Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care: the Hampshire Depression Project

Prevalence of depression in older people in England and Wales: the MRC CFA Study

BACKGROUND

Depression in old age is an important public health problem. The aims of this study were to report the prevalence of depression in the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS), a community-based, cohort.

METHOD

Following screening of 13 004 people aged 65 and over from a population base, a stratified random subsample of 2640 participants received the Geriatric Mental State (GMS) examination and were diagnosed using the Automated Geriatric Examination for Computer-Assisted Taxonomy (AGECAT) algorithm.

RESULTS

The prevalence of depression was 8.7% [95% confidence interval (CI) 7.3-10.2], increasing to 9.7% if subjects with concurrent dementia were included. Depression was more common in women (10.4%) than men (6.5%) and was associated with functional disability, co-morbid medical disorder, and social deprivation. Prevalence remained high into old age, but after adjustment for other associated factors, it was lower in the older age groups.

CONCLUSIONS

The prevalence of depression in the elderly is high and remains high into old age, perhaps due to increased functional disability.

A method for modelling GP practice level deprivation scores using GIS

Background

A measure of general practice level socioeconomic deprivation can be used to explore the association between deprivation and other practice characteristics. An area-based categorisation is commonly chosen as the basis for such a deprivation measure. Ideally a practice population-weighted area-based deprivation score would be calculated using individual level spatially referenced data. However, these data are often unavailable. One approach is to link the practice postcode to an area-based deprivation score, but this method has limitations. This study aimed to develop a Geographical Information Systems (GIS) based model that could better predict a practice population-weighted deprivation score in the absence of patient level data than simple practice postcode linkage.

Results

We calculated predicted practice level Index of Multiple Deprivation (IMD) 2004 deprivation scores using two methods that did not require patient level data. Firstly we linked the practice postcode to an IMD 2004 score, and secondly we used a GIS model derived using data from Rotherham, UK. We compared our two sets of predicted scores to "gold standard" practice population-weighted scores for practices in Doncaster, Havering and Warrington. Overall, the practice postcode linkage method overestimated "gold standard" IMD scores by 2.54 points (95% CI 0.94, 4.14), whereas our modelling method showed no such bias (mean difference 0.36, 95% CI -0.30, 1.02). The postcode-linked method systematically underestimated the gold standard score in less deprived areas, and overestimated it in more deprived areas. Our modelling method showed a small underestimation in scores at higher levels of deprivation in Havering, but showed no bias in Doncaster or Warrington. The postcode-linked method showed more variability when predicting scores than did the GIS modelling method.

Conclusion

A GIS based model can be used to predict a practice population-weighted area-based deprivation measure in the absence of patient level data. Our modelled measure generally had better agreement with the population-weighted measure than did a postcode-linked measure. Our model may also avoid an underestimation of IMD scores in less deprived areas, and overestimation of scores in more deprived areas, seen when using postcode linked scores. The proposed method may be of use to researchers who do not have access to patient level spatially referenced data.

Who is treated, and how, for depression? An analysis of statutory health insurance data in Germany

BACKGROUND

Studies on the treatment of depression using epidemiological survey methods suggest a high level of under-treatment. Little is known about the characteristics of those people receiving treatment and indeed what kind of treatment they are likely to receive.

METHOD

Analysis of the data of a statutory health insurance company in Germany.

RESULTS

In middle-aged groups, about 50% of those diagnosed as being depressed in outpatient care are prescribed antidepressants and/or psychotherapy in the course of a year. There is more pharmacologic treatment provided in rural areas and more psychotherapy in cities, suggesting that treatment is dependent upon service availability rather than evidence-based treatment decisions. Treatment rates are considerably lower in the very young and the very old and show gender bias. Young females receive less pharmacologic treatment than young males, and elderly men are, in general, treated less than women, suggesting under-treatment at least for these groups.

CONCLUSIONS

The low treatment rates following the diagnosis of depression in the young and the old require attention, in particular with respect to gender aspect.

Observational studies of depression in primary care: what do we know?

BACKGROUND

We undertook a systematic review of observational studies of depression in primary care to determine 1) the nature and scope of the published studies 2) the methodological quality of the studies; 3) the identified recovery and risk factors for persistent depression and 3) the treatment and health service use patterns among patients.

METHODS

Searches were conducted in MEDLINE, CINAHL and PsycINFO using combinations of topic and keywords, and Medical Subject Headings in MEDLINE, Headings in CINAHL and descriptors in PsycINFO. Searches were limited to adult populations and articles published in English during 1985-2006.

RESULTS

40 articles from 17 observational cohort studies were identified, most were undertaken in the US or Europe. Studies varied widely in aims and methods making it difficult to meaningfully compare the results. Methodological limitations were common including: selection bias of patients and physicians; small sample sizes (range 35-108 patients at baseline and 20-59 patients at follow-up); and short follow-up times limiting the extent to which these studies can be used to inform our understanding of recovery and relapse among primary care patients with depression. Risk factors for the persistence of depression identified in this review were: severity and chronicity of the depressive episode, the presence of suicidal thoughts, antidepressant use, poorer self-reported quality of life, lower self-reported social support, experiencing key life events, lower education level and unemployment.

CONCLUSION

Despite the growing interest in depression being managed as a chronic illness, this review identified only 17 observational studies of depression in primary care, most of which have included small sample sizes and been relatively short-term. Future research should be large enough to investigate risk factors for chronicity and relapse, and should be conducted over a longer time frame.

The effects of economic deprivation on psychological well-being among the working population of Switzerland

BACKGROUND

The association between poverty and mental health has been widely investigated. There is, however, limited evidence of mental health implications of working poverty, despite its representing a rapidly expanding segment of impoverished populations in many developed nations. In this study, we examined whether working poverty in Switzerland, a country with substantial recent growth among the working poor, was correlated with two dependent variables of interest: psychological health and unmet mental health need.

METHODS

This cross-sectional study used data drawn from the first 3 waves (1999-2001) of the Swiss Household Panel, a nationally representative sample of the permanent resident population of Switzerland. The study sample comprised 5453 subjects aged 20-59 years. We used Generalized Estimating Equation models to investigate the association between working poverty and psychological well-being; we applied logistic regression models to analyze the link between working poverty and unmet mental health need. Working poverty was represented by dummy variables indicating financial deficiency, restricted standard of living, or both conditions.

RESULTS

After controlling other factors, restricted standard of living was significantly (p < .001) negatively correlated with psychological well-being; it was also associated with approximately 50% increased risk of unmet mental health need (OR = 1.55; 95% CI 1.17-2.06).

CONCLUSION

The findings of this study contribute to our understanding of the potential psychological impact of material deprivation on working Swiss citizens. Such knowledge may aid in the design of community intervention programs to help reduce the individual and societal burdens of poverty in Switzerland.

A comparison of methods for calculating general practice level socioeconomic deprivation

Background

A measure of the socioeconomic deprivation experienced by the registered patient population of a general practice is of interest because it can be used to explore the association between deprivation and a wide range of other variables measured at practice level. If patient level geographical data are available a population weighted mean area-based deprivation score can be calculated for each practice. In the absence of these data, an area-based deprivation score linked to the practice postcode can be used as an estimate of the socioeconomic deprivation of the practice population. This study explores the correlation between Index of Multiple Deprivation 2004 (IMD) scores linked to general practice postcodes (main surgery address alone and main surgery plus any branch surgeries), practice population weighted mean IMD scores, and practice level mortality (aged 1 to 75 years, all causes) for 38 practices in Rotherham UK.

Results

Population weighted deprivation scores correlated with practice postcode based scores (main surgery only, Pearson r = 0.74, 95% CI 0.54 to 0.85; main plus branch surgeries, r = 0.79, 95% CI 0.63 to 0.89). All cause mortality aged 1 to 75 correlated with deprivation (main surgery postcode based measure, r = 0.50, 95% CI 0.22 to 0.71; main plus branch surgery based score, r = 0.55, 95% CI 0.28 to 0.74); population weighted measure, r = 0.66, 95% CI 0.43 to 0.81).

Conclusion

Practice postcode linked IMD scores provide a valid proxy for a population weighted measure in the absence of patient level data. However, by using them, the strength of association between mortality and deprivation may be underestimated.

The correlation between indices of deprivation and health-related quality of life in patients with oral and oropharyngeal squamous cell carcinoma

Deprivation influences the incidence and outcome of patients with cancer. Health-related quality of life (HR-QoL) is an important measure of outcome but there is little on this subject and its correlation with deprivation in patients with oral and oropharyngeal cancer. Our aim was to ascertain the extent of deprivation in a cohort of patients who had operations for primary oral and oropharyngeal cancer and how deprivation affected HR-QoL in these patients during and after their treatment. A total of 278 consecutive patients who were operated on for oral and oropharyngeal cancer were included in this study. Validated measures of deprivation scores (Townsend, Carstairs, Jarman and Index of Multiple Deprivation 2000) were calculated, as well as patient-based indicators of social circumstances (marital status, smoking habit, alcohol intake). Comparison was made with the University of Washington-Quality of Life (UW-QoL) scores before and after treatment (6, 12, and 24 months).

Anxiety and depression in primary care patients: predictors of symptom severity and developmental correlates

OBJECTIVE

A study in a German general practice used the Hospital Anxiety and Depression Scale (HADS) to determine the prevalence of anxiety and depression in 242 consecutive patients. The study had two additional goals: (1) to identify indicators of symptom severity and (2) to validate the HADS by relating it to measures of developmental psychopathology.

METHODS

In addition to the HADS, clinical/sociodemographic data were collected. Patients filled up additional questionnaires measuring attachment characteristics, recalled parental rearing behavior, resilience, adverse childhood experiences, and physical complaints.

RESULTS

Using HADS cutoff scores of > or =11 in total, we found that 21.1% of the patients showed clinically relevant anxiety levels; the rate for depression was 12.0%, that for anxiety or depression was 26.1%, and that for anxiety and depression combined was 7%. With the exception of psychiatric disorders, the HADS did not differentiate between subgroups with different somatic diseases. HADS scores were shown to be predicted by the patients' sex, family status, number of consultations, and subjective physical complaints. Patients with higher HADS scores also indicated lower resilience, more insecure attachment, and negative recalled parental rearing behavior. Resilience, attachment security, and specific parental behavior (control/warmth) independently predicted anxiety, depression, and physical complaints.

CONCLUSION

This study provides further support for the usefulness of the HADS as a measure for routine screening for anxiety and depression and its relationship with constructs from developmental psychopathology. We recommend the use of the HADS in combination with potential indicators of symptom severity (fatigue, cardiovascular symptoms, high number of consultations) to identify patients needing psychosocial support.

Does the presence of psychological distress in patients influence their choice of sitting position in face-to-face consultation with the GP?

Evidence exists that when a person is required to position him/herself to the right or left of another during a face-to-face encounter, the orientation chosen is influenced by the biases of visual attention. It is also known that such attentive biases may be disturbed in states of anxiety and depression. The aim of the present study was to investigate whether an association could be found between the presence of psychological distress in patients and their choice of lateral orientation relative to the doctor during face-to-face consultations. Patients routinely attending their GP (the author) were obliged to choose to sit either to the right or left for the face-on encounter. They then completed the Hospital Anxiety and Depression Scale questionnaire (HADS), its two subscales (0-21) measuring symptoms of anxiety and depression reported by patients. "Cases" of anxiety and/or depression were identified as those patients who scored > 8 on either or both subscales. Of the 756 patients studied, case status was significantly associated with seating preference (p = .001): 234 (58%) cases sitting on the left versus 107 (30%) non-cases. Handedness was not directly associated with seating preference, but did modify the case status-seating preference association. Thus among right-handers 213 (59%) cases sat on the left versus 85 (27%) non-cases, giving an odds ratio (sitting on the left) for cases versus non-cases of 4.0. For left-handers the odds ratio (sitting left) for cases versus non-cases was 0.54, although the small number of left-handers precluded statistical significance being achieved in this group. These results support the notion that orienting behaviour is influenced by biases of visual attention linked to handedness and that attentive biases may be disturbed in states of anxiety and depression.

Possibilities for intervention in adolescents' and young adults' depression from a public health perspective

When considering measures to decrease the burden of disease that is caused by depression, depressive disorders of adolescents and young adults are of increasing interest. The prevalence of depressive disorders in adolescents and young adults is high. The probable increases in prevalence affect predominantly young people and their prognosis is particularly bad. This review discusses the potentials to influence the burden of disease through interventions such as therapy, including measures to detect persons at risk early, selective and universal prevention, and health promotion for adolescents and young adults. It considers the available evidence for the effectiveness of these interventions on the public health level. In addition, the suitability of implementation and ethical considerations are discussed. As a conclusion, health policy in its aim to reduce the burden of depressive disease should focus on increasing treatment rates and improving the efficiency of treatment in adolescents and young adults as well for depression as for other mental disease that has high co-morbidity with depression. In addition, the focus should be set on indicated prevention for children of depressed parents and--for health promotion reasons--on policies that impact on living-conditions of families.

Which factors are important predictors of non-recovery from major depression? A 2-year prospective observational study

Our aim was to study factors associated with long-term non-recovery from major depression. A total of 109 patients with major depression were followed prospectively for 2 years. A diagnosis of major depression based on SCID interviews at follow-up indicated non-recovery. The effect of several established risk factors was assessed. A third (30%) of the patients did not recover. Severity of initial depression were associated with poor outcome according to univariate analysis. Nevertheless, personality disorder and rural area of residence were associated with non-recovery in final multivariate analysis. Major depression in patients with personality disorder should be treated as effectively as possible. Moreover, service planning in rural areas needs attention.

The Children's Depression Inventory (CDI) as measure of depression in Swedish adolescents. A normative study

Self-rating scales are an economical and practical aid in the diagnostic work-up. However, normative data from the general population are needed to interpret scores. Four hundred and five adolescents selected to be fairly representative of the general population (both ethnical Swedes and born abroad) filled in a questionnaire containing the Children's Depression Inventory (CDI), the Multidimensional Anxiety Scale for Children (MASC) and background data (including socio-economic status (SES). The CDI was reliable in terms of internal consistency (0.86) with a mean inter-item correlation of 0.18 and item-total score correlations ranging from 0.26 to 0.57. The CDI sub-scales (Negative Mood, Ineffectiveness, Anhedonia and Negative Self-esteem had good internal consistency values slightly above 0.60, except for sub-scale Interpersonal Problems with poor internal consistency (0.36). The 90th and 95th percentiles respectively were defined by scores 15 and 18 and above for boys and by scores 20 and 23 and above for girls. Common correlates of high scores were female gender, broken family but not SES, nor ethnicity. Also, some estimates of the convergent validity of the CDI were found in a Pearson correlation of 0.40 with the MASC total score and in the capacity of the CDI (predictive validity); OR = 1.1 in predicting suicidal ideation. The CDI has some, but as of yet not sufficient indications of being a valid and reliable measure of depression in adolescence and scores can be used to indicate, though not prove the absence or presence of, depression.

The troubled relationship between psychiatry and sociology

The alienated relationship between psychiatry and sociology is explored. The two disciplines largely took divergent paths after 1970. On the one side, psychiatry manifested a pre-occupation with methodological questions and sought greater medical respectability, with a biomedical approach returning to the fore. Social psychiatry and its underpinning biopsychosocial model became increasingly marginalised and weakened. On the other side, many sociologists turned away from psychiatry and the epidemiological study of mental health problems and increasingly restricted their interest to social theory and qualitative research. An interdisciplinary void ensued, to the detriment of the investigation of social aspects of mental health.

Does socioeconomic status affect the use of community-based psychiatric services? A South Verona case register study

OBJECTIVE

To assess the effect of socioeconomic status (SES) on psychiatric service use in an Italian area with a well-developed community-based psychiatric service.

METHOD

An index of SES was calculated from nine census variables and grouped into four categories, ranging from SES-I-affluent to SES-IV-deprived, for each of 328 census blocks (CB). Fifteen indicators of psychiatric service use were collected using the psychiatric case register. All patients resident in the catchment area, who had at least one psychiatric contact in 1996 (n=989), were included in the study.

RESULTS

Indicators of in-patient, day-patient, out-patient and community service use showed an inverse association with SES. Only first-ever and long-term psychotic patients were equally distributed in the four SES groups.

CONCLUSION

The inverse association between SES and most indicators of psychiatric service use suggests that the planning of community-based services and resource allocation should take into account the SES of residents.

Do antidepressants reduce the burden imposed by depression on employers?

The ability to perform paid or unpaid work is integral to an individual's quality of life. Therefore, we performed a systematic literature review to examine the impact of depression and its treatment on occupational outcomes. This review found absenteeism from work to be markedly higher among depressed employees and productivity to be dramatically undermined by some symptoms of depression. Gaps in the published literature point to the need for future economic and clinical analyses to include work-related outcomes. Published studies showed that antidepressants can enhance work-related outcomes by alleviating affective symptoms. However, the pharmacological properties of antidepressants may produce differential effects that influence work-related outcomes in other ways. For example, TCAs, but not SSRIs, produce sedation and impair cognitive function in ways that could undermine work-related outcomes. Formal analyses are required to quantify whether the improved social functioning, motivation and vigilance that may be associated with some newer antidepressants translate into improved work-related outcomes. Although few published studies have directly quantified the cost benefit of managing depression and associated lost productivity, existing studies that directly assessed work-related outcomes have suggested that treating depression is cost effective. Gaps in the published literature imply that the impact of depression and antidepressants on occupational outcomes has been understudied. This reflects, in part, the fact that antidepressant studies lasting 4 or 6 weeks are unlikely to capture the impact of treatment on work-related measures. In addition, the current evidence base is fraught with other methodological limitations. The effect of depression on non-paid employment also requires further assessment. In conclusion, the efficacy of antidepressants on work-related outcomes should be measured in clinical trials that have an adequate design and a suitable follow-up period, and included in health technology assessments. Until such studies are available, the evidence base supporting the use of antidepressants will remain incomplete.

Changes in mental disorder distribution among suicide attempters in mid-west area of Kanagawa

To clarify changes in mental disorder distribution in suicide attempters, a comparison was made between the period when an economic recession started (1992, 1993) and the period when the recession became serious (2000). The subjects were 212 suicide attempters admitted to the Emergency Medical Center of Tokai University Hospital during a 2-year period between 1992 and 1993 (group A) and 255 suicide attempters admitted during a 1-year period between January and December 2000 (group B). Mental disorders were classified according to the International Classification of Diseases (10th revision; ICD-10). Distribution was compared between groups A and B and significant differences were observed in mental disorder distribution (P < 0.001). The percentages of subjects with depression, those with neurotic disorders, and those with other disorders were higher in group B than in group A. Conversely, the percentage of subjects with schizophrenia was lower in group B than in group A. Mental disorder distribution in suicide attempters significantly changed. However, it was not certain that this change was related to the economic recession and increased unemployment in Japan.

Cardiovascular disease and psychological morbidity among rheumatoid arthritis patients

OBJECTIVES

To examine whether patients with rheumatoid arthritis (RA) with co-morbid cardiovascular disease (CVD) have different psychological morbidity (and psychosocial risk factors for it) compared with RA patients without co-morbid CVD.

METHODS

Patients with RA and co-morbid CVD (n = 44; hypertension alone for n = 27) were compared with RA patients without CVD (n = 110). Differences in psychological morbidity (depression and anxiety) and psychosocial risk factors for this (arthritis self-efficacy, acceptance, social support and optimism) were examined while controlling statistically for medical and demographic covariates.

RESULTS

Groups did not differ on RA duration, RA activity, marital status or socioeconomic status, but RA patients with co-morbid CVD were older, less likely to be female and less likely to be in employment than those without CVD. RA patients with co-morbid CVD had significantly higher depression and were more likely to score above cut-offs for depression than RA patients without CVD. No differences existed in anxiety, although anxiety appeared to be more common than depression. Low optimism was identified as a possible psychosocial risk factor for depression.

CONCLUSIONS

RA patients with co-morbid CVD have higher depression than RA patients without CVD; low optimism is a potentially modifiable risk factor that may mediate this difference. RA patients with co-morbid CVD may benefit from systematic screening for depression and targeted intervention if necessary.

Physicians' constructions of depression: inside/outside the boundaries of medicalization

A qualitative study explored primary care physicians' experiences of diagnosing and treating depression. Twenty physicians participated in semi-structured interviews. Interview questions asked physicians to consider a range of topics such as the etiology of depression, the diagnostic process and treatment of depression. Transcripts were analyzed discursively with a view to exploring the ways in which physicians construct depression. In this article, physicians' constructions of depression are examined through exploration of their descriptions of this condition, as well as their recognition of the social context of depression. Based on this analysis, it was concluded that physicians' medicalized understandings of depression conflict with recognition of the social context of depression. The result of this conflict is dissonant descriptions of depression. One implication of this research is that physicians' training would benefit from the integration of multidisciplinary perspectives on depression, which would better reflect physicians' experiences in routine practice situations.

Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care

OBJECTIVE

To assess the impact of leaflets encouraging patients to raise concerns and to discuss symptoms or other health related issues in the consultation.

DESIGN

Randomised controlled trial.

SETTING

Five general practices in three settings in the United Kingdom.

PARTICIPANTS

636 consecutive patients, aged 16-80 years, randomised to receive a general leaflet, a depression leaflet, both, or neither.

MAIN OUTCOMES

Mean item score on the medical interview satisfaction scale, consultation time, prescribing, referral, and investigation.

RESULTS

The general leaflet increased patient satisfaction and was more effective with shorter consultations (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both -0.045, -0.08 to-0.009), with similar results for subscales related to the different aspects of communication. Thus for a 10 minute consultation the leaflet increased satisfaction by 7% (seven centile points) and for a five minute consultation by 14%. The leaflet overall caused a small non-significant increase in consultation time (0.36 minutes, -0.54 to 1.26). Although there was no change in prescribing or referral, a general leaflet increased the numbers of investigations (odds ratio 1.43, 1.00 to 2.05), which persisted when controlling for the major potential confounders of perceived medical need and patient preference (1.87, 1.10 to 3.19). Most of excess investigations were not thought strongly needed by the doctor or the patient. The depression leaflet had no significant effect on any outcome.

CONCLUSIONS

Encouraging patients to raise issues and to discuss symptoms and other health related issues in the consultation improves their satisfaction and perceptions of communication, particularly in short consultations. Doctors do, however, need to elicit expectations to prevent needless investigations.

Prevalence and correlates of mental disorders among Native American women in primary care

OBJECTIVES

We examined the lifetime and the past-year prevalence and correlates of common mental disorders among American Indian and Alaska Native women who presented for primary care.

METHODS

We screened 489 consecutively presenting female primary care patients aged 18 through 45 years with the General Health Questionnaire, 12-item version. A subsample (n = 234) completed the Composite International Diagnostic Interview. We examined associations between psychiatric disorders and sociodemographic variables, boarding school attendance, and psychopathology in the family of origin.

RESULTS

The study participants had high rates of alcohol use disorders, anxiety disorders, and anxiety/depression comorbidity compared with other samples of non-American Indian/Alaska Native women in primary care settings.

CONCLUSIONS

There is a need for culturally appropriate mental health treatments and preventive services.

Maternal depression and child behaviour problems. Randomised placebo-controlled trial of a cognitive-behavioural group intervention

BACKGROUND

Despite the frequently reported association between maternal depression and childhood psychopathological disorder, few studies have attempted to intervene with both conditions.

AIMS

To evaluate the effect of group cognitive-behavioural therapy (CBT) on child behaviour problems and maternal depression in a group of women with young children.

METHOD

An assessor-masked, randomised placebo-controlled trial compared three treatments: CBT for depression and parenting skills enhancement; a mothers' support group; and no intervention. An epidemiological (general population) sample was recruited.

RESULTS

Analysis showed no significant difference between the groups. Within-group comparison suggested that at the end of treatment and at 6-month and 12-month follow-up, child problems and maternal depression had improved significantly in the CBT group.

CONCLUSIONS

There was no statistically significant difference between groups. Both contact interventions seemed to provide some benefits to mothers with depression, with a possibly improved outcome resulting from CBT for children with behavioural problems. The results must be treated with caution.

Panic disorder in public sector primary care: clinical characteristics and illness severity compared with "mainstream" primary care panic disorder

The prevalence of anxiety disorders is increased among low-income individuals, who are more likely to seek mental health care in medical as opposed to specialty settings because of limited insurance access and restricted availability of public sector mental health resources. However, little is known about the clinical characteristics and illness severity of anxiety disorders in this setting. We studied the clinical characteristics of low-income compared with middle-income primary care panic patients. Clinical, functional, and service use measures obtained at baseline interview in 39 panic disorder patients seen in one public sector medical clinic were compared with 76 patients seen in two middle-income clinics. All patients were participants in a randomized effectiveness pharmacotherapy trial [Roy Byrne et al., Arch Gen Psychiatry 2001;58:869-876]. Public sector patients were more often older, male, single, unemployed, of lower income, and non-Caucasian ethnicity. They had more severe clinical symptoms, more medical comorbidity, worse physical and role health status, and more emergency room visits. Low income and unemployment accounted for most of the differences in non-anxiety-related measures. However, type of clinic still contributed independently to the greater severity of specific measures of panic/anxiety (Panic Disorder Severity Scale and Marks Fear Scale scores), suggesting that the increased stress and limited social resources associated with low-income and disadvantaged status may have more specific effects on anxiety than other aspects of psychopathology.

Relationship of depression to diabetes types 1 and 2: epidemiology, biology, and treatment

This article reviews the rapidly accumulating literature on the relationship between mood disorders and diabetes mellitus. Recent studies have demonstrated that depression and its associated symptoms constitute a major risk factor in the development of type 2 diabetes and may accelerate the onset of diabetes complications. Since the mid-1980s, multiple longitudinal and cross-sectional studies have scrutinized the association of diabetes with depressive symptoms and major depression. Utilizing the search terms depressive disorders, psychiatry, diabetes, and pathophysiology in MEDLINE searches (1966-2003), this article reviews studies investigating pathophysiological alterations related to glucose intolerance and diabetes in depressed patients. The few randomized, controlled studies of treatment of depression in patients with diabetes are also described. Short-term treatment of depression in patients with diabetes improves their dysphoria and other signs and symptoms of depression. Future research will confirm whether response to psychotherapy and/or psychopharmacologic treatment improves glucose control, encourages compliance with diabetes treatment, and perhaps even increases longevity.

Predictors of response in depression

Conflicting or sparse data on predictors of treatment response in depression have resulted in lack of clear guidelines in choosing antidepressant treatment. Critical to treatment outcome are accurate diagnosis and adequate treatment. Other data easy to obtain, such as age, gender, and marital status, have failed to be consistent predictors; more elaborate studies, such as receptor analysis or neuroimaging, are not yet accessible to most clinicians or economically feasible; however, they offer hope for the future, when more biologically based diagnostic distinctions may come to guide treatment choices.

Socio-economic differences in psychiatric in-patient care

OBJECTIVE

We seek to investigate socio-economic differences in psychiatric in-patient care regarding admission, treatment and outcome.

METHOD

This study is undertaken on a comprehensive and exhaustive psychiatric case register of all psychiatric in-patient care carried out in Belgium in 1997 and 1998 (n=144 754).

RESULTS

Lower socio-economic groups were more likely to be compulsorily admitted, to be cared for in a non-teaching or psychiatric hospital, to be admitted in a hospital with unexpectedly long average length of stay and to be admitted to a ward with a more severe case-mix. They were less likely to receive antidepressants and psychotherapies. The improvements in functioning and in symptoms were also less favourable for these groups. The lowest group had a higher risk of dying in the hospital.

CONCLUSION

Psychiatric in-patient care is associated with moderate socio-economic differences in access, treatment and outcome. Further research is needed to clarify the causes of such disparities.

A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms

OBJECTIVE

To re-examine the widespread assumption that medically unexplained physical symptoms represent discrete syndromes resulting from somatization of mental illness.

METHOD

Primary care patients (N = 223) with medically unexplained symptoms of at least one year's duration were recruited to a study of exercise therapy. Data gathered from patients, from their general practitioners, and from medical records were used to examine relationships between self-defined disability, symptoms, mental state, and use of health care.

RESULTS

Levels of disability and health care use were both raised, but were only weakly correlated. While most patients were depressed and/or anxious, a minority (14 percent) were neither. Although mental state correlated with disability, health care use was unrelated to either. Among a wide range of recorded symptoms, few correlations were found to support the existence of discrete syndromes. Analysis of agreement between patients and their doctors in assigning symptoms to broadly defined "syndromes" appears to reflect collaboration that is largely expedient

CONCLUSIONS

In this sample of primary care patients with persistent unexplained physical symptoms, we found little evidence of discrete somatic syndromes. The level of health care use is no indication of mental state or level of disability, and the findings are equally consistent with depression or anxiety being secondary to disability and its consequences as with them being primary. The observed collaboration between patients and their doctors carries the risk of shaping, reinforcing, and legitimizing dubious syndromes.

Dimensional perspective on the recognition of depressive symptoms in primary care: The Hampshire Depression Project 3

BACKGROUND

Most studies of the recognition of depression in primary care have used a categorical definition of depression. This may overstate the extent of the problem.

AIMS

Our objective was to investigate the relationship between severity and recognition of depression, and its modification by patient and practitioner characteristics.

METHOD

An association study in multiple consecutive adult cohorts of 18 414 primary care consultations drawn from a representative sample of 156 general practitioners in Hampshire, UK.

RESULTS

There was a curvilinear relationship between the severity of depression and practitioners' ratings of depression. One case of probable depression was missed in every 28.6 consultations. Anxiety and unemployment altered the chances of recognition, but age, gender and deprivation scores did not.

CONCLUSIONS

A dimensional approach to severity of depression shows that general practitioners may be better able to recognise depression than previous categorical studies have suggested. Efforts to improve the care of depression should therefore focus on doctors who have been shown to have difficulty making the diagnosis and on improving the treatment of identified patients.

Treatment delivery and guidelines in primary care

Because depressive illness is so prevalent, the majority of patients are managed in primary care, without recourse to specialist services. Primary care management is seen to fall short of the standards set in secondary care, but unfortunately there is as yet relatively little evidence from primary care to guide management in this distinctive patient population. Guidelines have been introduced as a means of quality management, and their value in improving care has been assessed in trials. To date, the benefits of the implementation of guidelines have been marginal at best. By contrast, strategies which improve the access of patients to specialist services do seem to be beneficial. There is also evidence that such strategies may be associated with 'cost-offset'. Choice of antidepressant medication for maximum cost benefit should also be informed by an evidence base, which is beginning to be accumulated. Further research on this topic in the primary care context is still needed.