatient multimodal follow-up rather than admission in a psychiatric setting.

Evaluation of the Neurobehavioral Functioning Inventory as a Depression Screening Tool After Traumatic Brain Injury

OBJECTIVE

To examine the utility of the Neurobehavioral Functioning Inventory (NFI) for diagnosing depression in a rehabilitation setting.

DESIGN

In a prospective study, a structured clinical interview (Structured Clinical Interview for DSM-IV-TR) was used to identify DSM-IV-defined major depressive disorder (MDD) symptoms among patients with traumatic brain injury (TBI). NFI Depression scale items were compared with DSM-IV diagnosis obtained by the Structured Clinical Interview for DSM-IV Axis I Disorders.

SETTING

Outpatient neuropsychology clinic at a university hospital, private outpatient physical medicine and rehabilitation clinic, and a long-term specialized living assistance program.

PARTICIPANTS

Participants consisted of 78 patients with TBI who were at least 3 months postinjury and 18 years of age or older.

MAIN OUTCOME MEASURES

Structured Clinical Interview for DSM-IV Axis I Disorders and the NFI.

RESULTS

Psychiatric diagnostic interview with the Structured Clinical Interview for DSM-IV Axis I Disorders indicated that 50% of patients with TBI in our sample had at least one of the following in their lifetime: MDD, MDD due to general medical condition, dysthymia, or adjustment disorder with depressed mood. Thirty percent met diagnostic criteria for current MDD with or without general medical condition. Analyses of the NFI items revealed that individuals with depression endorsed greater levels of problems than did those without depression on 14 of the 32 items related to the DSM-IV symptom domains for depression (P < .00156 with Bonferroni correction). In predicting the diagnosis of depression using individual NFI items, the classification rate based on the Random Forests estimate was 83%.

CONCLUSION

Findings indicate that the NFI items differentiated between depressed and nondepressed patients with TBI. Imposing minimal burden on patients and staff, the NFI appears to have good predictive value in diagnosing major depression. In clinical practice and research, the NFI is a potentially valuable screening tool for identifying major depression in persons with TBI.

Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder

OBJECTIVE

To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation.

METHOD

This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up.

RESULTS

BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home.

CONCLUSIONS

This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.

Post-traumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates

This study documents the prevalence and correlates of post-traumatic stress disorder (PTSD) among Australian individuals with heroin dependence. Data was obtained from a cohort of 615 people dependent on heroin, 535 entering treatment for their heroin dependence and 80 individuals not in treatment. Trauma exposure (92%) and lifetime PTSD (41%) were highly prevalent. PTSD was prevalent across all treatment modalities, most commonly residential rehabilitation (52%) followed by maintenance therapies (42%), and detoxification (37%). The lowest prevalence was reported among those not in treatment (30%). Although men and women were equally likely to have experienced trauma (93% vs. 89%), women were more likely to develop lifetime PTSD (61% vs. 37%). For the large majority of those with PTSD, the condition was chronic (84%), with symptoms continuing for an average of 9.5 years. Those with PTSD had more extensive polydrug use histories, poorer general physical and mental health, and more extensive health service utilisation. It is concluded that PTSD is highly prevalent among individuals with heroin dependence, presenting a significant challenge to treatment providers.

Substance use disorder comorbidity in major depressive disorder: an exploratory analysis of the Sequenced Treatment Alternatives to Relieve Depression cohort

Patients with major depressive disorder (MDD) often present with concurrent substance use disorders (SUD) involving alcohol and/or illicit drugs. This analysis compares the depressive symptomatic presentation and a range of clinical and demographic features of patients with MDD and concurrent SUD symptoms vs those without SUD symptoms, to clarify how these two differ and to determine whether concurrent SUD symptoms may alter the clinical presentation of MDD. The first 1500 outpatients with nonpsychotic MDD enrolled in the Sequenced Treatment Alternatives to Relieve Depression study were divided into those with and without concurrent SUD symptoms as ascertained by a self-report instrument, the Psychiatric Diagnostic Screening Questionnaire (PDSQ). Of the 1484 cases with completed baseline PDSQ, 28% (n = 419) of patients with MDD were found to endorse symptoms consistent with current SUD. Patients with symptoms consistent with SUD were more likely to be men (P < .0001), to be either divorced or never married (P = .018), to have a younger age of onset of depression (P = .014), and to have a higher rate of previous suicide attempts (P = .014) than those without SUD symptoms. Patients with major depressive disorder who have symptoms consistent with SUD endorsed greater functional impairment attributable to their illness than those without concurrent SUD symptoms (P = .0111). The presence of SUD symptoms did not alter the overall depressive symptom pattern of presentation, except that the dual-diagnosed patients had higher levels of hypersomnia (P = .006), anxious mood (P = .047), and suicidal ideation (P = .036) compared to those without SUD symptoms. In conclusion, gender, marital status, age of onset of major depression, functional impairment, and suicide risk factors differ in depressed patients with concurrent SUD symptoms compared to those without SUD comorbidity.

Construct validation of actigraphic sleep measures in hospitalized depressed patients

This study validated wrist actigraphic-measured sleep in depressed patients using construct validity by experimental intervention methods. The experimental participants were 18 patients hospitalized for major depression. Control participants were hospital staff. A 2-between (depressed patients vs. controls) x 2-within (pre- vs. post-) experimental design was used. Sleep was evaluated for 1 week, 7 nights, using wrist actigraphy on hospitalization and for a second week just prior to discharge. Clinical improvement was corroborated by statistically significant changes in the Beck Depression Inventory and the Inventory to Diagnose Depression. Sleep-onset latency, number of nighttime awakenings, minutes awake after sleep onset, and sleep efficiency all improved significantly as hypothesized. Minutes of sleep changed in the predicted direction but not significantly. Significant differences from control participants remained at discharge regarding minutes awake after sleep onset and sleep efficiency. These findings extend practice guidelines for actigraphy established by the Standards of Practice Committee (1995) of the American Sleep Disorders Association.

Recovery from major depression: the role of support from family, friends, and spiritual beliefs

OBJECTIVE

Many of the risk factors for major depression are not amenable to change. The present study was designed to identify factors associated with recovery from depression that could be targets for clinical intervention.

METHOD

Sixty-two psychiatric in-patients who met diagnostic criteria for major depression were interviewed while hospitalized and re-interviewed 3 months after discharge. Analyses examined the relationship between depression and three sources of emotional support: family, friends, and spiritual beliefs.

RESULTS

Depression severity at baseline was the most consistent predictor of depression severity and diagnosis at follow-up. Patients who had recovered from depression by the time of the follow-up assessment reported higher perceived emotional support from family and friends at baseline. Support from friends, support from family and a composite of emotional support were significant predictors of depression beyond the effects of initial depression severity.

CONCLUSION

Aspects of emotional support were significantly associated with depression outcome.

Ratings of early major depressive disorder symptom change during a brief psychiatric hospitalization

Ratings of change in MDD severity during a brief psychiatric hospitalization were examined across informant sources to determine the extent of change from admission to discharge and if specific symptoms are especially likely to change. Study participants were 137 inpatients with a primary diagnosis of MDD. Symptom data were collected at admission and discharge from attending psychiatrists, nurses, and patients. Global ratings of MDD severity and specific MDD symptoms significantly decreased during the course of hospitalization. This effect held across informant sources. All symptoms were equally likely to change. Females were rated as more depressed at admission and discharge by psychiatrists, but no gender differences were seen in self-report or nurse ratings. Shorter length of stay and involuntary admission status were associated with greater reduction in MDD severity. The temporal course and magnitude of the symptom reduction may result in part from unique aspects of an inpatient setting or from an underreporting of symptoms. The association between a shorter length of stay and greater symptom reduction may reflect a distinction between treatment responders and nonresponders.

Can the Randomized Controlled Trial Literature Generalize to Nonrandomized Patients?

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.

Generalizability of brief psychiatric rating scale prototypical profiles and their use in evaluating treatment outcomes

The generalizability of previously isolated prototypical profiles of the Brief Psychiatric Rating Scale (BPRS) was examined in a sample of homeless individuals with both severe mental illness and substance-use problems who were part of a 24-month study that evaluated the effectiveness of various treatment interventions. These prototypical profiles (depressed, actively psychotic, and withdrawn) did generalize to the new sample, with a 59.4% coverage rate. In addition, some of the participants' BPRS profiles (10%) were characterized by negative correlations with the withdrawn profile (termed agitated) and others (17%) by minimal within-profile variability (labelled flat). Overall, with these additions, the coverage of the prototypical profiles was 86.4%. These prototypical profiles were then used to evaluate changes in profile elevation and shape over the course of the study. Generally, changes in both profile elevation and shape were moderated by the particular prototypical profile that the participants resembled. The use of these prototypical profiles in evaluating change permits a more precise analysis of what kind of individuals manifest particular effects. The clinical meaning of the BPRS profile changes observed was also discussed.

Diagnostic agreement between a doctor and a nurse for psychiatric disorders: a pilot study

The objective of the study was to examine inter-rater agreement for psychiatric disorders by means of a structured interview performed by a psychiatrist and a nurse. Sixteen psychiatric inpatients with a mean age of 38.9+/-12.9 years were assessed independently by a psychiatrist and a nurse using a structured psychiatric interview, Strukturert Psykiatrisk Intervju for Allmennpraksis (SPIFA). For most diagnoses, agreement was substantial to perfect (kappa = 1 for the diagnoses major depression, generalized anxiety disorder, obsessive-compulsive disorder and substance abuse). Fair to moderate kappa values were found for personality disturbances and dysthymia. The results of this study indicate that after adequate training nurses can perform structured psychiatric interviews with a high inter-rater agreement.

Psychosocial situations, quality of depression and schizophrenia in adolescents

The relationships between acute life events and type of depression were evaluated among inpatient adolescents with schizophrenia. Forty-two adolescent inpatients were assessed, 25 with schizophrenia and 17 with personality disorder. Acute life events and other psychosocial situations were identified with the ICD-10 Axis V semistructured interviews. The Depression Equivalent Questionnaire for Adolescents (DEQ-A) and the Positive and Negative Symptom Scale (PANSS) were used to measure quality and severity of depression. In the patients with schizophrenia, psychosocial situations were related to the anaclitic type of depression, whereas in the subjects with personality disorder, they were highly correlated with introjective depression. In the schizophrenic group, the psychosocial situations related to depression were of a more intrapersonal nature and, in the personality-disordered group, they were more interpersonal. Environmental factors play an important role in the course of schizophrenia in adolescents and should remain a focus of study. Object relations theory may be of heuristic value in the investigation of these factors.

Is apathy in late-life depressive illness related to age-at-onset, cognitive function or vascular risk?

BACKGROUND

Apathy has been shown to be an important feature of degenerative, vascular or traumatic brain disorder. Its presence is associated with high depression scores, higher age, low performance on frontal tasks, and more severe deep white matter hyperintensities. In late-life depression, lack of interest or motivation are often more prominent than depressed mood, especially in the late-onset type. It was hypothesized that in a heterogeneous sample of elderly depressed patients, apathy is associated with late-onset type of depression, cognitive dysfunction or vascular risk factors.

METHOD

The Apathy Evaluation Scale (AES) was administered to twenty-nine elderly (> or = 60 years) inpatients with a DSM-IV major depression or dysthymic disorder. The severity of the depression was measured with the Montgomery-Asberg Depression Rating Scale (MADRS) and cognitive function with the Mini-mental State Examination (MMSE). The presence of vascular risk factors was traced in the patient's medical records.

RESULTS

Apathy was found in 86% of the patients. The AES-score was correlated with the negative symptom score, but not with total MADRS or MMSE-score. No difference in AES-score between early-onset depressed (n = 16) and late-onset depressed (n = 13) patients was found, and between patients with or without vascular risk.

CONCLUSION

Apathy is a main feature of moderate to severe depressive illness in elderly patients and related to the negative symptoms of the disorder. Further studies should include less severely depressed patients and investigate the relation between depression severity and apathy.

Public attitudes to depression in urban Turkey - the influence of perceptions and causal attributions on social distance towards individuals suffering from depression

BACKGROUND

The aim of this study was to determine public attitudes towards patients with depression and the influence of perception and causal attributions on social distance towards individuals suffering from depression in urban areas.

METHODS

This study was carried out with a representative sample in Istanbul which is the biggest metropolis in Turkey. Seven hundred and seven subjects completed the public survey form which consisted of ten items screening the demographic features and health status of the participants, and 32 items rating attitudes towards depression.

RESULTS

The respondents' attitudes towards depression were very negative and nearly half of the subjects perceived people with depression as dangerous. More than half of the subjects stated that they would not marry a person with depression, and nearly half of the subjects stated that they would not rent their house to a person with depression. One-quarter of the subjects stated that depressive patients should not be free in the community. The subjects who considered depression as a disease and who believed that weakness of personality and social problems cause depression had negative attitudes towards depression.

CONCLUSIONS

In Istanbul, people recognise depression well, but their attitudes towards it are fairly negative. The urban public has unfavourable attitudes towards depression and a tendency to isolate patients from the society. Notwithstanding the high prevalence, there is still considerable stigmatisation associated with depression.