Health beliefs and perceived need for mental health care of anxiety and depression—The patients' perspective explored

Beliefs of people taking antidepressants about the causes of their own depression

BACKGROUND

The beliefs of people receiving treatment about the causes of their own mental health problems are researched less often than the causal beliefs of the public, but have important implications for relationships with prescribers, treatment choices and recovery.

METHOD

An online survey on a range of beliefs about depression, and experiences with antidepressants, was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants.

RESULTS

Six of 17 beliefs about the causes of their own depression were endorsed by more than half the sample: chemical imbalance, family stress, work stress, heredity, relationship problems and distressing events in childhood. There were some marked differences in content, structure and level of conviction of beliefs about one׳s own depression and the sample׳s previously published beliefs about depression in general. There were also significant differences between the beliefs of demographic groupings. Regression analyses revealed that self-reported effectiveness of the antidepressants was positively associated with bio-genetic causal beliefs. The quality of the relationship with the prescribing doctor was positively related to a belief in chemical imbalance as a cause and negatively related to a belief in unemployment as a cause.

LIMITATIONS

The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression.

CONCLUSIONS

People experiencing depression hold complex, multifactorial and idiosyncratic sets of beliefs about the causes of their own depression, apparently based at least in part on their own life experiences and circumstances. Exploring those beliefs may enhance the doctor-patient relationship and selection of appropriate treatment modality.

Attitudes and beliefs of patients with chronic depression toward antidepressants and depression

BACKGROUND

Many patients have erroneous views with regard to depression and its management, and it was noted that these attitudes and beliefs significantly affected their adherence rates.

OBJECTIVES

The primary aim of this study was to determine the attitudes and beliefs of patients with depression toward depression and antidepressants. A secondary aim was to assess the influence of ethnicity on patients' attitudes and beliefs.

PATIENTS AND METHODS

The study involved patients with chronic depression being followed up at an outpatient clinic at a government-run hospital in Malaysia. Patients' attitudes and beliefs were assessed using the Antidepressant Compliance Questionnaire.

RESULTS

A total of 104 patients of Malay, Chinese, and Indian ethnic groups met the selection criteria. Chinese patients had significantly negative attitudes and beliefs toward depression and antidepressants compared to Malays and Indians (b=-8.96, t 103=-3.22; P<0.05). Component analysis revealed that 59% of patients believed that antidepressants can cause a person to have less control over their thoughts and feelings, while 67% believed that antidepressants could alter one's personality; 60% believed it was okay to take fewer tablets on days when they felt better, while 66% believed that antidepressants helped solve their emotional problems and helped them worry less.

CONCLUSION

Patients had an overall positive view as to the benefits of antidepressants, but the majority had incorrect views as to the acceptable dosing of antidepressants and had concerns about the safety of the medication. Assessing patients' attitudes and beliefs, as well as the impact of their respective cultures, can be used in tailoring psychoeducation sessions accordingly.

Delays in depression treatment among Korean population

INTRODUCTION

Delays in mental health service utilization for patients with depression have been observed globally. To elucidate some aspects of delays, age-related associations with a series of variables representing different stages of mental health service use were studied concurrently.

METHODS

A total of 1,433 patients with depression participated in a nationwide Korean Depressive Patient Survey through the collaboration of 70 psychiatric clinics and hospitals. Using logistic and Poisson regression, we investigated whether there is variation in the associations by age.

RESULTS

Patients with depression in South Korea spent 3.4 years on average before starting a first depression treatment after the onset of depression, and 58% of them entered depression treatment in the first year of onset. Early onset appeared to lower the chance of "early depression treatment": e.g., adjusted odds ratio (OR)s for onset age of 40-54, 25-39 and <25 versus ≥55 were 0.65 (95% CI = 0.44, 0.94), 0.36 (95% CI = 0.16, 0.81) and 0.18 (95% CI = 0.06, 0.48), respectively. In contrast, favorable associations of early onset with "self-recognition as depression" and "number of nonpsychiatric clinics attended" before visiting psychiatrist were found. Younger cohorts were associated with more positive attitudes toward all mental health utilization measures.

DISCUSSION

Delays in depression treatment are lengthy in South Korea. Those with early onset are more likely to have delayed depression treatment but are more willing to seek help from a psychiatrist once they sought for the treatment.

Why visually impaired older adults often do not receive mental health services: the patient's perspective

PURPOSE

Older adults with a visual impairment are particularly vulnerable for increased depression and anxiety symptoms; however, they tend to underutilise mental health services. The present study aims to characterise the perceived need for and barriers to use mental health services in visually impaired older adults based on Andersen's behavioural model.

METHODS

A cross-sectional study in 871 visually impaired older adults (mean age 73 years) from outpatient low vision rehabilitation services was conducted. A multinomial logistic regression analysis was performed to assess potential-related factors to perceived need for mental health services, measured with the Perceived Need for Care Questionnaire (PNCQ).

RESULTS

About 35 % of the population had subthreshold depression and/or anxiety, and 13 % had a mood and/or anxiety disorder according to the DSM-IV. Almost 34 % of the participants with an actual disorder did not receive mental health services, even though 57 % perceived to be in need of these services. Participants who had more severe depression and/or anxiety, comorbid depression and anxiety, no history of major depressive disorder, a lower perceived health status and a younger age were more likely to be in need of mental health services. Barriers to receive these services were lack of knowledge and self-reliance.

CONCLUSIONS

Findings support the implementation of counselling methods, instead of medication, and patient empowerment to reduce an unmet need of mental health services in visually impaired older adults, for which extensive research is warranted.

Beliefs of people taking antidepressants about causes of depression and reasons for increased prescribing rates

BACKGROUND

Public beliefs about the causes of mental health problems are related to desire for distance and pessimism about recovery, and are therefore frequently studied. The beliefs of people receiving treatment are researched less often.

METHOD

An online survey on causal beliefs about depression and experiences with antidepressants was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants.

RESULTS

The most frequently endorsed of 17 causal beliefs were family stress, relationship problems, loss of loved one, financial problems, isolation, and abuse or neglect in childhood. Factor analysis produced three factors: 'bio-genetic', 'adulthood stress' and 'childhood adversity'. The most strongly endorsed explanations for increases in antidepressant prescribing invoked improved identification, reduced stigma and drug company marketing. The least strongly endorsed was 'Anti-depressants are the best treatment'. Regression analyses revealed that self-reported efficacy of the antidepressants was positively associated with bio-genetic causal beliefs, negatively associated with childhood adversity beliefs and unrelated to adulthood stress beliefs. The belief that 'People cannot׳ get better by themselves even if they try' was positively associated with bio-genetic beliefs.

LIMITATIONS

The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression.

CONCLUSIONS

Clinicians׳ should consider exploring patients׳ causal beliefs. The public, even when taking antidepressants, continues to hold a multi-factorial causal model of depression with a primary emphasis on psycho-social causes. A three factor model of those beliefs may lead to more sophisticated understandings of relationships with stigma variables.

Service provision for older people with mental health problems in a rural area of Australia

OBJECTIVES

Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia.

METHOD

Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data.

RESULTS

Two main themes were identified: 'Recognising the Problem' and 'Service Availability and Access'. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region.

CONCLUSION

This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people.

Experiences of work and sickness absence in employees with depression: an interpretative phenomenological analysis

PURPOSE

The experience of employment with depression is explored to develop understanding of the mediators that may influence the management of depression-related sickness absence and improve theoretical understanding.

METHOD

Data were collected from seven semi-structured interviews and Interpretative Phenomenological Analysis used to explore the data.

RESULTS

Three interrelated themes were drawn from the participants' accounts: (1) the interaction between depression and work; (2) illness beliefs; and (3) organisational context and depression. The analysis revealed that participants appeared to hold five key perceptions about their depression and work: low control in the workplace; lack of line manager support; diminishing ability to work; the need to address depressive symptoms; and perceptions of depression. Their strength resulted in individuals reaching sickness absence thresholds. The themes and participants' accounts of their work and sickness absence and return to work behaviour are discussed in relation to relevant theory and evidence to understand how these perceptions and beliefs mediate behaviour.

CONCLUSION

Individuals' health (illness representations) and work beliefs (outcome expectancies and self-efficacy for work tasks and management of health at work) appear to influence individuals' sickness absence decisions and experiences and these are mediated by individuals' experiences of organisational policies, line manager support and the messages and actions of GPs.

Predictors of primary care management of depression in the Veterans Affairs healthcare system

BACKGROUND

Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.

OBJECTIVE

To assess relationships between various CCM features, PCP characteristics, and PCP depression management.

DESIGN

Cross-sectional analysis of a provider survey.

PARTICIPANTS

180 PCPs in eight VA sites nationwide.

MAIN MEASURES

Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.

KEY RESULTS

Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.

CONCLUSIONS

PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.

Why don't they accept non-invasive ventilation?: insight into the interpersonal perspectives of patients with motor neurone disease

OBJECTIVES

Although non-invasive ventilation (NIV) can benefit survival and quality of life, it is rejected by a substantial proportion of people with motor neurone disease (MND). The aim of this study was to understand why some MND patients decline or withdraw from NIV.

METHOD

Nine patients with MND (male = 7, mean age = 67 years) participated in this study. These patients, from a cohort of 35 patients who were offered NIV treatment to support respiratory muscle weakness, did not participate in NIV treatment when it was clinically appropriate. Semi-structured interviews and interpretative phenomenological analysis (IPA) were employed to explore these patient's experience of MND and their thoughts and understanding of NIV treatment.

RESULTS

Using IPA, four themes were identified: preservation of the self, negative perceptions of NIV, negative experience with health care services, and not needing NIV. Further analysis identified the fundamental issue to be the maintenance of perceived self, which was interpreted to consist of the sense of autonomy, dignity, and quality of life.

CONCLUSIONS

The findings indicate psychological reasons for disengagement with NIV. The threat to the self, the sense of loss of control, and negative views of NIV resulting from anxiety were more important to these patients than prolonging life in its current form. These findings suggest the importance of understanding the psychological dimension involved in decision-making regarding uptake of NIV and a need for sensitive holistic evaluation if NIV is declined. Statement of contribution What is already known on this subject? Non-invasive ventilation is widely used as an effective symptomatic therapy in MND, yet about a third of patients decline the treatment. Psychological disturbance generated by NIV use leads to negative experiences of the treatment. Decision-making about treatment potentials is complex and unique to each individual affected by perceived impact of disease. What does this study add? A decision concerning NIV uptake was influenced by perceived impact on individuals' sense of self. Sense of self was influenced by the maintenance of autonomy, dignity, and quality of life. Individuals' sense of self was identified to have been challenged by the disease, NIV, and their experience of health care service.

Barriers to mental health treatment: results from the WHO World Mental Health surveys

BACKGROUND

To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders.

METHOD

Data were from the World Health Organization (WHO) World Mental Health (WMH) surveys. Representative household samples were interviewed face to face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n = 63,678) and analyzed at different levels of clinical severity.

RESULTS

Among those with a DSM-IV disorder in the past 12 months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. A desire to handle the problem on one's own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers to both initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment drop-out (39.3%), followed by negative experiences with treatment providers (26.9% of respondents with severe disorders).

CONCLUSIONS

Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation

Background

Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing.

Methods

A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network.

Results

A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92).

Conclusions

An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

How equitable are psychological therapy services in South East London now? A comparison of referrals to a new psychological therapy service with participants in a psychiatric morbidity survey in the same London borough

PURPOSE

Psychological therapy services are sometimes characterised as being small and inequitable, with an over-representation of white middle class women. The 'Improving Access to Psychological Therapies (IAPT)' initiative is a programme in England that attempts to make evidence-based therapies accessible to more people more equitably. The aim of this study is to assess whether an IAPT service is delivering an equitable service a London borough. Patients using services at the Southwark IAPT service (n = 4,781) were compared with a sub-group of participants in the South East London Community Health study (SELCOH) with diagnosable mental health problems and who were also resident in Southwark (n = 196).

METHODS

We compared Southwark IAPT patients and SELCOH participants on equity criteria of age, gender, ethnicity, occupational status and benefits status. To investigate if referral pathways influenced equity, patients referred by their general practitioner (GP pathway) (n = 3,738) or who self-referred (self-referral pathway) (n = 482) were compared with SELCOH participants.

RESULTS

Southwark IAPT patients significantly differed from SELCOH participants on all our equity criteria and similar differences were found with GP pathway patients. However, self-referrals did not differ from the SELCOH group on age, gender, ethnicity and benefit status.

CONCLUSIONS

When compared to a community sample with diagnosable mental disorders, health disparities were found with the overall Southwark IAPT service and with GP pathway patients. Although unemployed people did access IAPT, fewer disparities were found with the self-referral pathway patients, suggesting that the IAPT self-referral pathway may be important in reducing inequitable access to services.

Failure and delay in treatment-seeking across anxiety disorders

Anxiety disorders are a significant mental health problem. Despite the availability of effective treatments most sufferers do not seek help. The current study assesses delays in treatment-seeking, failure to seek treatment, and reasons for delaying treatment for individuals with anxiety disorders. Data were drawn from the Collaborative Psychiatric Epidemiological Surveys including 3,805 participants and analyses focused on treatment-seeking variables. Results indicate that individuals with anxiety disorders are less likely to seek treatment from a professional and more likely to experience delays in obtaining both any treatment, and effective treatment, than individuals with other forms of mental illness (in this case unipolar depression or substance use disorders). Deficits in mental health literacy (knowledge and beliefs about mental illness) were commonly endorsed as reasons for having delayed seeking treatment. The current study highlights the importance of improving knowledge about anxiety disorders to improve treatment-seeking.

Depression Treatment Non-adherence and its Psychosocial Predictors: Differences between Young and Older Adults?

Depression is a common disease among young and older adults. Although it can be treated, non-adherence is very common among individuals of different ages. The aim of the present paper is to review and summarize research findings regarding depression among young and older adults, with a special focus on the phenomenon of treatment non-adherence among young and older adults with depression. The first section of the review focuses on describing the characteristics of depression in young and older adults. The second section focuses on treatment non-adherence of young and older adults, the prevalence of this phenomenon, and its consequences. The third section focuses on several factors (illness beliefs, treatment beliefs, self-stigma, and self-esteem) that were identified as having a significant association with treatment non-adherence of individuals with depression, with special attention focused on age differences. Results of the review of the literature reveal that research in the area of depression treatment non-adherence and its predictors among young and older adults has received, to date, very minor and limited attention. Thus, there is a need to expand the current body of knowledge and promote future interventions geared towards the unique characteristics of depression among young and older adults, in order to increase their treatment adherence.

Self-stigma and attitudes about treatment in depressed patients in a hospital setting

AIMS

Many patients have stigma about depression, which may inhibit treatment seeking. However, most previous research in this area has been conducted in outpatient samples. The current study investigated self-stigma and its relationship with treatment beliefs in depressed patients receiving psychiatric hospital treatment.

METHOD

The sample consisted of 55 hospitalized patients with depressive disorders who completed measures of self-stigma, medication beliefs, psychotherapy beliefs and depression.

RESULTS

Multiple regression analyses controlling for demographic variables demonstrated that higher depression severity was associated with increased self-stigma related to treatment and having depression. Higher self-stigma about treatment was associated with more negative beliefs about psychiatric medications, but more positive beliefs about psychotherapy. In contrast, self-stigma about depression was associated with negative beliefs about medications, but not psychotherapy.

CONCLUSIONS

Psychiatric hospital treatment, particularly in the USA, emphasizes medication treatment while de-emphasizing evidence-based psychosocial interventions. Individuals with negative views about psychiatric medications and positive views about the value of psychotherapy have higher treatment self-stigma, which may discourage them from seeking hospital treatment when needed or negatively affect their treatment response.

Educating family physicians to recognize and manage depression: where are we now?

OBJECTIVES

To consider what the barriers are to effective depression education; to understand what attitudes, knowledge, and skills doctors need to acquire, and finally to examine what we currently know about effective ways of training family physicians (FPs) about depression.

METHODS

A narrative review of the published literature compiled from searching reviews and original articles was conducted using the following key words: education, training, attitudes, depression, and primary care. Further relevant articles were identified from reference lists.

RESULTS

The identified barriers are FPs' attitudes and confidence toward recognizing and managing depression, the way in which they conceptualize depression, and the difficulties they face in implementing change in the systems in which they work. We, as educators, can identify what FPs need to know, and this should include novel ways of organizing care. However, of key importance is the need to address how more effective interventions may be provided, recognizing that FPs may be starting from many different points on 3 differing continua of attitude, skills, and knowledge in relation to depression.

CONCLUSIONS

We have to not only ensure that the content of what we teach is perceived as relevant to primary care but also review exactly how we go about providing it, using methods that will engage and stimulate doctors at differing stages of readiness to acquire new attitudes, skills, and knowledge about depression. However, we still need to find better ways of helping FPs to recognize and acknowledge their educational needs. Further research is also required to thoroughly evaluate these novel approaches to tailoring educational interventions.

The public's knowledge and beliefs about obsessive compulsive disorder

BACKGROUND

Obsessive compulsive disorder (OCD) is a disabling condition associated with significant personal and societal burdens. Despite the availability of efficacious treatments, in most cases, the disorder remains unrecognized and untreated. Lack of knowledge (i.e. poor mental health literacy, MHL) regarding OCD may be an impediment to seeking treatment. Therefore, the current study assessed public knowledge and beliefs about OCD and examined factors influencing MHL.

METHODS

Five hundred seventy-seven US adults participated in a telephone survey. After hearing a vignette describing someone with OCD, participants' MHL for OCD was assessed across three domains as follows: recognition of OCD, knowledge and beliefs about available help, and concerns about being negatively evaluated for reporting symptoms.

RESULTS

The majority of participants (90.9%) reported that the symptoms were a cause for concern and that the person in the vignette should seek professional help (89.5%). However, only one-third of respondents correctly labeled the disorder as OCD. More respondents were optimistic about the likely success of psychotherapy than medication, but primary care physicians were the most frequently reported source of professional help. Finally, less education, lower income, and being in an older cohort were associated with poorer recognition of OCD.

CONCLUSIONS

When presented with brief vignettes describing a person with OCD, most community members can recognize the benefits of seeking professional help. However, recognition of the disorder and knowledge of treatment options can be improved.

"How will it help me?" Reasons underlying treatment preferences between sertraline and prolonged exposure in posttraumatic stress disorder

Individuals with posttraumatic stress disorder (PTSD) often wait years before seeking treatment. Improving treatment initiation and adherence requires a better understanding of patient beliefs that lead to treatment preferences. Using a treatment-seeking sample (N = 200) with chronic PTSD, qualitative reasons underlying treatment preferences for either prolonged exposure (PE) or sertraline (SER) were examined. Reasons for treatment preference primarily focused on how the treatment was perceived to reduce PTSD symptoms rather than practical ones. The patients were more positive about PE than SER. Individual differences did not reliably predict underlying preference reasons, suggesting that what makes a treatment desirable is not strongly determined by current functioning, treatment, or trauma history. Taken together, this information is critical for treatment providers, arguing for enhancing psychoeducation about how treatment works and acknowledging preexisting biases against pharmacotherapy for PTSD that should be addressed. This knowledge has the potential to optimize and better personalize PTSD patient care.

Older adult stroke survivors discussing poststroke depressive symptoms with a healthcare provider: a preliminary analysis

PURPOSE

The purposes of this study were to examine the relationship between the poststroke depressive symptoms, older adult stroke survivors' perceptions of the depressive symptoms, and the congruence with an informal caregiver about the presence of depressive symptoms, and comfort talking to the health care provider with whether or not older stroke survivors discussed their depressive symptoms with a health care provider.

METHOD

A cross-sectional study where 44 caregiver/older adult stroke survivor dyads completed questionnaires including the Center for Epidemiologic Studies Depression Scale, Symptom Perception Questionnaire, and reporting of depressive symptoms to the health care provider via one time interview.

RESULTS

Thirty-seven percent (n = 16) of all older stroke survivors reported depressive symptoms to their health care provider. Of the stroke survivors who had high levels of depressive symptoms (CESD ≥ 16; n = 11), seven reported the depressive symptoms to their health care provider. Identifying the symptoms as possible depression and attributing the cause of the depressive symptoms to the stroke were related to stroke survivors reporting the depressive symptoms to a health care provider.

CONCLUSIONS

High functioning, older stroke survivors may benefit from strategies to help them identify when they experience depressive symptoms, in order to be able to play an active role in their recovery by appropriately discussing their symptoms with a health care provider.

The evidence-based practice of psychotherapy: facing the challenges that lie ahead

What does the future hold for psychotherapy research and practice? We review some key influences, including declining psychotherapy utilization, increasing impact of evidence-based medical practices, over-medicalizing of mental health problems, and changing priorities from grant funding agencies. These factors hold potential opportunities but also major pitfalls that will need to be carefully navigated related to implementation/dissemination issues, interdisciplinary collaborations, and psychosocial versus biomedical perspectives related to the nature and treatment of psychopathology. In addition, we review and comment on the other articles contained in this special issue pertaining to the future of evidence-based psychotherapy.

Unmet depression information needs in the community

BACKGROUND

Despite the well acknowledged importance of consumer health information, little is known about the public's depression information needs. This study aimed to develop a formal measure of unmet need for depression information in the community, to investigate the level of this unmet need and to identify its predictors.

METHODS

Data were collected as part of a survey of 12,319 Australian adults aged 18-65 years. This survey incorporated 21 questions targeting depression information need, together with measures of demographic status, self-reported current depression and personal stigma. The information needs data were subjected to principal components analysis followed by linear regression analyses to determine the demographic and other predictors of each of the resulting components.

RESULTS

Between 50 and 75% of participants endorsed the need for more information on each of the 21 information need topics. The PCA yielded a 20-item Depression Information Needs Scale (DINS) of high reliability and factor validity comprising four subscales: General (facts about depression), Specific Treatments, Research and Policies, and Lived Experience. Controlling for other factors, those with self-reported current depression and those without tertiary education had greater information needs across all four factors.

LIMITATIONS

The survey response rate was low and further research is required to establish the adequacy of the psychometric properties of the DINS.

CONCLUSIONS

Given the high unmet need for depression information there is a need to develop and implement evidence-based strategies for ensuring the accessibility and uptake of depression information relevant to the needs of members of the community.

Cognitive therapy versus fluvoxamine as a second-step treatment in obsessive-compulsive disorder nonresponsive to first-step behavior therapy

BACKGROUND

To compare the effectiveness of second-step treatment with cognitive therapy (CT) versus fluvoxamine in patients with obsessive-compulsive disorder (OCD) who are nonresponsive to exposure in vivo with response prevention (ERP).

METHODS

A 12-week randomized controlled trial at an outpatient clinic in the Netherlands comparing CT with fluvoxamine in OCD. Of 118 subjects with OCD treated with 12 weeks of ERP, 48 appeared to be nonresponders (Y-BOCS improvement score of less than one third). These nonresponders were randomized to CT (n = 22) or fluvoxamine (n = 26). The main outcome measure was the Y-BOCS severity scale. Statistical analyses were conducted in the intention-to-treat sample (n = 45) on an 'as randomized basis' and in the per-protocol sample (n = 30). Due to selective dropout in the fluvoxamine group, two additional sensitivity analyses were performed.

RESULTS

Complete data could be obtained from 45 subjects (94%) after 12 weeks. Fifty percent of the patients refused fluvoxamine after randomization compared to 13% who refused CT [χ(2)(1) = 7.10; p = 0.01]. CT as a second-step treatment did not appear to be effective in this sample of nonresponders. Fluvoxamine was significantly superior to CT in the intention-to-treat sample, in the per-protocol sample and in the two separately defined samples in which the sensitivity analyses were performed.

CONCLUSIONS

OCD patients who are nonresponsive to ERP may benefit more from a switch to treatment with an antidepressant instead of switching to CT. In clinical practice, it may be important to motivate this subgroup of patients to undergo psychopharmacological treatment, as this may improve their outcome considerably.

Fixable or fate? Perceptions of the biology of depression

OBJECTIVE

Previous research has shown that biological (e.g., genetic, biochemical) accounts of depression--currently in ascendancy--are linked to the general public's pessimism about the syndrome's prognosis. This research examined for the first time whether people with depressive symptoms would associate biological accounts of depression with pessimism about their own prognoses and whether a psychoeducation intervention portraying the biology of depression as malleable could decrease prognostic pessimism among symptomatic individuals.

METHOD

In 3 studies, participants were recruited online and assessed for depression symptoms. Those with significant depressive symptomatology (a Beck Depression Inventory-II score of at least 16) rated their endorsement of biochemical and genetic causal attributions for their symptoms and indicated expected length of symptom duration. An audiovisual intervention emphasizing the malleability of gene effects and neurochemistry was developed, and its effects on symptomatic individuals' prognostic pessimism, feelings of agency, guilt, and general hopelessness were measured.

RESULTS

Biochemical and genetic causal attributions for depression were significantly associated with prognostic pessimism among symptomatic individuals. The malleability intervention significantly reduced prognostic pessimism, increased feelings of agency, and decreased general hopelessness.

CONCLUSIONS

Biochemical and genetic attributions for depression are related to prognostic pessimism among individuals with depressive symptoms, and not just among the general public. However, emphasizing the malleability of gene effects and brain chemistry in depression can foster more optimism about depression-related beliefs.

Short-term psychodynamic psychotherapy in patients with "male depression" syndrome, hopelessness, and suicide risk: a pilot study

Objectives and Methods. This was an observational study of the efficacy of short-term psychodynamic psychotherapy (STPP) in a sample of 35 (30 women and 5 men) patients with moderate-to-severe "male depression" (Gotland Scale for Male Depression (GSMD) ≥ 13) comorbid with unipolar mood disorder (dysthymia and major depression) or anxiety disorder. Outcome measures were GSMD and BHS (Beck Hopelessness Scale) score changes from baseline. Results. Patients had a strong response to STPP on the GSMD (estimated mean score change (± SE) = -9.08 ± 2.74; P < 0.01; partial eta squared = 0.50), but not on the BHS (estimated mean score change (± SE) = -0.92 ± 1.55; P = 0.57; partial eta squared   = 0.03). BHS score changes were significantly associated with GSMD score changes (Pearson's r = 0.56; P < 0.001), even when controlling for the severity of hopelessness at the baseline (partial r = 0.62; P < 0.001). Conclusions. STPP proved to be effective in patients suffering from "male depression" although hopelessness was only marginally reduced by this treatment which points to the need to better understand how STPP can be involved in the reduction of suicide risk.

The Autonomic Nervous System Questionnaire and the Brief Patient Health Questionnaire as screening instruments for panic disorder in Finnish primary care

PURPOSE

As panic disorder often remains unrecognized in the health care system, some screening methods have been developed to enhance its recognition. The aim of this study was to test and compare the Autonomic Nervous System Questionnaire (ANS) and the Brief Patient Health Questionnaire (BPHQ) in primary care.

SUBJECTS AND METHODS

A total sample of 211 primary care outpatients was studied. The Structured Clinical Interview for DSM-IV was the criterion standard for the presence of panic disorder. Indices of diagnostic utility for both screening methods were calculated and compared.

RESULTS

The AUC (area under the ROC curve) was 0.885 for the ANS and 0.877 for the BPHQ. At the optimal cut-off level, the ANS had the sensitivity of 0.88 and specificity of 0.77; the BPHQ had the sensitivity of 0.79 and the specificity of 0.87. There was not any statistically significant difference between the screens.

CONCLUSIONS

Both screening methods can be recommended both for clinical practice and research use. In busy primary care practice, the BPHQ may be more useful, as it can be used together with the depression module of the BPHQ.

Predictors of Treatments Acceptable to Patients for Late-Life Depression

Objectives. Describe older patients' perceptions about depression and characteristics associated with acceptance of treatments. Design. Cross-sectional study. Setting. Three primary care clinics in Iowa. Participants. Consecutive sample of 529 primary care patients. Measurements. Depression screening tool (a 9-item patient health questionnaire [PHQ-9]) and questionnaire including sociodemographic data, patient attitudes about depression, and acceptability of different treatments. Results. Mean age was 71.9 years (range 60–93 years), 314 (59%) female. Among the 529 participants, 93 (17.5%) had history of depression and 60 (11.3%) had PHQ-9 scores of 10 or greater. Participants believed depression is a disease for which they would use medication and counseling. Accepting medications from primary physicians was strongly associated with a past history of depression (P < 0.01) and with agreeing that depression needs treatment (P < 0.01). Counseling was not acceptable for those believing that they can control depression on their own (P < 0.01). Older patients (P < 0.001) and those with higher education levels (P < 0.01) were less likely to accept herbs or supplements as treatment options. Willingness to discuss treatments with family was associated with not using alcohol as a treatment and acceptance of all other treatment options (P < 0.001). Conclusions. Attitude that depression is a disease and the willingness to discuss depression with family may enhance treatment acceptance.

Determinants of receiving mental health care for depression in older adults

BACKGROUND

Major Depressive Disorder (MDD) is common among elderly people. However, it appears that only a minority receives treatment. This study aims to identify and analyse the factors that determine whether elderly people with depressive disorders have contact with health care professionals for mental problems.

METHOD

Cross-sectional analysis of cohort data collected in the Netherlands Study of Depression in Older persons (NESDO) and the Netherlands Study of Depression and Anxiety (NESDA) among 167 respondents aged ≥55 with a depressive disorder as indicated by the CIDI. Contacts for mental health problems during the past six months (TiC-P), and indicators of predisposing, enabling, and objective need factors were assessed by interview.

RESULTS

Of the total sample, 70% had contact for mental health problems, almost entirely within primary care (62%). The odds of having contact increased with advancing age; for respondents born in the Netherlands; for those who felt less lonely; and for those with a higher household income.

LIMITATIONS

Our study is based on base-line interviews and thus has a cross-sectional character. Therefore, causal conclusions cannot be drawn. Furthermore, we studied the respondents' perception whether mental health care was received.

CONCLUSIONS

The contact rate for mental health problems is high. Health care professionals should be aware that having contact is not associated with a higher objective need, but rather with increasing age, being Dutch-born, being less lonely and having a higher household income.

An overview of the effectiveness of psychological therapy for depression and stepped care service delivery models

Depression is one of the most prevalent health disorders globally and causes significant distress and cost to the sufferer and society. Psychological therapy for depression has been recommended over a number of decades; however, access to these treatments remains limited. Cognitive behaviour therapy, behavioural activation, self-help approaches, interpersonal therapy and non-directive therapy all demonstrate moderate to large effect sizes when compared to treatment as usual. Differences between psychological interventions however are small and unstable when reviewed in meta-analyses suggesting that for most people adding complexity to treatment does not result in improved outcomes. Stepped care is one system used to organise delivery of psychological therapy that stratifies interventions across several levels of symptom severity. There is debate regarding the ideal design and operation of this complex system resulting in considerable variability in its use in clinical settings. Further research is needed to identify the most cost effective approach to the delivery of psychological therapies for depression as we need to continue to reduce the gap between demand and access to therapy.

Beliefs about depression and its treatments: associated variables and the influence of beliefs on adherence to treatment

Beliefs and attitudes about treatment in patients with depression are significant factors related to treatment adherence. Despite their importance, few studies have evaluated the determining factors of these beliefs, and the positive or negative attitudes towards treatment. This review looks at areas such as, adherence to antidepressants and psychotherapy, influence of beliefs and attitudes on adherence to treatment, beliefs and attitudes about depression and its treatment, their assessment, variables associated with these beliefs, and limitations of available studies. Acknowledging the importance of patient beliefs about depression and treatment, and their assessment are essential to optimize the chances of success of therapy by identifying and addressing misconceptions, prejudices and negative attitudes, as well as the consideration of these aspects in order to improve treatment choice.

Mental health care as delivered by Dutch general practitioners between 2004 and 2008

OBJECTIVE

In the field of mental health care, a major role for general practice is advocated. However, not much is known about the treatment and referral of mental health problems in general practice. This study aims at the volume and nature of treatment of mental health problems in general practice; the degree to which treatment varies according to patients' gender, age, and social economic status; and trends in treatment and referral between 2004 and 2008.

DESIGN/SETTING

Descriptive study with trends in time in general practice in the Netherlands.

SUBJECTS

350,000 patients enlisted in general practice, whose data from the Netherlands Information Network of General Practice were routinely collected from 1 January 2004 to 31 December 2008.

MAIN OUTCOME MEASURES

For all episodes of mental health problems recorded by the GP, the proportion of patients receiving prolonged attention, medication, and referral during each year have been calculated.

RESULTS

More than 75% of patients with a recorded mental health problem received some kind of treatment, most often medication. In 15-20% of cases medication was accompanied by prolonged attention; 9-13% of these patients were referred (given referrals), the majority to specialized mental health care. Age is the most important variable associated with treatment received. During the period 2004-2008, treatment with medication declined slightly and referrals increased slightly.

CONCLUSION

Treatment for psychological disorders is mostly delivered in general practice. Although in recent years restraint has been advocated in prescribing medication and collaboration between primary and secondary care has been recommended, these recommendations are only partially reflected in the treatment provided.

Why depressive symptoms cause distress: the clients' perspective

BACKGROUND

Depressive symptoms are associated with distress, but research has not focused on the processes underlying this association.

METHOD

We interviewed 18 patients experiencing depressive symptoms to identify the various reasons why depressive symptoms cause distress. Digital recordings were transcribed and grounded theory methods were used in analyzing the data and building theory.

RESULTS

We identified 14 reasons for why patients find depressive symptoms distressing. These reasons frequently were particular thoughts, behaviors, or subsequent outcomes in response to the symptom; in other cases, the experience of the symptom itself directly caused distress.

CONCLUSIONS

We present a general model of direct and indirect symptom-distress relationships that may help target clinical interventions for depression.

How patients understand depression associated with chronic physical disease--a systematic review

BACKGROUND

Clinicians are encouraged to screen people with chronic physical illness for depression. Screening alone may not improve outcomes, especially if the process is incompatible with patient beliefs. The aim of this research is to understand people's beliefs about depression, particularly in the presence of chronic physical disease.

METHODS

A mixed method systematic review involving a thematic analysis of qualitative studies and quantitative studies of beliefs held by people with current depressive symptoms. MEDLINE, EMBASE, PSYCHINFO, CINAHL, BIOSIS, Web of Science, The Cochrane Library, UKCRN portfolio, National Research Register Archive, Clinicaltrials.gov and OpenSIGLE were searched from database inception to 31st December 2010. A narrative synthesis of qualitative and quantitative data, based initially upon illness representations and extended to include other themes not compatible with that framework.

RESULTS

A range of clinically relevant beliefs was identified from 65 studies including the difficulty in labeling depression, complex causal factors instead of the biological model, the roles of different treatments and negative views about the consequences of depression. We found other important themes less related to ideas about illness: the existence of a self-sustaining 'depression spiral'; depression as an existential state; the ambiguous status of suicidal thinking; and the role of stigma and blame in depression.

CONCLUSIONS

Approaches to detection of depression in physical illness need to be receptive to the range of beliefs held by patients. Patient beliefs have implications for engagement with depression screening.

Illness beliefs and treatment beliefs as predictors of short and middle term outcome in depression

The article investigates whether illness beliefs and beliefs about rehabilitation are predictors of short and middle term outcome in depression even when adjustments are made for variables, which are known to be predictors of the course of depression. Within the context of a non-controlled prospective study design, data were analyzed using forced entry hierarchical multiple regression analyses. The sample comprised N = 98 patients. Adjusting for a range of sociodemographic and medical predictors, illness beliefs and beliefs about rehabilitation predict outcome in depression. Illness beliefs and beliefs about rehabilitation are relevant starting points for designing patient-oriented interventions.

Perceptions of and attitudes toward antidepressants: stigma attached to their use--a review

The aim of this study was to ascertain whether there is any evidence of stigma related to the use of antidepressants. Using the PubMed and MEDLINE databases, we searched for the terms stigma, antidepressants, and depression. A protocol was developed to extract information from the papers, which were identified and explored further. Thirty-two papers were identified. We found that the stigma against depression differs from stigma against the use of antidepressants. Stigma against depression does not impact on therapeutic adherence to antidepressant use. Stigma related to antidepressant use appears to be linked with perceived emotional weakness, severity of illness, an inability to deal with problems, and a lack of belief in the therapeutic efficacy of antidepressants. Stigma against medication can be a useful target for interventions, just like the stigma related to depression. However, clinicians must be careful in avoiding the medicalization of symptoms.

The general practitioner's role in providing mental health services to Australians, 1997 and 2007: findings from the national surveys of mental health and wellbeing

OBJECTIVES

To compare the findings of the 1997 and 2007 Australian national surveys of mental health and wellbeing (NSMHWBs) with respect to the role of general practitioners in providing mental health services.

DESIGN, SETTING AND PARTICIPANTS

There were 10,641 participants Australia-wide in the 1997 survey and 8841 in the 2007 survey. Data were gathered through face-to-face interviews using a written questionnaire.

MAIN OUTCOME MEASURES

Rates of use of GPs and other health care providers for treatment of mental health problems; levels of met and unmet need for mental health services reported by those accessing GP services.

RESULTS

Between 1997 and 2007, the proportion of people accessing any mental health care service within the previous 12 months increased significantly, from 12.4% to 21.4% (P < 0.01), although the proportion accessing GP care for mental health problems did not increase. In both surveys, nearly 60% of individuals with self-assessed mental health problems sought no professional help for their problems, although about 80% of these non-users had seen GPs about other matters. The proportions of participants who reported receiving sufficient information, medication and/or therapy for their mental health problem increased significantly over the 10-year period. However, unmet need for information also increased. In both surveys, over 90% of participants aged 60 years or over with self-assessed mental health problems reported obtaining no help for their mental health problem despite seeing a GP for other reasons.

CONCLUSION

Despite a significant rise in the use of mental health services, the role of GPs in providing such services has not increased.

The costs of guideline-concordant care and of care according to patients' needs in anxiety and depression

AIM

To describe the direct and indirect costs for people with anxiety and depressive disorders where guidelines are adhered to and patients' perceived needs are fully met.

METHOD

Data were derived from the Netherlands Study of Depression and Anxiety. At baseline, adult patients were interviewed and they completed questionnaires to measure DSM-IV diagnoses, socio-demographic characteristics and perceived need for care. Actual care data were also derived from electronic medical records. Criteria for guideline adherence were based on general practice guidelines, issued by the Dutch College of General Practitioners. Direct and indirect costs were inferred from the Perceived Need for Care Questionnaire administered at baseline, and the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness administered at 1-year follow-up.

RESULTS

For 568 patients with a current anxiety or depressive disorder a complete dataset on health care use and absenteeism was available. Guideline adherence was significantly associated with increased care use and corresponding costs, while fully met perceived need was unrelated to costs. Socio-demographic characteristics, severity of symptoms and guideline adherence all affected the societal costs of patients with fully met perceived needs compared with patients with perceived unmet needs.

CONCLUSION

It appears that guideline-concordant care for anxiety and depression costs more than non-concordant care, while care that has fulfilled all of a patient's needs seems not to be more expensive than care that has not met all perceived needs. However, randomized controlled trials should first confirm this conclusion.

In what direction should we go to promote health in mental health care?

There is a growing recognition of the need for health promotion interventions in all health care today. In spite of this, health promotion interventions among patients with mental illnesses have been scarce in research, practice, and policies. There is also an ambiguous interpretation of the definition of health promotion in the literature. The emphasis in this paper is thus to (1) discuss why we should pay attention to the interpretations of the concept of health promotion and (2) present a possible model for what nurses do when they intend to promote health in mental health care. This paper was presented at the Nordic Conference of Mental Health Nursing in Helsinki, Finland in 2010.

Recruitment into a guided internet based CBT (iCBT) intervention for depression: lesson learnt from the failure of a prevalence recruitment strategy

INTRODUCTION

Internet based Cognitive Behavioural Therapy (iCBT) represents a significant development in the way psychological interventions are delivered. Studies tend to recruit via common media channels leading to criticisms of biased sample sizes and limited generalisability to primary care settings.

AIM

To evaluate the use of a prevalence recruitment strategy within primary care to recruit into an RCT examining a free to use iCBT intervention.

METHODS

Fully randomised controlled trial (RCT), utilising a prevalence based recruitment strategy, comparing the iCBT intervention with telephone support provided by NHS Direct Health Advisors with treatment-as-usual (TAU) control.

RESULTS

Recruitment rates were low with only 7 participants recruited over 8 months. Overall only 14% of expected study invitations were sent, with only 1% undertaking the consent and initial screening process.

DISCUSSION

Key differences with successful prevalence recruitment strategies highlight four main issues to consider when recruiting participants from primary care into iCBT studies--lack of equipoise, a need for an assertive approach, coding of depression in GP databases and help seeking behaviour in depression which can all act as potential contributors to failure to recruit. However other non-primary care recruitment methods, such as the use of media channels, which are already shown to be effective in non-primary care settings should be considered if these methods more accurately target the population who would be willing to adopt iCBT more generally.

Ratings of patient-provider communication among veterans: serious mental illnesses, substance use disorders, and the moderating role of trust

Many individuals with a mental illness are not satisfied with their communication with their primary provider. The present study examined the relationship of serious mental illness (SMI), substance use disorder (SUD), and trust for the provider with provider communication. The sample included Veterans Administration (VA) patients throughout the United States who either had a SMI diagnosis (schizophrenia or bipolar disorder) or were in a random sample of non-SMI patients (total N=8,089). Latent class (LC) modeling identified three classes of provider communication ratings in the sample: very good, good, and poor. In LC regression, poor trust for the provider was associated with a decrease in the likelihood of being in the "very good" or "good" compared to the "poor" provider communication ratings group, and the decrease was significantly greater for VA patients with a SMI or SUD diagnosis than those without. Training providers on creating trust is particularly important for those who serve patients with SMI and SUD diagnoses.

Can general practitioners identify people with distress and mild depression? A meta-analysis of clinical accuracy

BACKGROUND

There is increasing emphasis on distress and mild depression but uncertainty regarding how well general practitioners (GPs) identify these conditions. Further, the proportion of attendees suffering distress is also unclear.

AIM

To quantify the rate of distress in primary care and to clarify the ability of GPs to identify distressed and/or mildly depressed individuals using their clinical skills.

METHODS

Meta-analysis of clinical recognition of distress and mild depression defined on a continuum (severity scale) or categorically (semi-structured interview).

RESULTS

From 157 studies that examined the ability of GPs to diagnose any emotional or mental disorder, we identified 23 that focused on defined distress and 9 that reported on mild depression. The prevalence of broadly defined distress was 37.4% (n=23, 95% CI=29.5% to 45.5) although it was 47.3% (n=14, 95% CI=38.0% to 56.7%) using self-report methods. GPs correctly identified distressed individuals in 48.4% (n=21, 95% CI=42.6% to 54.2%) of presentations and identified non-distressed people in 79.4% (n=21, 95% CI=74.3% to 84.1%) of presentations without distress. GPs correctly identified 33.8% (95% CI=27.3% to 40.7%) of people with mild depression and had a detection specificity of 80.6% (95% CI=66.4% to 91.6%) for the non-depressed. Clinicians' ability to recognize mild depression was significantly lower than their ability to recognize moderate-severe depression. Out of 100 consecutive presentations, a typical GP making a single assessment would correctly identify 19 out of 39 people with distress, missing 20. He or she would correctly re-assure 48 out of 61 people without distress, falsely label 13 people as distressed. For mild depression, out of 100 consecutive presentations, a typical GP would correctly identify 4 out of 11 people with mild depression, missing 7. GPs would correctly re-assure 72 out of 89 people without distress, falsely diagnosing 19.

CONCLUSIONS

Clinicians have considerable difficulty accurately identifying distress and mild depression in primary care with only one in three people correctly diagnosed. Clinicians are better able to identify distress than mild depression but success remains limited. However not all such individuals want professional help, and some people who are overlooked get help elsewhere, or improve spontaneously, therefore the implications of these detection problems are not yet clear.

Use of mental health care by community-dwelling older adults

OBJECTIVES

To examine relationships between perceived need for care, illness characteristics, attitudes toward care, and probability that older adults will use mental health care (MHC).

DESIGN

Secondary data analysis.

SETTING

The Collaborative Psychiatric Epidemiology Surveys (2001-2003).

PARTICIPANTS

One thousand six hundred eighty-one community-dwelling adults aged 65 and older.

MEASUREMENTS

Self-reported MHC use and perceived need for care in the previous 12 months, previous year and history of mental illness, history of physical illness, attitudes toward care, and sociodemographic characteristics.

RESULTS

Of the entire sample, 6.5% had received some type of MHC in the previous year, although 65.9% of those with major depressive disorder (MDD) and 72.5% with anxiety did not receive MHC. In respondents with previous-year depression or anxiety, use was less likely for those with low World Health Organization Disability Assessment Scale (WHO-DAS) self-care ability. Use was more likely for those with more chronic physical conditions and worse WHO-DAS cognitive capacity. Seventeen percent of those with perceived need for MHC did not receive it. In respondents with perceived need, subthreshold generalized anxiety disorder was associated with lower likelihood of use. Use was more likely for older respondents and those with more household members, at least a high school education, and better self-care ability. Forty-one percent of those who perceived a need for care but did not use it met previous-year diagnostic criteria for anxiety, and 17% met criteria for MDD.

CONCLUSION

Understanding the perceptions that underlie individuals' health care-seeking behavior is an important step toward reducing underuse of MHC by older adults.

Illness representations of depression and perceptions of the helpfulness of social support: comparing depressed and never-depressed persons

BACKGROUND

Interactions between depressed persons and persons within their social network are often characterized by misunderstanding and unsuccessful social support attempts. These interpersonal problems could be fostered by discrepancies between depressed and never-depressed persons' illness representations of depression and/or discrepancies in the perceived helpfulness of supportive behaviors.

METHODS

Illness representations of depression (IPQ-R) and perceptions of the helpfulness of different social support behaviors (ISU-DYA and ISAD) were assessed in 41 currently depressed persons and 58 persons without a history of depression.

RESULTS

Never-depressed persons perceived depression as more controllable by treatment and as less emotionally impairing than depressed persons, but also as having more severe consequences. Never-depressed persons considered activation-oriented support (motivation to approach problems) as more helpful and protection-oriented support (allowance to draw back) as less helpful in comparison to depressed persons.

LIMITATION

Data were collected in unrelated samples of depressed and never-depressed persons.

CONCLUSIONS

Discrepancies in illness representations and perceptions of the helpfulness of social support do exist and may be the origin of problematic social interactions between depressed patients and persons within their social network. Therapeutic interventions should address the issue of conflicting perceptions and encourage depressed patients to acknowledge and discuss this topic within their social network.

Patients' beliefs about the cause of their depression

BACKGROUND

Patients' beliefs about the cause of their depression can affect their help-seeking behavior, treatment preferences, coping strategies and treatment compliance. There are few studies exploring depressed patients' beliefs about the causes and to our knowledge none in a Swedish population. However, previous studies show that the patients more often mention environmental and psychological causes than biological. The aim of this study was to further explore depressed patients' answers to an open-ended question about the etiology of their depression.

METHODS

Primary care patients, participating in a study evaluating patient education, were asked an open-ended question about their beliefs about what had caused their depression. Answers were obtained from 303 patients.

RESULTS

The analysis of the patients' beliefs emerged into 16 different categories of explanations for depression that could be organized into three larger themes: current life stressors, past life events and constitutional factors. Work-related stress was the most commonly mentioned cause, followed by personality and current family situation. Only 3.6% stated biological reasons.

LIMITATIONS

We could only count the frequency of mentioned causes, but no ranking of the importance of these causes.

CONCLUSIONS

Primary care patients often gave multi-causal explanations to their depression. Biological explanations were rare. Their beliefs were predominantly current life stressors such as work or family situation and also their own personality. Patients' beliefs about their illness are important in the patient-doctor encounter, when developing new treatment strategies aiming at improved adherence to both psychopharmacological and psychotherapeutic treatments and also in patient education programs.