Is the impact of depressive complaints on the use of general health care services dependent on severity of somatic morbidity?

The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review

OBJECTIVES

This paper aims to systematically review observational studies that have analysed whether depressive symptoms in the community are associated with higher general hospital admissions, longer hospital stays and increased risk of re-admission.

METHODS

We identified prospective studies that looked at depressive symptoms in the community as a risk factor for non-psychiatric general hospital admissions, length of stay or risk of re-admission. The search was carried out on MEDLINE, PsycINFO, Cochrane Library Database, and followed up with contact with authors and scanning of reference lists.

RESULTS

Eleven studies fulfilled our inclusion and exclusion criteria, and all were deemed to be of moderate to high quality. Meta-analysis of seven studies with relevant data suggested that depressive symptoms may be a predictor of subsequent admission to a general hospital in unadjusted analyses (RR=1.36, 95% CI: 1.28-1.44), but findings after adjustment for confounding variables were inconsistent. The narrative synthesis also reported depressive symptoms to be independently associated with longer length of stay, and higher re-admission risk.

CONCLUSIONS

Depressive symptoms are associated with a higher risk of hospitalisation, longer length of stay and a higher re-admission risk. Some of these associations may be mediated by other factors, and should be explored in more details.

Cost utility analysis of a collaborative stepped care intervention for panic and generalized anxiety disorders in primary care

OBJECTIVE

Generalized anxiety and panic disorders are a burden on the society because they are costly and have a significant adverse effect on quality of life. The aim of this study was to evaluate the cost-utility of a collaborative stepped care intervention for panic disorder and generalized anxiety disorder in primary care compared to care as usual from a societal perspective.

METHODS

The design of the study was a two armed cluster randomized controlled trial. In total 43 primary care practices in the Netherlands participated in the study. Eventually, 180 patients were included (114 collaborative stepped care, 66 care as usual). Baseline measures and follow-up measures (3, 6, 9 and 12 months) were assessed using questionnaires. We applied the TiC-P, the SF-HQL and the EQ-5D respectively measuring health care utilization, production losses and health related quality of life.

RESULTS

The average annual direct medical costs in the collaborative stepped care group were 1854 Euro (95% C.I., 1726 to 1986) compared to €1503 (95% C.I., 1374 to 1664) in the care as usual group. The average quality of life years (QALYs) gained was 0.05 higher in the collaborative stepped care group, leading to an incremental cost effectiveness ratio (ICER) of 6965 Euro per QALY. Inclusion of the productivity costs, consequently reflecting the full societal costs, decreased the ratio even more.

CONCLUSION

The study showed that collaborative stepped care was a cost effective intervention for panic disorder and generalized anxiety disorder and was even dominant when a societal perspective was taken.

TRIAL REGISTRATION

trialregister.nl, Netherlands Trial Register NTR107.

Recent medical service utilization and health conditions associated with a history of suicide attempts

OBJECTIVES

Suicide is a leading cause of death; unfortunately most individuals at risk for suicide are not identified, assessed or treated by the mental health system. Investigating medical healthcare utilization among individuals with a history of suicide attempt may identify alternative settings for case finding and brief intervention.

METHODS

The study sample (n=1422, 58% female, 72% African-American) is from a prospective cohort of adults (27-31 years) who participated in a randomized trial of school-based interventions. Logistic regression evaluated the relationship between lifetime history of suicide attempt with past year medical service utilization and selected self- reported health conditions, controlling for lifetime Major Depressive Disorder (MDD), demographic factors, health insurance status and employment.

RESULTS

A suicide attempt history was associated with past year emergency department medical visits [aOR 1.51, 95% CI 1.04-2.18, P=.03], but not primary care visits or inpatient hospitalization, when controlling for MDD and other covariates. Severe headaches and chronic gastrointestinal conditions were also associated with lifetime suicide attempt [aOR 1.50, 95% CI 1.03-2.17 and aOR 1.67, 95% CI 1.06-2.63, respectively].

CONCLUSIONS

Suicide prevention, including universal screening and brief intervention, is indicated in emergency department settings. Restricting screening to subgroups, such as those individuals presenting with depression, may miss at-risk individuals with somatic concerns.

Help-seeking for emotional problems in major depression : findings of the 2006 Estonian health survey

To study help-seeking among the general population and people with major depression. 12-month help-seeking for emotional problems was assessed in a cross-sectional 2006 Estonian Health Survey. Non-institutionalized individuals aged 18-84 years (n = 6,105) were interviewed. A major depressive episode was assessed using the Mini-International Neuropsychiatric Interview. The factors associated with help-seeking, received help, and health service use were analyzed. The prevalence of 12-month help-seeking for emotional symptoms was 4.8%. The rate of 12-month help-seeking in the depressed sample was 34.1%. Depressed people used non-mental health services 1.5-3 times more than non-depressed persons even when adjusted for the chronic somatic disorder. Only one third of depressed persons sought help, which was most of all associated with severity of depression. Underdiagnosis and undertreatment of depression leads to an increased use of expensive but non-specific health services by depressed persons.

A systematic review of non-pharmacological treatments for depression in people with chronic physical health problems

OBJECTIVE

To review the efficacy of non-pharmacological treatment for depression in people with depression and chronic physical health problems.

METHOD

Five electronic databases were searched including EMBASE, Medline and PsycINFO for randomized controlled trials (RCTs). Each paper was assessed for quality, data extracted and, where possible, the data meta-analyzed. The overall quality of each meta-analysis was assessed.

RESULTS

35 studies met our inclusion criteria and 22 were meta-analyzed using a random-effects model. The largest and strongest evidence base supports individual- and group-based cognitive and behavioral interventions (18 trials). The evidence was strongest for those interventions aimed solely at reducing depression in comparison to those aimed more broadly at reducing the psychosocial stress associated with having a chronic physical health problem.

CONCLUSION

Overall, the efficacy of certain types of non-pharmacological interventions for people with depression and chronic physical health problems has been demonstrated. The overall impression is that their efficacy in this population is comparable to that in people with depression without chronic physical health problems but the evidence-base is currently inadequate and larger trials with long-term follow-up are required.

Adolescent behavioral risk screening and use of health services

This study assessed whether primary care based computerized screening for substance use, mental health issues and suicidal thoughts affects subsequent use of medical and behavioral health care services in adolescents. Administrative claims data were used to determine service use 6 months after a visit where screening could have occurred. Controlling for previous service use, screened youths were more likely to have post screening use than those not screened. Among the screened patients, medical service use did not differ by screening result. However, behavioral service use was higher for screened youths who screened positive for depression or suicidal thoughts.

Recognition and treatment of depression in primary care: effect of patients' presentation and frequency of consultation

OBJECTIVE

Primary care physicians (PCPs) are expected to recognize depression and appropriately prescribe antidepressants. This article investigated the single and combined effects of different patient presentations and frequency of visits on detection and antidepressant use.

METHODS

Data came from an Italian nationwide survey on depressive disorders in primary care, involving 191 PCPs and 1910 attenders. Two hundred fifty patients suffering from major or subthreshold depression were compared in relation to their presentation (psychological, physical, and pain) and frequency of visits (low and high).

RESULTS

Recognition of depression significantly varied according to both presentation and frequency of visits. When compared to patients with psychological complaints, the odds ratios for nonrecognition of depression were higher for patients presenting with physical symptoms [2.3; 95% confidence interval (CI)=1.1-5.3] and with pain (4.1; 95% CI=1.6-9.9). Subjects who rarely attended the practice were 2.3 times less likely to receive a diagnosis of depression, compared with those having a high frequency of visits (95% CI=1.2-4.6). Similarly, patients presenting with physical symptoms or with pain and those with a low frequency of visits were rarely treated with antidepressants. The combination of physical or pain presentation with low frequency of visits further increased the risk for nonrecognition, which was sixfold that of the reference category.

CONCLUSIONS

Some subgroups of depressed patients still run a high risk of having their depression unrecognized by the PCP. Screening for depression among patients presenting with pain might be useful in order to improve recognition and management.