Patient-reported depression treatment and future treatment preferences: an observational study in general practice

Norwegian general practitioners' perceptions of their depression care - a national survey

BACKGROUND

The General Practitioner (GP) is often the first professional contact for patients with depression. Depression care constitutes a substantial part of GPs' workload.

OBJECTIVE

To assess how GPs experience their patients' expectations and their own provision of depression care; further, how their depression care was associated with doctor- and practice-characteristics.

METHODS

A cross-sectional questionnaire study about depression care in general practice among the GPs in the Norwegian Physician Survey of 2021.

RESULTS

Of the 221 responding GPs, 50% were female and 70% agreed to have constant time pressure due to workload. The GPs believed that patients with depression were interested in their professional assessment (87.2%) and saw them as providers of talking therapy (76,9%). Still, 77,8% of the GPs thought the patients expected a referral. Talking therapy was commonly provided (79.6%) along with consultations of more than 30 min (80.4%). The youngest age group and GPs with shorter patient lists spent more time. Most GPs (92.3%) considered their help to be of great benefit for depressed patients. However, one-fourth of the GPs did not feel competent in providing talking therapy, less frequently reported by the GPs aged 40-54 years.

CONCLUSIONS

Talking therapy is commonly provided by GPs. However, there is a need to investigate what GP talking therapy implies, and to strengthen GP skills in this regard. Overall, the GPs experience their depression care to be useful for their patients, and do not de-prioritize this although they experience workload pressure.

Depressive symptomatology in older adults treated with behavioral activation: A network perspective

BACKGROUND

Late-life depression is a serious mental health problem. Behavioral Activation (BA) is an effective, accessible psychotherapeutic treatment for older adults. However, little is known about which symptoms decrease and how associations between depressive symptoms change during BA treatment.

METHODS

Using data from a cluster-randomized trial for older adults with late-life depression, we estimated a partial correlation network and a relative importance network of depressive symptoms before and after 8 weeks of BA treatment in primary care (n = 96). Networks were examined with measures of network structure, connectivity, centrality as well as stability.

RESULTS

The most central symptoms at baseline and post-treatment were anhedonia, fatigue, and feeling depressed. In contrast, sleeping problems had the lowest centrality. The post-treatment network was significantly more interconnected than at baseline. Moreover, all symptoms were significantly more central at post-treatment.

CONCLUSION

Our findings highlight the utility of the network approach to better understand symptom networks of depressed older adults before and after BA treatment. Results show that network connectivity and centrality of all symptoms increased after treatment. Future studies should investigate longitudinal idiographic networks to explore symptom dynamics within individuals over time.

Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial

INTRODUCTION

Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the cost-effectiveness compared to treatment as usual (TAU) is unknown.

METHODS

An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios.

RESULTS

Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -€485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs.

DISCUSSION

Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.

Looking through the lens of stigma: Understanding and anticipating concerns about the responsible development and use of psychiatric electroceutical interventions (PEIs)

Psychiatric electroceutical interventions (PEIs) show promise for treating depression, but few studies have examined stakeholders' views on them. Using interview data and survey data that analyzed the views of psychiatrists, patients, caregivers, and the general public, a conceptual map was created to represent stakeholders' views on four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and adaptive brain implants (ABIs). Stigma emerged as a key theme connecting diverse views, revealing that it is a significant factor in the acceptance and usage of PEIs. Stigma not only discourages seeking mental health services for depression but also inhibits the acceptance of PEIs. Addressing the pervasive and complex effects of stigma highlights the need to change societal attitudes toward mental illnesses and their treatments and to provide support to patients who may benefit from these interventions. The map also demonstrates the value of conceptual mapping for anticipating and mitigating ethical considerations in the development and use of PEIs.

The 'discontinuity hypothesis' of depression in later life-clinical and research implications

The term depression is overused as an umbrella term for a variety of conditions, including depressed mood and various psychiatric disorders. According to psychiatric diagnostic criteria, depressive disorders impact nearly all aspects of human life and are a leading cause of disability worldwide. The widespread assumption that different types of depression lie on a continuum of severity has stimulated important research on subthreshold depression in later life. This view assumes that depressed mood is a precursor of a depressive disorder. The present narrative review argues why in later life depressed mood might either (i) lie on a continuum with depressive disorders among people vulnerable for a depressive disorder or (ii) be an ageing-related epiphenomenon of underlying physical illnesses in people who are resilient to depressive disorders ('discontinuity hypothesis'). Three arguments are discussed. First, the course of depressed mood and depressive disorders differs across the life span. Second, screening instruments for depression have low predictive value for depressive disorders in later life. Third, a dose-response relationship has not been consistently found across different types of depression and detrimental health outcomes. Using the umbrella term depression may partly explain why pharmacological treatment is less effective with increasing age, and negative health-related outcomes might be overestimated. The discontinuity hypothesis may prevent pharmacological overtreatment of milder subtypes of depression and may stimulate comprehensive multidisciplinary assessment as well as the development of separate treatment algorithms for depressed mood and depressive disorders.

Identifying depression and its determinants upon initiating treatment: ChatGPT versus primary care physicians

OBJECTIVE

To compare evaluations of depressive episodes and suggested treatment protocols generated by Chat Generative Pretrained Transformer (ChatGPT)-3 and ChatGPT-4 with the recommendations of primary care physicians.

METHODS

Vignettes were input to the ChatGPT interface. These vignettes focused primarily on hypothetical patients with symptoms of depression during initial consultations. The creators of these vignettes meticulously designed eight distinct versions in which they systematically varied patient attributes (sex, socioeconomic status (blue collar worker or white collar worker) and depression severity (mild or severe)). Each variant was subsequently introduced into ChatGPT-3.5 and ChatGPT-4. Each vignette was repeated 10 times to ensure consistency and reliability of the ChatGPT responses.

RESULTS

For mild depression, ChatGPT-3.5 and ChatGPT-4 recommended psychotherapy in 95.0% and 97.5% of cases, respectively. Primary care physicians, however, recommended psychotherapy in only 4.3% of cases. For severe cases, ChatGPT favoured an approach that combined psychotherapy, while primary care physicians recommended a combined approach. The pharmacological recommendations of ChatGPT-3.5 and ChatGPT-4 showed a preference for exclusive use of antidepressants (74% and 68%, respectively), in contrast with primary care physicians, who typically recommended a mix of antidepressants and anxiolytics/hypnotics (67.4%). Unlike primary care physicians, ChatGPT showed no gender or socioeconomic biases in its recommendations.

CONCLUSION

ChatGPT-3.5 and ChatGPT-4 aligned well with accepted guidelines for managing mild and severe depression, without showing the gender or socioeconomic biases observed among primary care physicians. Despite the suggested potential benefit of using atificial intelligence (AI) chatbots like ChatGPT to enhance clinical decision making, further research is needed to refine AI recommendations for severe cases and to consider potential risks and ethical issues.

Behavioural Activation versus Treatment as Usual for Depressed Older Adults in Primary Care: A Pragmatic Cluster-Randomised Controlled Trial

INTRODUCTION

Effective non-pharmacological treatment options for depression in older adults are lacking.

OBJECTIVE

The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated.

METHODS

In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up.

RESULTS

Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = -2.77, 95% CI = -4.19 to -1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42-1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = -1.53, 95% CI = -2.81 to -0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07-0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = -0.89 (-2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = -0.82 to 0.24).

CONCLUSIONS

BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.

The Frail Depressed Patient: A Narrative Review on Treatment Challenges

Although the public importance of frailty is widely acknowledged by the World Health Organization, physical frailty is still largely neglected in geriatric mental health care. Firstly in this narrative review, we summarize the knowledge on the epidemiology of the association between depression and frailty, whereafter implications for treatment will be discussed. Even though frailty and depression have overlapping diagnostic criteria, epidemiological studies provide evidence for distinct constructs which are bidirectionally associated. Among depressed patients, frailty has predictive validity being associated with increased mortality rates and an exponentially higher fall risk due to antidepressants. Nonetheless, guidelines on the treatment of depression neither consider frailty for risk stratification nor for treatment selection. We argue that frailty assessment enables clinicians to better target the pharmacological and psychological treatment of depression as well as the need for interventions targeting primarily frailty, for instance, lifestyle interventions and reduction of polypharmacy. Applying a frailty informed framework of depression treatment studies included in a meta-analysis reveals that the benefit–harm ratio of antidepressants given to frail depressed patients can be questioned. Nonetheless, frail-depressed patients should not withhold antidepressants as formal studies are not available yet, but potential adverse effects should be closely monitored. Dopaminergic antidepressants might be preferable when slowness is a prominent clinical feature. Psychotherapy is an important alternative for pharmacological treatment, especially psychotherapeutic approaches within the movement of positive psychology, but this approach needs further study. Finally, geriatric rehabilitation, including physical exercise and nutritional advice, should also be considered. In this regard, targeting ageing-related abnormalities underlying frailty that may also be involved in late-life depression such as low-grade inflammation might be a promising target for future studies. The lack of treatment studies precludes firm recommendations, but more awareness for frailty in mental health care will open a plethora of alternative treatment options to be considered.

Patient experiences with depression care in general practice: a qualitative questionnaire study

OBJECTIVE

To investigate patient experiences and preferences regarding depression care in general practice.

DESIGN AND SETTING

A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis.

SUBJECTS

250 persons completed the web-based survey, 86% were women.

RESULTS

The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful.

CONCLUSIONS

Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment.KEY POINTSDepression is common, and GPs are often patients' first point of contact when they seek help.  • Patients who feel depressed appreciate help from their GP.  • Patients prefer an empathetic GP who listens attentively and acknowledges their problems.  • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.

Barriers and opportunities for the treatment of mild-to-moderate depression with a watchful waiting approach

OBJECTIVE

The aim of this study is to explore barriers and opportunities in non-pharmacological treatment of depression in primary care (PC) from the perspective of family physicians (FPs).

METHODS

Qualitative analysis was used to explore a sample of 36 FPs treating patients with depressive symptoms. Criteria to maximize variability were followed. Participants were identified by key informants. Six group interviews were developed following a semi-structured thematic script. All interviews were transcribed, analyzed and triangulated. Information was saturated. Principals of reflexivity and circularity were implemented.

RESULTS

The results obtained followed 3 main theoretical axes: the FP, the patient, the healthcare system, and the interaction between them. Barriers included poor alignment with clinical practice guidelines, inadequate FP training, patients' preferences and structural challenges in PC. Among opportunities were good FP clinical interview skills, the beneficial bond of trust between patients and FPs and improved communication with mental healthcare services.

CONCLUSION

Based on FPs' perceptions, non-pharmacological treatment of depression in PC is particularly limited by lack of structured training; patients' preferences and treatment expectations; structural challenges in PC; and insufficient support from specialized mental health professionals.

PRACTICE IMPLICATIONS

Resources for education, structural support in PC and modified back up from mental healthcare services are needed.

GPs' drug treatment for depression by patients' educational level: registry-based study

Background

Antidepressant drugs are often prescribed in general practice. Evidence is conflicting on how patient education influences antidepressant treatment.

Aim

To investigate the association between educational attainment and drug treatment in adult patients with a new depression diagnosis, and to what extent sex and age influence the association.

Design & setting

A nationwide registry-based cohort study was undertaken in Norway from 2014–2016.

Method

The study comprised all residents of Norway born before 1996 and alive in 2015. Information was obtained on all new depression diagnoses in general practice in 2015 (primary care database) and data on all dispensed depression medication (Norwegian Prescription Database [NorPD]) 12 months after the date of diagnosis. Independent variables were education, sex, and age. Associations with drug treatment were estimated using a Cox proportional hazard model and performed separately for sex.

Results

Out of 49 967 patients with new depression (61.6% women), 15 678 were dispensed drugs (30.4% women, 33.0% men). Highly educated women were less likely to receive medication (hazard ratio [HR] = 0.93; 95% confidence interval [CI] = 0.88 to 0.98) than women with low education. No such differences appeared among men. Women aged 20–29 years were more likely to be treated with drugs than those aged 30–59 years, and women aged ≥70 years were more likely to receive drugs (HR = 1.65; 95% CI = 1.54 to 1.77) than those aged 20–29 years. The pattern was similar but less pronounced for men.

Conclusion

Educational differences in antidepressant therapy among women may reflect different treatment approaches that clinicians should be aware of to avoid unintended variation. Reasons for this variation and consequences for quality of treatment should be explored.