The development of valid subtypes for depression in primary care settings: a preliminary study using an explanatory model approach

Attitudes towards depression and its treatment among white, hispanic, and multiracial adults

BACKGROUND

Depression is present in all societies and affects members of all racial and ethnic groups. However, attitudes about depression differ across groups and have been shown to impact help-seeking behaviors, preferences for treatments, and compliance with treatments.

METHODS

Taking a cross-cultural approach, this project used a case vignette of depression to examine race/ethnic group differences in attitudes about depression and its treatment among young adults in the U.S.

RESULTS

Data analyses revealed significant racial/ethnic group differences in attitudes as well as the treatments/strategies participants reported they would use. Gender x race/ethnicity interactions revealed that White and Multiracial/ethnic men were more likely to believe the vignette character should find a partner to help with symptoms, while White and Multiracial/ethnic women did not endorse those strategies. Hispanic men and women did not show a gender difference in that strategy, but gender differences were observed in other strategies. In a rare comparison, majority-minority Multiracial/ethnic participants (i.e., White selected as one of their races/ethnicities) rated identified helpers and treatments similarly to White participants and significantly higher than multiple-minority Multiracial participants (i.e., White not selected as one of their races/ethnicities).

CONCLUSIONS

Findings supported previous research that indicates different U.S. racial/ethnic group ideas of depression and its treatment are potentially linked with cultural values, and we suggest that investigating these more fine-grained group differences can help to inform treating professionals as well as public health messages.

A distress-continuum, disorder-threshold model of depression: a mixed-methods, latent class analysis study of slum-dwelling young men in Bangladesh

BACKGROUND

Binary categorical approaches to diagnosing depression have been widely criticized due to clinical limitations and potential negative consequences. In place of such categorical models of depression, a 'staged model' has recently been proposed to classify populations into four tiers according to severity of symptoms: 'Wellness;' 'Distress;' 'Disorder;' and 'Refractory.' However, empirical approaches to deriving this model are limited, especially with populations in low- and middle-income countries.

METHODS

A mixed-methods study using latent class analysis (LCA) was conducted to empirically test non-binary models to determine the application of LCA to derive the 'staged model' of depression. The study population was 18 to 29-year-old men (n = 824) from an urban slum of Bangladesh, a low resource country in South Asia. Subsequently, qualitative interviews (n = 60) were conducted with members of each latent class to understand experiential differences among class members.

RESULTS

The LCA derived 3 latent classes: (1) Severely distressed (n = 211), (2) Distressed (n = 329), and (3) Wellness (n = 284). Across the classes, some symptoms followed a continuum of severity: 'levels of strain', 'difficulty making decisions', and 'inability to overcome difficulties.' However, more severe symptoms such as 'anhedonia', 'concentration issues', and 'inability to face problems' only emerged in the severely distressed class. Qualitatively, groups were distinguished by severity of tension, a local idiom of distress.

CONCLUSIONS

The results indicate that LCA can be a useful empirical tool to inform the 'staged model' of depression. In the findings, a subset of distress symptoms was continuously distributed, but other acute symptoms were only present in the class with the highest distress severity. This suggests a distress-continuum, disorder-threshold model of depression, wherein a constellation of impairing symptoms emerge together after exceeding a high level of distress, i.e., a tipping point of tension heralds a host of depression symptoms.

The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months' follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, -9.2 ± 0.8 95% CI -10.9, -7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

Understanding the body-mind in primary care

Patients' experience of symptoms does not follow the body-mind divide that characterizes the classification of disease in the health care system. Therefore, understanding patients in their entirety rather than in parts demands a different theoretical approach. Attempts have been made to formulate such approaches but many of these, such as the biopsychosocial model, are still basically dualistic or methodologically reductionist. In primary care, patients often present with diffuse symptoms, making primary care the ideal environment for understanding patients' undifferentiated symptoms and disease patterns which could readily fit both bodily and mental categories. In this article we discuss theoretical models that have attempted to overcome this challenge: The psychosomatic approach could be called holistic in the sense of taking an anti-dualistic stance. Primary care theorists have formulated integrative views but these have not gained a foothold in primary care medicine. McWhinney introduced a new metaphor, 'the body-mind', and Rudebeck advocated cultivating 'bodily empathy'. These views have much in common with both phenomenological thinking and mentalization, a psychological concept for understanding others. In the process of understanding patients there is a need for the physician to enter an intersubjectivity that aims at understanding the patient's experiences and sensations without initially jumping to diagnostic conclusions or into a division into mental and physical phenomena. Mentalization theory could form the basis of an approach to a more comprehensive understanding of patients. The success of such an approach is, however, dependent upon structural and organizational conditions that do not counteract it.

Why underserved patients do not consult their general practitioner for depression: results of a qualitative and a quantitative survey at a free outpatient clinic in Paris, France

BACKGROUND

The prevalence of depression in the general population is 5 to 10% but can exceed 50% in the most socially vulnerable populations. The perceptions of this disease are widely described in the literature, but no research has been carried out in France to explain the reasons for not consulting a general practitioner during a depressive episode, particularly in people in the most precarious situations. The objective of this study was to describe the reasons for not seeking primary care during a depressive episode in a socially vulnerable population.

METHODS

An exploratory sequential design with a preliminary qualitative study using a phenomenological approach. Subsequently, themes that emerged from the qualitative analysis were used in a questionnaire administered in a cross-sectional observational study at a free outpatient clinic in Paris in 2010. Lastly, a logistic regression analysis was performed.

RESULTS

The qualitative analysis revealed four aspects that explain the non-consulting of a general practitioner during a depressive episode: the negative perception of treatment, the negative perception of the disease, the importance of the social environment, and the doctor-patient relationship. The quantitative analysis showed that close to 60% of the patients who visited the free clinic were depressed and that only half of them had talked with a care provider. The results of the statistical analysis are in line with those of the qualitative analysis, since the most common reasons for not seeing a general practitioner were the negative perception of the disease (especially among the men and foreigners) and its treatments (more often among the men and French nationals).

CONCLUSIONS

Close to 50% of the depressed individuals did not seek primary care during a depressive episode, and close to 80% of them would have liked their mental health to be discussed more often by a health professional. Better information on depression and its treatments, and more-systematic screening by primary care personnel would improve the treatment of depressed patients, especially those in the most precarious situations.

What is depression? Psychiatrists' and GPs' experiences of diagnosis and the diagnostic process

The diagnosis of depression is defined by psychiatrists, and guidelines for treatment of patients with depression are created in psychiatry. However, most patients with depression are treated exclusively in general practice. Psychiatrists point out that general practitioners' (GPs') treatment of depression is insufficient and a collaborative care (CC) model between general practice and psychiatry has been proposed to overcome this. However, for successful implementation, a CC model demands shared agreement about the concept of depression and the diagnostic process in the two sectors. We aimed to explore how depression is understood by GPs and clinical psychiatrists. We carried out qualitative in-depth interviews with 11 psychiatrists and 12 GPs. Analysis was made by Interpretative Phenomenological Analysis. We found that the two groups of physicians differed considerably in their views on the usefulness of the concept of depression and in their language and narrative styles when telling stories about depressed patients. The differences were captured in three polarities which expressed the range of experiences in the two groups. Psychiatrists considered the diagnosis of depression as a pragmatic and agreed construct and they did not question its validity. GPs thought depression was a "gray area" and questioned the clinical utility in general practice. Nevertheless, GPs felt a demand from psychiatry to make their diagnosis based on instruments created in psychiatry, whereas psychiatrists based their diagnosis on clinical impression but used instruments to assess severity. GPs were wholly skeptical about instruments which they felt could be misleading. The different understandings could possibly lead to a clash of interests in any proposed CC model. The findings provide fertile ground for organizational research into the actual implementation of cooperation between sectors to explore how differences are dealt with.

General practitioners' and psychiatrists' responses to emotional disclosures in patients with depression

OBJECTIVE

To investigate general practitioners' (GPs') and psychiatrists' responses to emotional disclosures in consultations with patients with depression.

METHODS

Thirteen patient consultations with GPs and 17 with psychiatrists were video-recorded and then analyzed using conversation analysis (CA).

RESULTS

Psychiatrists responded to patients' emotional disclosures by attempting to clarify symptoms, by rational argumentation, or by offering an interpretation of the emotions from their own perspectives. GPs responded by claiming to understand the emotions or by formulating the patients' statements, but without further exploring the emotions.

CONCLUSION

GPs displayed a greater engagement with patients' emotions than psychiatrists. Their approach could be described as empathic, corresponding to a mentalizing stance. The different approaches taken by psychiatrists could represent conceptual differences and might affect fruitful interdisciplinary work. Psychiatric nurses' responses to patients' emotions must also be studied to complete our knowledge from psychiatry.

PRACTICE IMPLICATIONS

Experiences from training in mentalization could be used to develop physicians' empathic or mentalizing approach. As most patients with depression are treated in primary care, developing GPs' mentalizing capacity instead of offering didactic training could have a substantial effect in the population.

Differences in neurobiological pathways of four "clinical content" subtypes of depression

Although often considered as a mental disorder, depression is best described as a behavioral-neurobiological phenomenon. In addition, although usually reported as a unitary diagnosis, major depressive episode is composed of a range of different symptoms that can occur in nearly 1500 possible combinations to fulfill the required diagnostic criterion. To investigate and describe the underlying behavioral and neurobiological substrates of these symptoms, they were clustered into "clinical content" subtypes of depression according to their predominant common behavioral characteristics. These subtypes were then found to possess different neurobiological pathways that argue for different treatment approaches.

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

BACKGROUND

Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment.

AIM

The study sought to understand conversational influences on physician decision making about treatment for depression.

DESIGN

A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication.

METHOD

The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.

RESULTS

Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.

CONCLUSION

Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the 'action' in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients' views and preferences.

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.

Psychophysiologic treatment for patients with medically unexplained symptoms: a randomized controlled trial

BACKGROUND

Patients presenting with medically unexplained physical symptoms (MUPS) typically present with significant distress and marked impairment in functioning and pose a unique challenge to health care providers. The purpose of this study was to examine the efficacy of a psychophysiological treatment (PT) for MUPS.

METHODS

Thirty-eight participants meeting criteria for subthreshold somatization disorder (abridged somatization) were randomly assigned to one of two conditions: (1) standard medical care augmented by a psychiatric consultation intervention (wait-list) or (2) a 10-session, manualized, individually-administered PT added to the psychiatric consultation intervention. Assessments were conducted at baseline, at midpoint (after four sessions), and after completing the last session. The primary outcome measure was the severity scale of the Clinical Global Impression Scale anchored for Somatic Symptoms (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-report measures of mental and physical functioning.

RESULTS

At the end of the trial, the severity (and frequency) of physical symptoms improved significantly more (p<0.05) in the intervention group. The average improvement in the CGI-SD was 0.80 points greater in the intervention group than in the wait-list group. PT was also associated with greater improvements in self-reported functioning and depressive symptomatology. The effect sizes at the final assessment point indicate that this intervention had a robust effect on complex somatic symptom presentations.

CONCLUSION

For patients with high levels of MUPS (abridged somatization), PT produces significant improvements in symptoms and functional status.

Relational barriers to depression help-seeking in primary care

OBJECTIVE

To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.

METHODS

Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25-64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.

RESULTS

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs' knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.

CONCLUSION

Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs' mental health-related capabilities and interests.

PRACTICE IMPLICATIONS

PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

Depression treatment preferences of Hispanic individuals: exploring the influence of ethnicity, language, and explanatory models

PURPOSE

there is uncertainty regarding Hispanic individuals' depression treatment preferences, particularly regarding antidepressant medication, the most available primary care option. We assessed whether this uncertainty reflected heterogeneity among subgroups of Hispanic persons and investigated possible mechanisms. Specifically, we examined factors associated with medication preferences in non-Hispanic white and Spanish-speaking and English-speaking Hispanic persons.

METHODS

we analyzed data from a follow-up telephone interview of 839 non-Hispanic white and 139 Hispanic respondents originally surveyed via the 2008 California Behavioral Risk Factor Surveillance System. Measures included treatment preferences (for treatment plans including vs not including antidepressants); depression history and current symptoms; sociodemographics; and psychological measures.

RESULTS

compared with non-Hispanic white respondents (adjusting for age, sex, history of depression diagnosis, and current depression symptoms), Spanish-speaking Hispanic (adjusted odds ratio [AOR] 0.41; 95% CI, 0.19-0.90) but not English-speaking Hispanic (AOR, 1.18; 95% CI, 0.60-2.33) respondents had a lower preference for antidepressant inclusive options. Endorsing a biomedical explanation of depression was associated with a preference for antidepressant inclusive options (AOR, 4.76; 95% CI, 3.13-7.14) for all respondents and accounted for the effect of Spanish-language interview. Accounting for other factors did not change these relationships, although older age and history of depression diagnosis remained significant predictors of antidepressant inclusive treatment preference for all respondents.

CONCLUSIONS

Spanish-language interview and less belief in a biomedical explanation for depression were associated with Hispanic respondents' lower preferences for pharmacologic treatment of depression; ethnicity was not. Understanding treatment preferences and illness beliefs could help optimize depression treatment in primary care.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

OBJECTIVE

We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.

METHODS

We explore the characteristics and techniques of patient-clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.

RESULTS

We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.

CONCLUSIONS

It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes.

"I didn't know what was wrong:" how people with undiagnosed depression recognize, name and explain their distress

BACKGROUND

Diagnostic and treatment delay in depression are due to physician and patient factors. Patients vary in awareness of their depressive symptoms and ability to bring depression-related concerns to medical attention.

OBJECTIVE

To inform interventions to improve recognition and management of depression in primary care by understanding patients' inner experiences prior to and during the process of seeking treatment.

DESIGN

Focus groups, analyzed qualitatively.

PARTICIPANTS

One hundred and sixteen adults (79% response) with personal or vicarious history of depression in Rochester NY, Austin TX and Sacramento CA. Neighborhood recruitment strategies achieved sociodemographic diversity.

APPROACH

Open-ended questions developed by a multidisciplinary team and refined in three pilot focus groups explored participants' "lived experiences" of depression, depression-related beliefs, influences of significant others, and facilitators and barriers to care-seeking. Then, 12 focus groups stratified by gender and income were conducted, audio-recorded, and analyzed qualitatively using coding/editing methods.

MAIN RESULTS

Participants described three stages leading to engaging in care for depression - "knowing" (recognizing that something was wrong), "naming" (finding words to describe their distress) and "explaining" (seeking meaningful attributions). "Knowing" is influenced by patient personality and social attitudes. "Naming" is affected by incongruity between the personal experience of depression and its narrow clinical conceptualizations, colloquial use of the word depression, and stigma. "Explaining" is influenced by the media, socialization processes and social relations. Physical/medical explanations can appear to facilitate care-seeking, but may also have detrimental consequences. Other explanations (characterological, situational) are common, and can serve to either enhance or reduce blame of oneself or others.

CONCLUSIONS

To improve recognition of depression, primary care physicians should be alert to patients' ill-defined distress and heterogeneous symptoms, help patients name their distress, and promote explanations that comport with patients' lived experience, reduce blame and stigma, and facilitate care-seeking.

Recognition of depression in people of different cultures: a qualitative study

BACKGROUND

Many minority group patients who attend primary health care are depressed. To identify a depressive state when GPs see patients from other cultures than their own can be difficult because of cultural and gender differences in expressions and problems of communication. The aim of this study was to explore and analyse how GPs think and deliberate when seeing and treating patients from foreign countries who display potential depressive features.

METHODS

The data were collected in focus groups and through individual interviews with GPs in northern Sweden and analysed by qualitative content analysis.

RESULTS

In the analysis three themes, based on various categories, emerged; "Realizing the background", "Struggling for clarity" and "Optimizing management". Patients' early life events of importance were often unknown which blurred the accuracy. Reactions to trauma, cultural frictions and conflicts between the new and old gender norms made the diagnostic process difficult. The patient-doctor encounter comprised misconceptions, and social roles in the meetings were sometimes confused. GPs based their judgement mainly on clinical intuition and the established classification of depressive disorders was discussed. Tools for management and adequate action were diffuse.

CONCLUSION

Dialogue about patients' illness narratives and social context are crucial. There is a need for tools for multicultural, general practice care in the depressive spectrum. It is also essential to be aware of GPs' own conceptions in order to avoid stereotypes and not to under- or overestimate the occurrence of depressive symptoms.