Primary care patients with depression are less accepting of treatment than those seen by mental health specialists

Heterogeneity in Antidepressant Treatment and Major Depressive Disorder Outcomes Among Clinicians

Importance

While abundant work has examined patient-level differences in antidepressant treatment outcomes, little is known about the extent of clinician-level differences. Understanding these differences may be important in the development of risk models, precision treatment strategies, and more efficient systems of care.

Objective

To characterize differences between outpatient clinicians in treatment selection and outcomes for their patients diagnosed with major depressive disorder across academic medical centers, community hospitals, and affiliated clinics.

Design, Setting, and Participants

This was a longitudinal cohort study using data derived from electronic health records at 2 large academic medical centers and 6 community hospitals, and their affiliated outpatient networks, in eastern Massachusetts. Participants were deidentified clinicians who billed at least 10 International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) diagnoses of major depressive disorder per year between 2008 and 2022. Data analysis occurred between September 2023 and January 2024.

Main Outcomes and Measures

Heterogeneity of prescribing, defined as the number of distinct antidepressants accounting for 75% of prescriptions by a given clinician; proportion of patients who did not return for follow-up after an index prescription; and proportion of patients receiving stable, ongoing antidepressant treatment.

Results

Among 11 934 clinicians treating major depressive disorder, unsupervised learning identified 10 distinct clusters on the basis of ICD codes, corresponding to outpatient psychiatry as well as oncology, obstetrics, and primary care. Between these clusters, substantial variability was identified in the proportion of selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and tricyclic antidepressants prescribed, as well as in the number of distinct antidepressants prescribed. Variability was also detected between clinician clusters in loss to follow-up and achievement of stable treatment, with the former ranging from 27% to 69% and the latter from 22% to 42%. Clinician clusters were significantly associated with treatment outcomes.

Conclusions and Relevance

Groups of clinicians treating individuals diagnosed with major depressive disorder exhibit marked differences in prescribing patterns as well as longitudinal patient outcomes defined by electronic health records. Incorporating these group identifiers yielded similar prediction to more complex models incorporating individual codes, suggesting the importance of considering treatment context in efforts at risk stratification.

PATHway: Intervention optimization of a prevention program for adolescents at-risk for depression in the primary care setting

With as many as 13% of adolescents diagnosed with depressive disorders each year, prevention of depressive disorders has become a key priority for the National Institute of Mental Health (NIMH). Currently, we have no widely available interventions to prevent these disorders. To address this need, we developed a multi-health system collaboration to develop and evaluate the primary care based technology "behavioral vaccine," Competent Adulthood Transition with Cognitive-Behavioral Humanistic and Interpersonal Therapy (CATCH-IT). The full CATCH-IT program demonstrated evidence of efficacy in prevention of depressive episodes in clinical trials. However, CATCH-IT became larger and more complex across trials, creating issues with adherence and scalability. We will use a multiphase optimization strategy approach to optimize CATCH-IT. The theoretically grounded components of CATCH-IT include: behavioral activation, cognitive-behavioral therapy, interpersonal psychotherapy, and parent program. We will use a 4-factor (2x2x2x2) fully crossed factorial design with N = 16 cells (25 per cell, after allowing 15% dropout) to evaluate the contribution of each component. Eligible at-risk youth will be high school students 13 through 18 years old, with subsyndromal symptoms of depression. The study design will enable us to eliminate non-contributing components while preserving efficacy and to optimize CATCH-IT by strengthening tolerability and scalability by reducing resource use. By reducing resource use, we anticipate satisfaction and acceptability will also increase, preparing the way for an implementation trial.

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis

PURPOSE

Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care.

METHODS

We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool.

RESULTS

Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness.

LIMITATIONS

The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety.

CONCLUSIONS

E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.

A Social Media Website (Supporting Our Valued Adolescents) to Support Treatment Uptake for Adolescents With Depression and/or Anxiety and Their Parents: Protocol for a Pilot Randomized Controlled Trial

Background

Few adolescents who experience depression or anxiety connect to mental health treatment. Supporting Our Valued Adolescents (SOVA) is a stakeholder-informed technology intervention that consists of 2 blog-format websites—one for adolescents and another for parents. SOVA is designed to intervene on targets, which may increase the mental health treatment uptake when adolescents with depression or anxiety are identified in primary care settings.

Objective

This study aims to describe the protocol for a pilot randomized controlled trial designed to refine recruitment and retention strategies, document intervention fidelity and implementation outcomes, and assess changes in health beliefs and knowledge, emotional or informational support, and parent-adolescent communication quality in adolescents and their parents.

Methods

Adolescents identified with symptoms of depression or anxiety, for which a health care provider recommends treatment, and their parents will be recruited from clinics where adolescents are seen for primary care. Adolescent-parent dyads will be randomized at 1:1 to both receive the SOVA websites and enhanced usual care or enhanced usual care alone. Baseline measures and 6-week and 3-month outcomes will be collected by Web-based self-report surveys and electronic health record review. The main pilot outcome is the 6-week study retention rate. Analyses will also assess changes in health beliefs and knowledge, emotional support, and parent-adolescent communication in both adolescents and their parents.

Results

The project was funded in 2017. Recruitment commenced in April 2018 and enrollment is ongoing, with completion anticipated at the end of 2019 with subsequent plans for data analysis and publication submission in early 2020.

Conclusions

The findings of this research will inform the design of a multisite hybrid effectiveness-implementation randomized controlled trial examining the effectiveness and optimal implementation strategies for using SOVA in community primary care settings.

Trial Registration

ClinicalTrials.gov NCT03318666; https://clinicaltrials.gov/ct2/show/NCT03318666

International Registered Report Identifier (IRRID)

PRR1-10.2196/12117

Treatment Initiation for New Episodes of Depression in Primary Care Settings

BACKGROUND

Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment.

OBJECTIVE

To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings.

DESIGN

A retrospective observational design was used to analyze electronic health record data.

PATIENTS

A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013.

MAIN MEASURES

ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis.

KEY RESULTS

Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged  ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication.

CONCLUSIONS

Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.

Assessing Cognitive Representations of Antidepressants: Development and Validation of the Attitudes Toward Medication–Depression Inventory

Antidepressant drugs represent the mainstay of treatment for depression; however, nonadherence is a major problem. Attitudes are predictors of long-term adherence and drive medication use. The Attitudes Toward Medication–Depression (ATM-D) Inventory was developed and tested with 131 patients in primary care settings who reported a diagnosis of depression. Content validity was assessed by experts with a 94.4% agreement on item relevancy. Exploratory factor analysis showed three factors (course of medication treatment, identity, and control) that accounted for 57% of the total variance in the final 17-item scale. The instrument demonstrated good internal consistency reliability (α = .76-.84) and test–retest reliability (α = .74-.83). Results support the construct validity and reliability of the instrument and revealed unique insights into patients’ cognitive representations of their antidepressants. This study supported that patients have cognitive representations related to depression and antidepressants that go beyond simple concerns about the effects of the medication.

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity

BACKGROUND

Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

METHODS

In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

RESULTS

The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

LIMITATIONS

Moderate sample size. Data collected in 2002-2004.

CONCLUSIONS

The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.

The Rise of Primary Care Physicians in the Provision of US Mental Health Care

Primary care physicians have assumed an increasingly important role in US outpatient mental health care. They are providing an increasing volume of outpatient mental health services, prescribing a growing number and variety of psychotropic medications, and treating patients with a broader array of mental health conditions. These trends, which run counter to a general trend toward specialization and subspecialization within US health care, place new strains on the clinical competencies of primary care physicians. They also underscore the importance of implementing more effective models of collaboration between primary care physicians and mental health specialists. Several elements of the Affordable Care Act provide options for financing and organizing the delivery of integrated general medical and behavioral services. Such integrated services have the potential to improve access and quality of outpatient mental health care for a range of psychiatric disorders. Because people with severe and persisting mental disorders commonly require a higher-level medical expertise than is readily available within primary care as well as a complex array of social services, separate specialized mental health will likely continue to play a vitally important role in caring for this population.

Stigma, Attitudes, and Help-Seeking Intentions for Psychological Problems in Relation to Regional Suicide Rates

In this ecological study, we investigated whether help-seeking related to stigma, intentions, and attitudes toward suicide are associated with the suicide rates of 20 regions within the Netherlands and Belgium. Significant associations were found between regional suicide rates and the intention to seek informal help (β = -1.47, p = .001), self-stigma (β = 1.33, p = .038), and shame (β = .71, p = .030). The association between self-stigma and suicide rate was mediated by intentions to seek informal help. These results suggest that to promote suicide prevention at the level of the regional population, stigma, shame, and intentions to seek help should be targeted in the public domain.

Development of a technology-based behavioral vaccine to prevent adolescent depression: A health system integration model

Efforts to prevent depression have become a key health system priority. Currently, there is a high prevalence of depression among adolescents, and treatment has become costly due to the recurrence patterns of the illness, impairment among patients, and the complex factors needed for a treatment to be effective. Primary care may be the optimal location to identify those at risk by offering an Internet-based preventive intervention to reduce costs and improve outcomes. Few practical interventions have been developed. The models for Internet intervention development that have been put forward focus primarily on the Internet component rather than how the program fits within a broader context. This paper describes the conceptualization for developing technology based preventive models for primary care by integrating the components within a behavioral vaccine framework. CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training) has been developed and successfully implemented within various health systems over a period of 14 years among adolescents and young adults aged 13-24.

Differences in patients' perceived helpfulness of depression treatment provided by general medical providers and specialty mental health providers

OBJECTIVE

This study examined the differences in the level of perceived helpfulness of treatments received for a major depressive episode (MDE) from a general medical provider only, a specialty mental health provider only or both.

METHOD

This study examined a sample of 8900 respondents from the 2008-2012 National Survey on Drug Use and Health aged 18-64 who had past 12-month MDE (based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition) and received treatment for depression. Generalized ordered logistic regression analyses were conducted to estimate the association between the type of treatment providers and perceived helpfulness of depression treatment.

RESULTS

Adults who received depression treatment from either specialty mental health providers alone or from both specialty mental health providers and general medical providers in the past year were more likely to report that treatment helped them. The differences persisted after adjusting for sociodemographic characteristics, comorbid health conditions, receipt of depression medication and severity of depression (adjusted odds ratios across level of perceived helpfulness ranged from 1.63 to 3.96).

CONCLUSIONS

This finding calls for greater attention to factors associated with provider type and organizational context that may contribute to differences in perceived helpfulness of depression treatment.

Pilot Study of Implementation of an Internet-Based Depression Prevention Intervention (CATCH-IT) for Adolescents in 12 US Primary Care Practices: Clinical and Management/Organizational Behavioral Perspectives

OBJECTIVE

To explore the implementation of CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral Humanistic and Interpersonal Training), an Internet-based depression intervention program in 12 primary care sites, occurring as part of a randomized clinical trial comparing 2 versions of the intervention (motivational interview + Internet program versus brief advice + Internet program) in 83 adolescents aged 14 to 21 years recruited from February 1, 2007, to November 31, 2007.

METHOD

The CATCH-IT intervention model consists of primary care screening to assess risk, a primary care physician interview to encourage participation, and 14 online modules of Internet training to teach adolescents how to reduce behaviors that increase vulnerability to depressive disorders. Specifically, we evaluated this program from both a management/organizational behavioral perspective (provider attitudes and demonstrated competence) and a clinical outcomes perspective (depressed mood scores) using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, and Maintenance of the intervention).

RESULTS

While results varied by clinic, overall, clinics demonstrated satisfactory reach, efficacy, adoption, implementation, and maintenance of the CATCH-IT depression prevention program. Measures of program implementation and management predicted clinical outcomes at practices in exploratory analyses.

CONCLUSION

Multidisciplinary approaches may be essential to evaluating the impact of complex interventions to prevent depression in community settings. Primary care physicians and nurses can use Internet-based programs to create a feasible and cost-effective model for the prevention of mental disorders in adolescents in primary care settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT00152529 and NCT00145912.

Randomized Clinical Trial of a Primary Care Internet-based Intervention to Prevent Adolescent Depression: One-year Outcomes

OBJECTIVE

We developed a primary care/Internet-based intervention for adolescents at risk for depression (CATCH-IT, Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training). This phase II clinical trial compares two forms of primary care provider (PCP) engagement (motivational interview [MI] and brief advice [BA]) for adolescents using the Internet program.

METHOD

ADOLESCENTS SCREENING POSITIVE FOR DEPRESSION WERE RECRUITED FROM PRIMARY CARE PRACTICES AND RANDOMLY ASSIGNED TO A VERSION OF THE INTERVENTION: PCP MI + Internet program or PCP BA + Internet program. Between-group and within-group comparisons were conducted on depressive disorder outcome measures at baseline and one-year post-enrollment. Regression analyses examined factors predicting declines in depressed mood.

RESULTS

Both groups demonstrated significant within-group decreases in depressed mood, loneliness, and self-harm ideation. While no between-group differences were noted in depressed mood or depressive disorder measures at one-year, fewer participants in the MI group had experienced a depressive episode. Greater participant automatic negative thoughts and more favorable ratings of a component of the Internet-based training experience predicted declines in depressed mood at one-year.

CONCLUSIONS

A primary care/Internet-based intervention for depression prevention demonstrated sustained reductions in depressed mood, and, when coupled with motivational interviewing, reduction in the likelihood of being diagnosed with a depressive episode. This tool may help extend the services at the disposal of a primary care provider and can provide a bridge for adolescents at risk for depression prior to referral to mental health specialists.

Economic factors in of patients' nonadherence to antidepressant treatment

PURPOSE

Patients' nonadherence to antidepressant treatment hampers cost and efficacy of depression-specific treatment. However, previous studies have failed to find consistent findings in economic effect on nonadherence and also failed to reach consensus in how to measure nonadherence to treatment. The study attempts to investigate income effect on nonadherence to selective serotonin reuptake inhibitors (SSRIs) treatment with clear definitions of nonadherence: self discontinuation of SSRIs (nonpersistence) and under-dose of SSRIs (noncompliance).

METHODS

The study extracted data from the National Comorbidity Survey-Replication (NCS-R). The study sample (n = 280) includes adults between the ages of 18 and 64 who were diagnosed with Diagnostic Statistics Manual IV Major Depressive Episode (MDE) at some point during their lifetime and medicated with SSRIs in the past 12 months.

RESULTS

Just above poverty level of family income and no health insurance increased the risk of medication nonpersistence in SSRIs treatment. The study findings confirmed that African Americans were at higher risk of medication noncompliance than Whites (odds ratio, 4.53) and MDE comorbidity was positively associated with medication noncompliance (odds ratio, 4.25).

CONCLUSIONS

Low income level, combined with health insurance status, and race/ethnicity, predict nonadherence to antidepressant treatment. The study findings would help physicians and hospitals developing interventional strategies and programs to increase patients' adherence rates in antidepressant treatment.

Development and pilot study of a marketing strategy for primary care/internet-based depression prevention intervention for adolescents (the CATCH-IT intervention)

BACKGROUND

Adolescent depression is both common and burdensome, and while evidence-based strategies have been developed to prevent adolescent depression, participation in such interventions remains extremely low, with less than 3% of at-risk individuals participating. To promote participation in evidence-based preventive strategies, a rigorous marketing strategy is needed to translate research into practice.

OBJECTIVE

To develop and pilot a rigorous marketing strategy for engaging at-risk individuals with an Internet-based depression prevention intervention in primary care targeting key attitudes and beliefs.

METHOD

A marketing design group was constituted to develop a marketing strategy based on the principles of targeting, positioning/competitor analysis, decision analysis, and promotion/distribution and incorporating contemporary models of behavior change. We evaluated the formative quality of the intervention and observed the fielding experience for prevention using a pilot study (observational) design.

RESULTS

The marketing plan focused on "resiliency building" rather than "depression intervention" and was relayed by office staff and the Internet site. Twelve practices successfully implemented the intervention and recruited a diverse sample of adolescents with > 30% of all those with positive screens and > 80% of those eligible after phone assessment enrolling in the study with a cost of $58 per enrollee. Adolescent motivation for depression prevention (1-10 scale) increased from a baseline mean value of 7.45 (SD = 2.05) to 8.07 poststudy (SD = 1.33) (P = .048).

CONCLUSIONS

Marketing strategies for preventive interventions for mental disorders can be developed and successfully introduced and marketed in primary care.

[Views of patients diagnosed with depression and cared for by general practitioners and psychiatrists]

OBJECTIVES

To explore the experiences of patients treated for depression either by general practitioners (GPs) or psychiatrists (Ps) with the aim of identifying improvement strategies.

DESIGN

Health services research-oriented qualitative methodology. Exploratory design. PARTICIPANTS AND CONTEXTS: A total of 31 patients diagnosed with depression receiving pharmacological treatment for at least one year, belonging to 20 Health Centres and 8 Mental Health Centres of the Basque Health Service-Osakidetza in Bizkaia, and grouped according to the type of professional (GPs/Ps) and socioeconomic level.

METHOD

Information generation by means of 5 discussion groups and 2 in-depth interviews carried out in 2009 and 2010. Recording and transcription with previous confidentiality agreement and informed consent. Sociological discourse analysis. Technique triangulation and agreement among researchers.

RESULTS

Patients' experiences of depression are associated with their social contexts and their previous experience outside and inside the health services. These components also appear in perceptions on quality of care, with different expectations related to GPs and Ps. Deficiencies in time and psychotherapy are mentioned in general. Collaboration between both professionals does not spontaneously emerge as a patient priority.

CONCLUSIONS

Patient assessments provide dimensions of individual and contextual components in the diagnosis and treatment of depression. These dimensions should be taken into account in the identification of needs and the design of strategies shared by GPs and Psychiatrists to improve care.

Development and process evaluation of a primary care internet-based intervention to prevent depression in emerging adults

BACKGROUND

Primary care is a potential setting for implementation of depression prevention interventions using cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). The purpose of this study was to develop and conduct a process evaluation of a primary care/ Internet-based intervention that addresses key dissemination barriers in a community setting.

METHOD

We used an interdisciplinary team of investigators in a multistep intervention development process among a sample of primary care patients (aged 18 to 24 years). The intervention included an initial primary care motivational interview to engage the participant, 11 Internet-based modules based on CBT (to counter pessimistic thinking) and IPT (to activate social networks and strengthen relationship skills), and a follow-up motivational interview in primary care to enhance behavior change. Each component of the intervention was rated with regard to dissemination barriers of (1) fidelity, (2) motivation, (3) dose, (4) perceived helpfulness (rated on a Likert scale), and (5) potential costs. The study was conducted from April through June of 2004.

RESULTS

Fidelity checklist and serial reviews were satisfactory (100% core concepts translated into intervention). Key motivations for participation included (1) risk reduction, (2) intervention effectiveness, (3) "resiliency," and (4) altruism. In terms of dose, 13 of 14 participants engaged the Internet-based components, completing a mean of 7.2 modules (SD = 3.9). The 2 primary care interviews and the self-assessment and resiliency modules received the highest helpfulness ratings. The duration of the 2 motivational interviews was approximately 17-18 minutes, which is similar to a typical primary care visit.

CONCLUSIONS

By using multidisciplinary teams and incorporating the opinions of potential users, complex preventive mental health interventions can be translated into primary care settings with adequate fidelity, motivation, dose, and perceived helpfulness, and at a reasonably low cost.

Screening depression aging services clients

OBJECTIVES

To establish the psychometric characteristics of the Patient Heath Questionnaire (PHQ) (PHQ-2, -9, and their sequential administration) in older adults who use community-based, social service care management.

DESIGN

Comparison of screening tools with criterion standard diagnostic interview.

SETTING

A community-based aging services agency.

PARTICIPANTS

Three hundred seventy-eight adults aged 60 years or older undergoing in-home aging services care management assessments.

MEASUREMENTS

Subjects were administered the PHQ-9 and Structured Clinical Interview for DSM-IV-TR- fourth edition. The authors examined the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and receiver operating characteristic (ROC) curve for the PHQ-2 and PHQ-9 separately, and for a two-stage screening process that used each in sequence (the PHQ-2/9).

RESULTS

Using a cut score of 3, the sensitivity of the PHQ-2 was 0.80 and the specificity was 0.78. The area under the ROC curve (AUC) for the PHQ-2 was 0.87. Using a cut score of 10, the sensitivity and specificity of the PHQ-9 were 0.82 and 0.87. The AUC was 0.91. The sensitivity and specificity of the two-stage PHQ-2/9 were 0.81 and 0.89, respectively, and the AUC was 0.91.

CONCLUSIONS

The greater specificity of the PHQ-9 is an advantage over the PHQ-2 in aging service settings in which false-positive tests have potentially high cost. The PHQ-2/9 performed equally well as the PHQ-9, but would be more efficient for the agency to administer. Combined with an appropriate referral system to healthcare providers, use of the PHQ-2/9 sequence by aging services personnel can efficiently assist in reducing the burden of late-life depression.

Guideline recommendations for long-term treatment of depression with antidepressants in primary care--a critical review

BACKGROUND

Long-term treatment with antidepressants is considered effective in preventing recurrence of major depressive disorder (MDD). It is unclear whether this is true for primary care.

OBJECTIVES

We investigated whether current guideline recommendations for long-term treatment with antidepressants in primary care are supported by evidence from primary care.

METHODS

Data sources for studies on antidepressants: PubMed, Cochrane Library, Embase, PsycInfo, Cinahl, articles from reference lists, cited reference search.

SELECTION CRITERIA

adults in primary care, continuation or maintenance treatment with antidepressants, with outcome relapse or recurrence, (randomized controlled) trial/naturalistic study/review.

LIMITS

published before October 2009 in English.

RESULTS

Thirteen depression guidelines were collected. These guidelines recommend continuation treatment with antidepressants after remission for all patients including patients from primary care, and maintenance treatment for those at high risk of recurrence. Recommendations vary for duration of treatment and definitions of high risk. We screened 804 literature records (title, abstract), and considered 27 full-text articles. Only two studies performed in primary care addressed the efficacy of antidepressants in the long-term treatment of recurrent MDD. A double-blind RCT comparing mirtazapine (n = 99) and paroxetine (n = 98) prescribed for 24 weeks reported that in both groups 2 patients relapsed. An open study of 1031 patients receiving sertraline for 24 weeks, who were naturalistically followed-up for up to two years, revealed that adherent patients had a longer mean time to relapse.

CONCLUSIONS

No RCTs addressing the efficacy of maintenance treatment with antidepressants as compared to placebo were performed in primary care. Recommendations on maintenance treatment with antidepressants in primary care cannot be considered evidence-based.

Depression symptoms and treatment among HIV infected and uninfected veterans

Depression is one of the most common comorbid conditions affecting persons with HIV. We compared depressive symptoms and depression treatment using data from the Veterans Aging Cohort Study (VACS), a prospective cohort of HIV-infected and uninfected subjects. We identified subjects with a Patient Health Questionnaire score of 10 or greater. Treatment was defined as prescription of a selective serotonin reuptake inhibitor (SSRI) or mental health counseling. Overall, 16% of 4,480 subjects had depressive symptoms, and HIV-infected patients were more likely to have had depressive symptoms (OR = 1.38, 95% CI = 1.18, 1.62). Geographic site of care and having a mental health provider at the clinic was associated with treatment. In multivariable models restricted to 732 patients with depressive symptoms, receipt of depression treatment did not differ by HIV status (Adjusted OR = 1.11, 95% CI = 0.80, 1.54). Non-Hispanic whites were more likely to receive treatment (Adjusted OR = 2.09, 95% CI 1.04, 4.24). Primary care and HIV providers were equally unlikely to treat active depressive symptoms. Treatment variation by race, site, and availability of a mental health provider, suggests targets for intervention.

Adolescent Internet Depression Prevention: Preferences for Intervention and Predictors of Intentions and Adherence

Adolescents in primary care with sub-threshold depression (not reaching criteria for disorder) symptoms may be candidates for early intervention to prevent onset of major depressive disorder. However, we know little about their attitudes toward such interventions or what may predict motivation or adherence for preventive interventions. We also describe preferences for different types of interventions and conduct exploratory analyses to identify predictors of motivation to prevent depression and subsequent adherence to an Internet-based intervention. Adolescents with sub-threshold depressed mood favored novel behavioral treatment approaches, such as Internet-based models for depression prevention. Adolescent beliefs about the intervention and perceived social norms predicted intention to participate in depression prevention. The most important significant predictors of adherence were beliefs about the intervention. Careful attention to the specific beliefs and attitudes of users toward intervention should be incorporated into intervention design as well as evolving public health strategies to prevent depressive disorders.

Non-adherence with psychotropic medications in the general population

BACKGROUND

Non-adherence with medications is a general medical issue that has received much attention. However, the majority of studies have been on various clinical populations and the relevance of their results to the general population is unknown. In this study, we sought to determine the degree of non-adherence with antidepressants, antipsychotics, anxiolytics, mood stabilizers and sedative hypnotics, and to determine the reasons for non-adherence, in the general population of Canada.

METHODS

We used data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), conducted in 2002 (n = 36,984 adults), to produce population-based estimates of the degree of reported non-adherence with psychotropic medications and the reasons for non-adherence.

RESULTS

The number of individuals taking psychotropic medications was 6,201. The prevalence of antipsychotic use over the last 12 months was estimated at 0.4% (95% CI 0.3-0.4). The corresponding estimates for sedative-hypnotics, anxiolytics, mood stabilizers and antidepressants were 10.2% (95% CI 9.8-10.7), 5.5% (95% CI 5.2-5.8), 1.1% (1.0-1.3) and 5.8% (95% CI 5.5-6.2), respectively. Non-adherence was estimated to be 34.6% (95% CI 25.5-44.9) for antipsychotics, 34.7% (95% CI 32.2-37.4) for sedative-hypnotics, 38.1% (95% CI 35.0-41.4) for anxiolytics, 44.9% (95% CI 38.1-51.9) for mood stabilizers and 45.9% (95% CI 43.1-48.7) for antidepressants. The degree of non-adherence decreased with age for antidepressants and anxiolytics. Forgetting was the main reported reason for non-adherence, but its degree varied with medication class. The proportion of respondents that reported forgetting as a reason was 36.3% (95% CI 32.0-40.8) for sedative-hypnotics, 46.7% (95% CI 41.3-52.2) for anxiolytics, 72.7% (95% CI 55.5-85.0) for antipsychotics, 74.2% (95% CI 64.0-82.3) for mood stabilizers and 74.5% (95% CI 70.7-77.9) for antidepressants. The degree of non-adherence and the frequency of forgetting were not associated with the level of interference by the associated condition with usual activities. The majority of these estimates were also not impacted by educational status, employment status, rural/urban residence, income or the presence of a comorbid physical condition.

CONCLUSION

A high frequency of non-adherence was found with all five classes of psychotropic medication. Both the frequency of reported non-adherence and the reasons reported for it differ according to the medication. However, the degree of non-adherence was not affected by the level of interference of the associated condition.

Wishing upon a STAR*D: the promise of ideal depression care by primary care providers

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial found that after initial treatment, depressed patients treated in primary care settings had the same or slightly better outcomes than those treated in specialty care settings. The authors describe challenges to using the STAR*D approach and protocols in usual primary care settings. These include inadequate availability of appointments, insufficient resources for care management and treatment monitoring, and lack of payment to primary care providers for providing mental health care. Substantial reengineering of payment and delivery systems is needed in order for the STAR*D approach to be viable in primary care clinics.

Attitudes and beliefs of patients of first episode depression towards antidepressants and their adherence to treatment

BACKGROUND

Treatment adherence is influenced by factors like illness and patient characteristics, side effects, time taken to improve and the doctor-patient relationship. One of the important patient characteristic which has been reported to influence treatment adherence is their attitudes and beliefs towards medication.

METHODOLOGY

50 subjects of first episode unipolar depression (except for severe depression with psychotic symptoms), aged 18-50 years, duration of depression of more than 1 month, with no comorbid psychiatric disorders and comorbid medical illnesses were assessed twice. At first intake, antidepressant compliance questionnaire (ADCQ) was administered. Second intake was done after 3 months for assessment of treatment adherence by using the questionnaire for assessment of treatment adherence.

RESULTS

On component-1 of ADCQ (doctor-patient relationship), 92% agreed that doctor gave sufficient time to listen to their problem, explained the causes of depression sufficiently, felt confident that antidepressants are suitable treatment of their depression. On component-2 (preserved autonomy), most (88%) subjects believed that antidepressants are difficult to stop when taken over a long period of time and can alter patient's personality. On component-3 (positive beliefs on anti-depressants), 72% of the subjects felt, fewer tablets could be taken on days one feels better. On component-4 (partner agreement), 96% of subjects reported their partner's positive attitude towards diagnosis and treatment. At the time of second assessment, majority of the subjects (88%) missed the antidepressant medication on less than 25% days in the last 3 months whereas only 4% of the subjects missed antidepressants for more than 75% of the days. Thirty eight percent of the subjects dropped out of the follow up at 3 months of first assessment.

CONCLUSION

Most of the patients value the doctor-patient relationship & their partners are also supportive regarding diagnosis and treatment of depression. However, most patients have erroneous beliefs regarding antidepressants per se which in turn influence the drug compliance.

Treat depressed teens with medication and psychotherapy

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Collaborative mental health and primary care for bipolar disorder

This article discusses the use of integrated care models, in particular, collaborative care, in the treatment of bipolar disorder. Dr. Williams first discusses how care delivered via a collaboration between primary care and psychiatric providers has the potential to improve both mental health and general medical outcomes for patients with bipolar disorder. He describes promising findings from studies of the use of collaborative care in the treatment of depression, an area where this model has received the most study. Dr. Williams then discusses how such collaborative care models might best be implemented in the treatment of bipolar disorder. In the second half of the article, Dr. Manning focuses on five key issues that are an especially appropriate focus for collaborative care for bipolar disorder and for which the STAndards for BipoLar Excellence (STABLE) Project developed quality improvement performance measures: assessment for risk of suicide, assessment for substance use/abuse, monitoring for extrapyramidal symptoms, monitoring of metabolic parameters (e.g., monitoring for weight gain, hyperglycemia, hyperlipidemia), and provision of bipolar-specific psychoeducation.

Psychotherapy in the Veterans Health Administration: Missed Opportunities?

Informed by data on the dose-response effect, the authors assessed use of psychotherapy in the Veterans Health Administration (VA). The authors identified 410,923 patients with newly diagnosed depression, anxiety, or posttraumatic stress disorder using VA databases (October 2003 through September 2004). Psychotherapy encounters were identified by Current Procedural Terminology codes for the 12 months following patients' initial diagnosis. Psychotherapy was examined for session exposure received within the 12-month follow-up period and time (in days) between diagnosis and treatment. Of the cohort, 22% received at least one session of psychotherapy; 7.9% received four or more sessions; 4.2% received eight or more sessions; and 2.4% received 13 or more sessions. Delays between initial mental health diagnosis and initiation of care averaged 57 days. Patient variables including age, marital status, income, travel distance, psychiatric diagnosis, and medical-illness burden were significantly related to receipt of psychotherapy. Treatment delays and general underuse of psychotherapy services are potential missed opportunities for higher-quality psychotherapeutic care in integrated health care settings.

Reducing health disparities in depressive disorders outcomes between non-Hispanic Whites and ethnic minorities: a call for pragmatic strategies over the life course

There are significant disparities in treatment process and symptomatic and functional outcomes in depressive disorders for racial and ethnic minority patients. Using a life-course perspective, the authors conducted a systematic review of the literature to identify modifiable mechanisms and effective interventions for prevention and treatment at specific points -- system, community, provider, and individual patient -- in health care settings. Multicomponent chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions. Socioculturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs. Future research should focus on identifying key components of case management and sociocultural tailoring that are essential for effective interventions and developing new low-cost dissemination mechanisms for treatment and preventive programs that could be tailored to racial and ethnic minorities.

Psychotherapy by Primary-Care Providers: Results of a National Sample

The authors used the National Ambulatory Medical Care Survey to examine visit characteristics associated with psychotherapy by primary-care physicians, as compared with psychiatrists. Chi-square tests and hierarchical logistic-regression models were developed to examine visit characteristics associated with receiving psychotherapy by primary-care physicians versus psychiatrists. Over 19% of all psychotherapy visits were reported by primary-care physicians. Visits to primary-care physicians, versus visits to psychiatrists, were significantly greater among those over age 65, in Hispanic patients, and those in rural areas. Primary-care physicians are reporting that they provide psychotherapy and may be filling a void for underserved populations.

Systematic review of multifaceted interventions to improve depression care

OBJECTIVE

Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions.

METHOD

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes.

RESULTS

Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable.

CONCLUSION

There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

Attitudes and illness factors associated with low perceived need for depression treatment among young adults

BACKGROUND

We do not yet fully understand how low perceived need for treatment leads many young adults to not seek care for their depression.

METHODS

A cross-sectional study of 10,962 depressed young adults (ages 16-29) who visited a depression screening/education Internet website. Based on the Theory of Reasoned Action, we developed a multivariate model to determine the effects of beliefs and attitudes, social norms, past treatment behavior, and symptom severity on low perceived depression treatment need (i.e., not agreeing that one needs depression treatment).

RESULTS

Negative beliefs and attitudes, social norms, and past treatment behavior predicted low perceived depression treatment need and explained more than half the model variance. Even after adjusting for depression severity and symptoms of other mental disorders, lacking confidence in either a biological or counseling based explanation or treatment approach for depression predicted low perceived depression treatment need.

CONCLUSIONS

Lack of helpful treatment experiences and/or confidence in either of the currently practiced depression treatment models may prevent many young adults from seeking depression treatment.

What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms

BACKGROUND

Referral from primary care to the mental health specialty sector is important but poorly understood.

OBJECTIVE

Identify physician characteristics influencing mental health referral.

DESIGN

Randomized controlled trial using Standardized Patients (SPs).

SETTING

Offices of primary care physicians in 3 cities.

PARTICIPANTS

One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.

INTERVENTION

Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.

MEASUREMENTS

Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire.

RESULTS

Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92).

LIMITATION

The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients.

CONCLUSIONS

Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care.

Primary care patients' involvement in decision-making is associated with improvement in depression

BACKGROUND

Depression is undertreated in primary care settings. Little research investigates the impact of patient involvement in decisions on guideline-concordant treatment and depression outcomes.

OBJECTIVE

The objective of this study was to determine whether patient involvement in decision-making is associated with guideline-concordant care and improvement in depression symptoms.

DESIGN

Prospective cohort study.

SETTING

Multisite, nationwide randomized clinical trial of quality improvement strategies for depression in primary care.

SUBJECTS

Primary care patients with current symptoms and probable depressive disorder.

MEASUREMENTS

Patients rated their involvement in decision-making (IDM) about their care on a 5-point scale from poor to excellent 6 months after entry into the study. Depressive symptoms were measured every 6 months for 2 years using a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale. We examined probabilities (Pr) of receipt of guideline-concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors.

RESULTS

For each 1-point increase in IDM ratings, the probability of patients' report of receiving guideline-concordant care increased 4% to 5% (adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings, respectively, P < 0.001). Similarly, for each 1-point increase in IDM ratings, the probability of depression resolution increased 2% to 3% (adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively, P = 0.004).

CONCLUSIONS

Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline-concordant care and improving their symptoms over an 18-month period. Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression.

Satisfaction with treatment among patients with depressive and bipolar disorders

BACKGROUND

Patients' satisfaction with care may be an important factor in relation to adherence to treatment and continued psychiatric care. Few studies have focused on satisfaction in patients with depressive and bipolar disorders.

METHOD

A comprehensive multidimensional questionnaire scale, the Verona Service Satisfaction Scale-Affective, was mailed to a large population of patients with depressive or bipolar disorders representative of outpatients treated at their first contact to hospital settings in Denmark.

RESULTS

Among the 1,005 recipients, 49.9% responded to the letter. Overall, patients were satisfied with the help provided, but satisfaction with the professionals' contact to relatives was low. Younger patients (age below 40 years) were consistently more dissatisfied with care especially with the efficacy of treatment, professionals' skills and behaviour and the information given. There was no difference in satisfaction between genders or between patients with depressive disorder and patients with bipolar disorder.

CONCLUSION

There is a need to strengthen outpatient treatment for patients discharged from a psychiatric hospital diagnosed of having affective disorders, focusing more on information and psychoeducation for patients and relatives.

Mental illness and principal physical diagnoses among Asian American and Pacific Islander users of emergency services

The stigma of mental illness is one of the factors that prevents Asian Americans/Pacific Islanders (APIs) from seeking formal mental health services. A somatic complaint is more acceptable in expressing psychiatric/emotional distress. Admission diagnoses in API emergency service users with secondary psychiatric diagnoses were identified from the 2001 National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP). The sample consisted of 10,623 adult APIs. The study examined the differences in the six leading principal physical admission diagnoses between API emergency service users with psychiatric diagnoses and those without psychiatric diagnoses. Several of the study findings create concern (e.g., the higher percentage of APIs with psychiatric diagnosis who were discharged against medical advice, the high percentage admitted with medication intoxication). Further study is needed to provide guidance for clinical practice.

Personal characteristics and depression-related attitudes of older adults and participation in stages of implementation of a multi-site effectiveness trial (PRISM-E)

BACKGROUND

No study has assessed attitudes about depression and its treatment and participation at each step of recruitment and implementation of an effectiveness trial. Our purpose was to determine the association between personal characteristics and attitudes of older adults about depression with participation at each step of the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) treatment effectiveness trial.

METHODS

Information on personal characteristics and attitudes regarding depression and its treatment were obtained from all potential participants in PRISM-E.

RESULTS

Persons who reported better social support were more likely to complete a baseline interview, but were less likely to meet with the mental health professional carrying out the intervention. Attitudes about taking medicines were significantly associated with uptake of the intervention, but not with earlier phases of recruitment. Persons were much more likely to have a visit with the mental health professional for treatment of depression if they were willing to take medicine for depression but did not endorse waiting for the depression to get better [odds ratio (OR) = 3.16, 95% confidence interval (CI) = 1.48-6.75], working it out on one's own (OR = 5.18, 95% CI = 1.69-15.85), or talking to a minister, priest, or rabbi (OR = 2.01, 95% CI = 1.02-3.96).

CONCLUSION

Social support and other personal characteristics may be the most appropriate for tailoring recruitment strategies, but later steps in the recruitment and implementation may require more attention to specific attitudes towards antidepressant medications.

Pilot study of a primary care internet-based depression prevention intervention for late adolescents

INTRODUCTION

There is currently no depression prevention intervention available to adolescents in primary care.

METHOD

Fourteen late adolescents evaluated the acceptability (performance and ratings), potential adverse effects (negative emotions), and benefits (pre/post measures of three risk factors for depression) of a combined primary care Internet-based depression prevention intervention. Nearly all participants engaged the website (13/14) and 8/14 completed the entire intervention.

RESULTS

Completers reported high levels of readability and ease of understanding and low levels of negative emotions. Completers showed favorable trends for the targeted risk factors: depressive symptoms, dysfunctional thinking, and low social support.

CONCLUSION

A primary care/prevention intervention may be acceptable and favorably impact risk factors for depression.

Beliefs and attitudes associated with the intention to not accept the diagnosis of depression among young adults

PURPOSE

Negative attitudes and beliefs about depression treatment may prevent many young adults from accepting a diagnosis and treatment for depression. We undertook a study to determine the association between depressive symptom severity, beliefs about and attitudes toward treatment, subjective social norms, and past behavior on the intent not to accept a physician's diagnosis of depression.

METHODS

We conducted a cross-sectional study of 10,962 persons aged 16 to 29 years who participated and had positive screening results on the Center for Epidemiologic Studies Depression (CES-D) score in an Internet-based public health depression screening program. Participants reported whether they would accept their physician's diagnosis of depression. Based on the theory of reasoned action, we developed a multivariate model of the factors that predict intent not to accept a diagnosis of depression.

RESULTS

Twenty-six percent of the participants stated their intent not to accept their physician's diagnosis of depression. Disagreeing that medications are effective in treating depression (strongly disagree, odds ratio ( OR ) = 6.5, 95% confidence interval (CI), 4.6-9.3), that there is a biological cause for depression (strongly disagree, OR = 1.9, 95% CI, 1.3-2.7), and agreeing that you would be embarrassed if your friends knew you had depression were associated with the intent not to accept a diagnosis of depression (strongly agree, OR = 2.3, 95% CI, 1.8-2.9). Beliefs and attitudes, subjective social norms, and past behavior explained most of the variance in this model (84%).

CONCLUSIONS

Negative beliefs and attitudes, subjective social norms, and lack of past helpful treatment experiences are associated with the intent to not accept the diagnosis of depression and may contribute to low rates of treatment among young adults.