The Hampshire Depression Project: development and piloting of clinical practice guidelines and education about depression in primary health care

Chile: Acceptability of a Training Program for Depression Management in Primary Care

Background: In Chile, there are inconsistencies in the management of depression in primary care settings, and the National Depression Program, currently in effect, was implemented without a standardized training program. The objective of this study is to evaluate the acceptability of a training program on the management of depression for primary care health teams.

Methods: The study was a randomized controlled trial, and two primary centers from the Metropolitan Region of Santiago were randomly selected to carry out the intervention training program. Pre-post surveys were applied, to evaluate expectations and satisfaction with the intervention, respectively. Descriptive and content analysis was carried out.

Result: The sample consisted of 41 health professionals, 56.1% of who reported that their expectations for the intervention were met. All of the training activities were evaluated with scores higher than 6.4 (on a 1–7 scale). The trainers, the methodology, and the learning environment were considered strengths and facilitators of the program, while the limited duration of the training, the logistical problems faced during part of the program, and the lack of educational material were viewed as weaknesses.

Conclusion: The intervention was well accepted by primary health care teams. However, the clinical impact in patients still has to be evaluated.

Recognition of depressive symptoms by physicians

OBJECTIVE

To investigate the recognition of depressive symptoms of major depressive disorder (MDD) by general practitioners.

INTRODUCTION

MDD is underdiagnosed in medical settings, possibly because of difficulties in the recognition of specific depressive symptoms.

METHODS

A cross-sectional study of 316 outpatients at their first visit to a teaching general hospital. We evaluated the performance of 19 general practitioners using Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect depressive symptoms and compared them to 11 psychiatrists using Structured Clinical Interview Axis I Disorders, Patient Version (SCID I/P). We measured likelihood ratios, sensitivity, specificity, and false positive and false negative frequencies.

RESULTS

The lowest positive likelihood ratios were for psychomotor agitation/retardation (1.6) and fatigue (1.7), mostly because of a high rate of false positive results. The highest positive likelihood ratio was found for thoughts of suicide (8.5). The lowest sensitivity, 61.8%, was found for impaired concentration. The sensitivity for worthlessness or guilt in patients with medical illness was 67.2% (95% CI, 57.4-76.9%), which is significantly lower than that found in patients without medical illness, 91.3% (95% CI, 83.2-99.4%).

DISCUSSION

Less adequately identified depressive symptoms were both psychological and somatic in nature. The presence of a medical illness may decrease the sensitivity of recognizing specific depressive symptoms.

CONCLUSIONS

Programs for training physicians in the use of diagnostic tools should consider their performance in recognizing specific depressive symptoms. Such procedures could allow for the development of specific training to aid in the detection of the most misrecognized depressive symptoms.

The importance of somatic symptoms in depression in primary care

OBJECTIVE

Patients with depression present with psychological and somatic symptoms, including general aches and pains. In primary care, somatic symptoms often dominate. A review of the literature was conducted to ascertain the importance of somatic symptoms in depression in primary care.

DATA SOURCES AND EXTRACTION

MEDLINE, EMBASE, and PsychLIT/PsychINFO databases (1985-January 2004) were searched for the terms depression, depressive, depressed AND physical, somatic, unexplained symptoms, complaints, problems; somatised, somatized symptoms; somatisation, somatization, somatoform, psychosomatic; pain; recognition, under-recognition; diagnosis, underdiagnosis; acknowledgment, under-acknowledgment; treatment, undertreatment AND primary care, ambulatory care; primary physician; office; general practice; attribution, re-attribution; and normalising, normalizing. Only English-language publications and abstracts were considered.

STUDY SELECTION

More than 80 papers related to somatic symptoms in depression were identified using the content of their titles and abstracts.

DATA SYNTHESIS

Approximately two thirds of patients with depression in primary care present with somatic symptoms. These patients are difficult to diagnose, feel an increased burden of disease, rely heavily on health care services, and are harder to treat. Patient and physician factors that prevent discussion of psychological symptoms during consultations must be overcome.

CONCLUSIONS

Educational initiatives that raise awareness of somatic symptoms in depression and help patients to re-attribute these symptoms should help to improve the recognition of depression in primary care.

The development and implementation of an educational intervention on first episode psychosis for primary care

INTRODUCTION

This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis.

METHOD

The Medical Research Council complex interventions framework was used to guide the development of the intervention. The theoretical phase included a literature review of previous educational interventions in primary care and consideration of the literature on attitude formation and change, and the relationship between attitudes and behaviour. The modelling phase included focus groups with GPs and service users, and a training needs analysis questionnaire administered to GPs. The 2-stage intervention consisted of a video featuring role-plays of primary care consultations, GP-led discussion and discussion with early intervention service users. The acceptability and utility of the educational programme was evaluated using a 5-point Likert scale questionnaire administered at the end of each session.

RESULTS

General practitioners from each of the 39 intervention practices participated in the initial session and from 27 practices in the booster session. Information about symptoms and signs of first episode psychosis was the most valued aspect of the initial session. The booster session was also well received, with GPs valuing the opportunity to gain insight into first episode psychosis from users.

CONCLUSIONS

This paper adds a pragmatic description to the literature on the development of educational interventions in primary care. The Medical Research Council framework helped to identify and clarify component parts of the intervention and how the active components may relate to the expected outcome of behaviour change.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers.

OBJECTIVES

To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken.

MAIN RESULTS

We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

A letter of consequence: referral letters from general practitioners to secondary mental health services

The referral letter is a key instrument in moving patients from primary to secondary care services. Consequently, the circumstances in which a referral should be made and its contents have been the subject of clinical guidelines. This article is based on a project that demonstrated that physicians do not adhere to clinical guidelines when referring patients to secondary mental health services. This research supports earlier findings into noncompliance with guidelines by general practitioners (GPs). The authors briefly note possible reasons, which have been the subject of some debate. They also present a content analysis of referral letters to demonstrate the important ways in which they differ from guideline criteria. However, their central argument is that the role of the referral letter in relation to the GP's repertoire of treatments has not been understood fully. Such understanding implies the need for a reexamination of the support available for GPs.

Low dosage tricyclic antidepressants for depression

BACKGROUND

Tricyclic antidepressants are still extensively prescribed worldwide. Evidence for the recommended dosage of tricyclics, however, is poor.

OBJECTIVES

To compare the effects and side effects of low dosage tricyclic antidepressants with placebo and with standard dosage tricyclics in acute phase treatment of depression.

SEARCH STRATEGY

Electronic search of the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), incorporating results of group searches of MEDLINE (1966-), EMBASE (1980-), CINAHL (1982-), PsycLIT (1974-), PSYNDEX (1977-) and LILACS (1982-1999) and hand searches of major psychiatric and medical journals. Reference search and SciSearch of the identified studies. Personal contact with authors of significant papers.

SELECTION CRITERIA

All randomised controlled trials 1) comparing low dosage TCA (=< 100 mg/d on average at the end of trial) with placebo or 2) comparing low and standard dosages of the same TCA, in acute phase treatment of depressive disorder

DATA COLLECTION AND ANALYSIS

Two independent reviewers examined eligibility of the identified studies, and extracted data for outcomes at 1 week, 2 weeks, 4 weeks, 6-8 weeks and later. Main outcome measures were relative risk of response in depression (random effects model), according to the original authors' definition but usually defined as 50% or greater reduction in severity of depression according to the last-observation-carried-forward intention-to-treat method, and relative risks of overall dropouts and dropouts due to side effects. Other outcome measures included worst-case-scenario intention-to-treat analysis of response as defined above (in which dropouts were considered non-responders in the active treatment group and as responders in the comparison group), and standardised weighted mean scores of continuous depression severity scales (usually calculated by last-observation-carried-forward method).

MAIN RESULTS

35 studies (2013 participants) compared low dosage tricyclics with placebo, and six studies (551 participants) compared low dosage tricyclics with standard dosage tricyclics. Low dosage tricyclics, mostly between 75 and 100 mg/day, were 1.65 (95% confidence interval 1.36 to 2.0) and 1.47 (1.12 to 1.94) times more likely than placebo to bring about response at 4 weeks and 6-8 weeks, respectively. Standard dosage tricyclics failed, however, to bring about more response but produced more dropouts due to side effects than low dosage tricyclics.

REVIEWER'S CONCLUSIONS

Treatment of depression in adults with low dose tricyclics is justified. However, more rigorous studies are needed to definitively establish the relative benefits and harms of varying dosages.

Impact of the ICD-10 Primary Health Care (PHC) diagnostic and management guidelines for mental disorders on detection and outcome in primary care. Cluster randomised controlled trial

BACKGROUND

The World Health Organization (WHO) ICD-10 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (1996) have not been evaluated in a pragmatic randomised controlled trial (RCT).

AIMS

To evaluate the effect of local adaptation and dissemination of the guidelines.

METHOD

Pragmatic, pair-matched, cluster RCT involving 30 practices.

RESULTS

Guideline practices were less sensitive but more specific in identifying morbidity, but these differences were not significant. Guideline patients did not differ from usual-care patients on 12-item General Health Questionnaire scores at 3-month follow-up or in the proportion who were still cases. There were no significant differences in secondary outcomes.

CONCLUSIONS

Attempts to influence clinician behaviour through a process of adaptation and extension of guidelines are unlikely to change detection rates or outcomes.

A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems

Interprofessional education (IPE) is commonly advocated in policy documentation as a means of enhancing collaboration between heath and social care staff. However, little is known about the effects of this type of education. This paper reports findings from a systematic review which was commissioned to search and begin assessing the quality of the published evidence relating to the effects of IPE on staff involved in the care of adults with mental health problems. Results from this study indicate that there is a current lack of rigorous evidence into the effects of IPE in this field. Conclusions from this work are made in connection to mental health policy and recommendations are offered for strengthening the evaluation of IPE.

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.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology

A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.

Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial

BACKGROUND

Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression.

METHODS

We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat.

FINDINGS

The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve.

INTERPRETATION

Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.

Pragmatic randomised controlled trials in psychiatry

BACKGROUND

Randomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.

AIMS

To explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.

METHOD

A narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.

RESULTS

Obstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.

CONCLUSIONS

Researchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.