Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the medical outcomes study

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes.

Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried.

Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need.

Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy.

Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders.

Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

Improving Services for Women with Depression in Primary Care Settings

Women have a higher prevalence of depressive disorders compared to men. The current system of care for women with depressive disorders provides significant financial barriers for patients with lower incomes to access mental health services. Primary care systems are used extensively by women and have the potential to diagnose patients at early stages of mental illness and to provide evidence-based treatments, but this potential is largely unfulfilled because of significant system-level barriers inherent in primary care. Recent effectiveness research provides an excellent framework for cost-effectively improving care of depression using stepped care principles and strategies effective for improving care of other chronic conditions. Psychologists have the potential to help implement stepped care models by providing training, consultation and ongoing quality assurance, as well as by delivering collaborative care models of acute-phase treatment and relapse prevention interventions.

Changes in Antipsychotic Drug Use Following Shifts in Policy

This case study of antipsychotic drug use in nursing homes illustrates the potential benefits and limits of multilevel hierarchical linear analysis in long-term care research. Multilevel (MLn) logistic regression models were used to assess changes in exposure and average daily dose and their associations with resident and facility characteristics following implementation of the 1987 Omnibus Budget Reconciliation Act regulations. Data were obtained for 8,158 elderly Oregon Medicaid residents residing in 128 facilities between July 1991 and December 1994. Findings support the general hypothesis that resident characteristics are the main determinants of drug use and that drug use decreased over time among some resident populations and some facility types. Although challenges were encountered in the use of the MLn software, hierarchical modeling has advantages that make it attractive for long-term care multilevel applications such as the drug use study reported here.

Effect of soothing-liver and nourishing-heart acupuncture on early selective serotonin reuptake inhibitor treatment onset for depressive disorder and related indicators of neuroimmunology: a randomized controlled clinical trial

OBJECTIVE

To observe the effect of soothing-liver and nourishing-heart acupuncture on selective serotonin reuptake inhibitor (SSRIs) treatment effect onset in patients with depressive disorder and related indicators of neuroimmunology.

METHODS

Overall, 126 patients with depressive disorder were randomly divided into a medicine and acupuncture-medicine group using a random number table. Patients were treated for 6 consecutive weeks. The two groups were evaluated by the Montgomery-Asberg Depression Rating Scale (MADRS) and Side Effects Rating Scale (SERS) to assess the effect of the soothing-liver and nourishing-heart acupuncture method on early onset of SSRI treatment effect. Changes in serum 5-hydroxytryptamine (5-HT) and inflammatory cytokines before and after treatment were recorded and compared between the medicine group and the acupuncture-medicine group.

RESULTS

The acupuncture-medicine group had significantly lower MADRS scores at weeks 1, 2, 4, and 6 after treatment compared with the medicine group (P < 0.01). The acupuncture group had significantly lower SERS scores at weeks 1, 2, 4, and 6 after treatment compared with the medicine group (P < 0.01). At 6 weeks after treatment, serum 5-HT in the acupuncture-medicine group was significantly higher compared with the medicine group (P < 0.01). Interleukin-6 (IL-6) in the acupuncture-medicine group was significantly lower than that in the medicine group (P < 0.01), whereas there was no significant difference in IL-1β between the groups (P > 0.05). Anti-inflammatory cytokines IL-4 and IL-10 were significantly higher in the acupuncture-medicine group compared with the medicine group (P < 0.01, P < 0.05, respectively).

CONCLUSION

The soothing-liver and nourishing-heart acupuncture method can effectively accelerate the onset of SSRI effects when treating depressive disorder and can significantly reduce the adverse reactions of SSRIs. Moreover, acupuncture can enhance serum 5-HT and regulate the balance of pro-inflammatory cytokines and anti-inflammatory cytokines.

Factors Associated with Symptoms of Depression among Injection Drug Users Receiving Antiretroviral Treatment in Indonesia

OBJECTIVE

Few studies have examined psychiatric comorbidity among HIV positive injection drug users (IDUs) in resource-limiting settings. We sought to identify key factors associated with symptoms of depression among IDUs receiving antiretroviral (ARV) treatment in Jakarta and Denpasar, Indonesia.

METHODS

The cross-sectional study was conducted at five ARV delivery sites in Indonesia. Former IDUs aged 18 years or older having received ARV treatment for at least three months (n=117) were recruited and interviewed face-to-face. A 9-item version of the Center for Epidemiologic Studies Depression Scale was used to measure symptoms of depression. A structured questionnaire measured participants' demographic characteristics, social support and services received, current substance use, and treatment for drug dependency and HIV. Multiple logistic regression was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI).

RESULTS

Of the 117 participants, 33% (39) exhibited symptoms of depression, 24% (28) reported using an illicit substance in the past month, and 29% (34) were in methadone treatment. Depressive symptoms were significantly associated with recent substance use in the last 30 days (AOR, 95% CI: 5.3, 1.9 to 15.4) and being on methadone (3.5, 1.2 to 10). Older age (per year 0.9, 0.8 to 1), full-time employment (0.2, 0.1 to 0.7), and living with parents (0.2, 0.1 to 0.6) appeared to be protective.

CONCLUSION

The results suggest that depression is common among Indonesian IDUs, even among patients enrolled in methadone treatment. HIV clinics and drug treatment programs need to recognize the risk/protective factors and also provide services to address this common comorbidity.

Carers' representations of affective mental disorders in British Chinese communities

Infrequent use of and delayed presentation to professional services have increased the burden of mental illness in minority ethnic communities. Within the growing literature on informal carers, the Chinese remain relatively unstudied. This article reports a qualitative study of 14 carers to explore illness representations of affective disorders in British Chinese communities. Firstly, it places the study within a theoretical framework that permits an understanding of mental health and illness in different sociocultural belief systems. Next, it presents carers' narrative accounts in conceptualising mental illness, including its causes, manifestations and impact on patients and carers, and contextualises the findings within the existing literature. Finally, the article examines how the caring role may be constructed from the broader social experience of carers and their relationships within a community structure that values the group over the individual. Coping mechanisms are discussed in the context of the practice of caring as a moral obligation and of policy implications for more culturally appropriate support services for both Chinese carers and mental health patients.

Treatment of depression in older adults

Depression is the most frequent mental disorder in older people, often causing emotional distress and reduced quality of life. Despite its clinical significance, depression remains underdiagnosed and inadequately treated in older patients. Regarding prognosis, data suggest that almost 70% of patients, treated long enough and with appropriate doses, recover from an index episode of depression. Antidepressants are efficient for treating depressed outpatients with several comorbid physical diseases as well as hospitalized patients, with selective serotonin reuptake inhibitors being the antidepressants of choice for older patients. Available data can guide pharmacological treatment in both the acute and maintenance stages, but further research is required to guide clinical strategies when remission is not achieved. Approaches for the management of resistance to treatment are summarized, including optimization strategies, drug changes, algorithms, and combined and augmentation pharmacological treatments. Finally, additional therapeutic choices such as electroconvulsive therapy, transcranial magnetic stimulation, and integrated psychotherapy are presented.

Evaluating the effectiveness of cognitive-behavioral teletherapy in depressed adults

Telephone psychotherapy is an emerging form of delivery of care that has recently demonstrated utility and efficacy for adult depression when provided as an adjunct to antidepressant treatment in primary care trials. This study constitutes one of the initial evaluations of cognitive behavioral therapy-telephone treatment (CBT-TT) as a stand-alone treatment for adult depression in specialty care. Thirty adults initiating psychotherapy for depression at a mental health clinic participated in the trial. The majority of participants (69%) were very satisfied with the 8-session CBT-TT, reduction in depression severity was significant over 3 and 6 months, and 42% of participants were considered recovered at termination. These outcomes closely parallel the findings from an earlier primary care trial, despite specialty care participants beginning treatment with more severe depression and without adjunctive antidepressant medication. These findings suggest that CBT-TT for adult depression is feasible and has potential as a stand-alone treatment. Implementation of this telephone-based delivery approach in primary and specialty care settings is discussed.

Treatment of major depressive disorder in the Finnish general population

BACKGROUND

Few general population studies of the treatment of major depressive disorder (MDD) have included the whole spectrum of treatments. We estimated the rates of different treatments and the effect of individual and disorder characteristics plus provider type on treatment received.

METHODS

In the Health 2000 Study, a representative sample (n=6,005) from the adult Finnish population (> or =30 years) were interviewed (CIDI) in 2000-2001 for the presence of DSM-IV mental disorders during the past 12 months. Logistic regression models were used to examine factors influencing the type of treatment: either pharmacotherapies (antidepressants, anxiolytics, sedatives/hypnotics, antipsychotics) or psychological treatment.

RESULTS

Of the individuals with MDD (n=288), currently 24% used antidepressants, 11% anxiolytics, 16% sedatives/hypnotics, 5% antipsychotics, and 17% reported having received psychological treatment. Overall, 31% received antidepressants or psychological treatment or both; 18% received minimally adequate treatment. Of those 33% (n=94) using health care services for mental reasons, 76% received antidepressants or psychological treatment or both; 54% received minimal adequate treatment. In logistic regression models, the use of antidepressants was associated with female sex, being single, severe MDD, perceived disability, and comorbid dysthymic disorder; psychological treatment with being divorced, perceived disability, and comorbid anxiety disorder.

CONCLUSIONS

Due to the low use of health services for mental reasons, only one-third of subjects with MDD use antidepressants, and less than one-fifth receives psychological treatment. The treatments provided are determined mostly by clinical factors such as severity and comorbidity, in part by sex and marital status, but not education or income.

[Major depression in primary care and clinical impacts of treatment strategies: a literature review]

Major or clinical depression represents a frequent mental illness that is often associated with a high level of morbidity and mortality. Yet, major depression remains under-diagnosed and under-treated. On the level of treatment, it would appear desirable for reasons of better prognosis, to aim more than the simple reduction of depressive symptoms and target their remission resolutely and the fastest return to the individual's optimal functioning. This article presents a systematic review of the literature relating to the clinical impacts of treatment strategies aiming at the improvement of services offered to people who suffer of clinical depression and who consult in primary care. The authors summarize results drawn from 41 studies that include a measurement of the clinical impacts (reduction of symptoms, response, remission and functioning) of various treatment strategies. It appears that using complex treatment strategies favour positive outcomes. The authors propose various paths of research to further increase current knowledge.

Factors influencing variation in prescribing of antidepressants by general practices in Scotland

BACKGROUND

The prescribing of antidepressants has been rising dramatically in developed countries.

AIM

As part of an investigation into the reasons for the rise and variation in the prescribing of antidepressants, this study aimed to describe, and account for, the variation in an age-sex standardised rate of antidepressant prescribing between general practices.

DESIGN OF STUDY

Cross-sectional study involving analyses of routinely available data.

SETTING

A total of 983 Scottish general practices.

METHOD

Age-sex standardised prescribing rates were calculated for each practice. Univariate and multivariate regression analyses were undertaken to examine how the variation in prescribing was related to population, GP, and practice characteristics at individual practice level.

RESULTS

There was a 4.6-fold difference between the first and ninth deciles of antidepressant prescribing, standardised for registered patients' age and sex composition. The multivariate model explained 49.4% of the variation. Significantly higher prescribing than expected was associated with more limiting long-term illness (highly correlated with deprivation and the single most influential factor), urban location, and a greater proportion of female GPs in the practices. Significantly lower prescribing than expected was associated with single-handed practices, a higher than average list size, a greater proportion of GP partners born outside the UK, remote rural areas, a higher proportion of patients from minority ethnic groups, a higher mean GP age, and availability of psychology services. None of the quality-of-care indicators investigated was associated with prescribing levels.

CONCLUSION

Almost half of the variation in the prescription of antidepressants can be explained using population, GP, and practice characteristics. Initiatives to reduce the prescribing of antidepressants should consider these factors to avoid denying appropriate treatment to patients in some practices.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment of mental disorders for adolescents in Mexico City

OBJECTIVE

This study describes the prevalence, adequacy and correlates of 12-month mental health service use among participants in the Mexican Adolescent Mental Health Survey.

METHODS

The authors conducted face-to-face household surveys of a probability sample of 3005 adolescents aged 12-17 years residing in the Mexico City metropolitan area during 2005. The prevalence of mental health disorders and the use of services were assessed with the computer-assisted adolescent version of the World Mental Health Composite International Diagnostic Interview. Correlates of service use and adequate treatment were identified in logistic regression analyses that took into account the complex sample design and weighting process.

FINDINGS

Less than one in seven respondents with psychiatric disorders used any mental health services during the previous year. Respondents with substance-use disorders reported the highest prevalence of service use and those with anxiety disorders the lowest. Approximately one in every two respondents receiving any services obtained treatment that could be considered minimally adequate.

CONCLUSION

We found large unmet needs for mental health services among adolescents with psychiatric disorders in Mexico City. Improvements in the mental health care of Mexican youth are urgently needed.

Patient-physician communication in the primary care visits of African Americans and whites with depression

BACKGROUND

Little research investigates the role of patient-physician communication in understanding racial disparities in depression treatment.

OBJECTIVE

The objective of this study was to compare patient-physician communication patterns for African-American and white patients who have high levels of depressive symptoms.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study-Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices.

MAIN OUTCOMES

Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients' physical and emotional health status and stress levels were measured by post-visit surveys.

RESULTS

African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07).

CONCLUSIONS

This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care.

[Improving the management of depression in primary care: review and prospects]

BACKGROUND

Depression is a common disorder, associated with significant social and functional impairment, and whose natural course tends to chronicity. The majority of the patients suffering from this disorder are attended in primary health care settings. General practitioners represent the greatest part of the prescribers of antidepressants. Unfortunately, there are many barriers with detection and with the treatment of depression, thus only a minority of patients profits from a treatment with effective posology and with sufficient duration.

LITERATURE FINDINGS

Several programs of interventions directed by mental health professionals aim at improving the management of depression in primary care. There are single interventions consisting of an educational program to physicians or a single intervention to the patient. The assessments of an educational strategy find some contradictory results. Single interventions are not sufficient by themselves. On the other hand, programs associating several interventions are effective. These associations consist of an educational intervention to the physicians and an intervention or more to the patient treated by antidepressant. Interventions are generally carried out by nurses and supervised by a psychiatrist. Mental health professionals share their informations with general practitioners. Interventions can be telephone or in <<face to face>>. Telephone interventions have the advantage of a low cost and appear quite as relevant as interventions in <<face to face>>.

RESULTS

But the effectiveness of these programs grows blurred in time, unless the program itself does continue. Moreover, this effectiveness is variable according to the severity of symptomatology. Indeed, the interest of this type of programs for the patients suffering from minor depression is limited. These various programs can be supplemented by the contribution of tools of detection or assessment of the depressive symptomatology to general practitioners, like by the contribution of oral and/or written informations to the patient concerning the disorder from which he suffers. The setting-up of such programs represents a considerable cost but depression is itself responsible for an important cost for our society. Several estimates concerning the setting-up of these programs find a good cost-effectiveness ratio; it should facilitate their installation taking into account their effectiveness.

CONCLUSION

A close cooperation, based on the complementarity between general practitioners and mental health professionals is required to improve the management of depression.

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.

Receiving guideline-concordant pharmacotherapy for major depression: impact on ambulatory and inpatient health service use

OBJECTIVE

This study aimed to determine the associations between guideline-concordant pharmacotherapy for depression and the use of health services in the year following diagnosis.

METHOD

This population-based, retrospective cohort study examined Quebec drug plans between 1999 and 2002. We included beneficiaries aged 18 to 64 years who were newly diagnosed with an episode of depression by primary care physicians and psychiatrists between October 1, 2000, and March 31, 2001, and who made at least one psychotropic pharmacy claim within 31 days of diagnosis. We defined guideline concordance as the receipt of recommended medication, starting dosage, and treatment duration as defined by the Canadian Network for Mood and Anxiety Treatments guidelines. We measured outcomes on use of ambulatory (number of visits to prescribing physician, other physicians, or emergency departments) and inpatient (hospitalization) services.

RESULTS

There were 2742 patients (mean age 42 years; 64% female patients) who met the study criteria. Of the 2047 (75%) patients to whom an antidepressant was dispensed, 1958 (71%) received a recommended first-line medication, 1297 (63%) received a recommended starting dosage, and 304 (15%) received a recommended duration. According to the 3 criteria, only 8% were treated appropriately; 21% received benzodiazepines rather than antidepressants. There were 2 median visits (inferquartile range [IQR] 1 to 3) to prescribing physicians, 0 visits (IQR 0 to 1) to other physicians, and 0 visits (IQR 0 to 0) to emergency departments; 497 (18%) patients were hospitalized. In separate multivariate models for repeated measures, recommended first-line medication, dosage, and duration were associated with more prescribing physician visits. Recommended first-line medication reduced the odds of hospitalization.

CONCLUSION

Guideline concordance was associated with more visits to prescribing physicians and lower odds of hospitalization.

Conceptual models of treatment in depressed Hispanic patients

PURPOSE

Though patient variables are likely to play an important role in the undertreatment of depression, little is known of patients' perceptions of standard depression treatments. In an effort to understand their perspective, we investigated depressed Hispanic patients' perceptions of primary care treatments and the specific benefits associated with them.

METHODS

We undertook semistructured interviews with 121 depressed Hispanic medical patients waiting for their appointments. We developed and implemented a coding scheme using standard iterative procedures.

RESULTS

More than one half of the patients viewed physician consultation and medication as helpful. Almost all patients considered psychotherapy to be helpful. Supportive talk was the most commonly mentioned specific benefit of physician consultation. The most common benefit of medication was its anxiolytic, sedative effect; energizing effects were less common. The most common benefits associated with psychotherapy included support, advice, and catharsis. Patients currently taking medication for depression had a more favorable view of pharmacological treatment; differences by language of interview were noted.

CONCLUSIONS

Patients' perceptions of the specific efficacies of depression treatment did not match priorities implicit in current treatment guidelines. Such perceptions may play a key role in shaping patients' decisions to initiate and maintain treatment.

Prise en charge des personnes souffrant de troubles dépressifs–Données d’enquête en population générale

INTRODUCTION

The depressive disorders are among the most frequent disorders in the general population. Various validated treatments exist but, according to international psychiatric epidemiologic surveys, only a minority of currently depressed people seek and receive treatment. To date, in France, few national studies have investigated these problems.

OBJECTIVES

By using the data of the national French survey: "Santé mentale en population générale (SMPG)": 1) to estimate the prevalence of use of care services by depressed people in the general population, 2) to evaluate the proportion of depressive subjects who have received drug and/or psychological treatments, 3) to identify the demographic and clinical factors and representations associated with use.

METHOD

SMPG was a transversal survey carried out by the WHO national collaborative center (CCOMS) and the Direction of the statistics of the ministry for Health (DREES). A representative sample of 36 105 non-institutionalised French individuals aged 18 or over was interviewed. Three main questionnaires was used: the Mini International Neuropsychiatric Interview (MINI) questionnaire was used to assess several mental disorders according to the ICD-10 classification, a questionnaire on the representations of the mental disease and the treatments, and a questionnaire on use of care services and treatments received.

RESULTS

- 71.9% of depressed people sought or received a treatment and 47.1% stated claimed to be treated for depression. About 20% of people classified as having a recurrent or chronic depressive disorder have never used health care services for mental health. Only 53.4% of subjects having a mild or moderate Major Depressive Episode (MDE) already received a treatment: 42.1% had taken psychotropic drugs only, 3.2% had psychotherapy only, 8.1% had both, and 25.6% had taken antidepressants among the subjects treated by psychotropic drugs; 24% of subjects classified as having a recurrent or chronic depressive disorder have never received a treatment and about 3/4 of them have never received a minimal adequate treatment. Use of services by depressed people was associated with sociodemographic factors, the severity of the disorder and several representations.

CONCLUSION

- The SMPG survey confirms the international finding concerning the treatment of depressed people. Several problems were pointed out: an important part of depressed people had never taken any treatment, less than half claimed they were stated to be treated for depression, a minority received a psychotherapy, and very few had a minimal adequate treatment. In France, more psychiatric epidemiologic surveys are needed to confirm and specify these findings.

Influence of patient preference and primary care clinician proclivity for watchful waiting on receipt of depression treatment

OBJECTIVE

We examined whether patients' preference for watchful waiting and their primary care clinician's proclivity for watchful waiting were associated with decreased likelihood of receiving depression treatment.

METHODS

In a quality improvement intervention for depression in primary care, patients with depressive symptoms were identified through screening in 46 clinics from June 1996 to March 1997. We analyzed baseline survey data completed by clinicians and patients using logistic regression models.

RESULTS

Of 1140 patients, 179 (16%) preferred watchful waiting over active treatment. After controlling for covariates, patients with depressive disorders who preferred watchful waiting were less likely to report use of antidepressants (OR=0.86, 95% CI=0.77-0.95). Among patients with depressive symptoms only, those who preferred watchful waiting were less likely to report antidepressant use (OR=0.84, 95% CI=0.76-0.93) or counseling (OR=0.84, 95% CI=0.77-0.95). Patients with less knowledge about depression were less likely to receive depression treatment. Clinician proclivity for watchful waiting was not associated with the likelihood that patients received depression treatment.

CONCLUSIONS

Patient preference for watchful waiting is associated with lower rates of some depression treatments, especially among patients with subsyndromal depression. Addressing patient preference for watchful waiting in primary care may include active symptom monitoring and patient education.

Recognition and treatment of depression and anxiety in patients with acute myocardial infarction

The objective of this study was to determine the ability of providers (medical residents and nurse practitioners) on inpatient cardiac units to recognize and appropriately treat patients with clinically significant depression and anxiety among a cohort admitted with acute myocardial infarction. Patients within 72 hours of acute myocardial infarction underwent screening with the Standardized Clinical Instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition module for major depressive disorder (MDD), the Beck Depression Inventory (BDI-II), and the Beck Anxiety Inventory (BAI). In addition, the study psychiatrist and a treatment team clinician independently assessed whether they believed that patients had clinically significant depression or anxiety. Prescription of antidepressants and benzodiazepines during hospitalization was recorded by chart review. Assessments were completed for 74 patients. Providers identified < 15% of patients with current MDD or with a BDI score > or = 10; 11% of patients with current MDD had appropriate treatment with antidepressants. There was no significant correlation of providers' assessment of depression with current MDD, BDI scores, or psychiatrists' clinical assessment of depression. In contrast, providers identified 31% of patients with a BAI score > or = 10 and 50% of patients who were assessed by psychiatrists as anxious; > 80% of patients with high anxiety received benzodiazepines. Providers' assessments of anxiety were significantly correlated with BAI scores and with psychiatrists' clinical assessments. In conclusion, medical residents and nurse practitioners routinely under-recognize and undertreat depression among patients with acute myocardial infarction on inpatient cardiac units. Recognition and treatment of anxiety is substantially better, up to 50% of patients who are found to be anxious by psychiatrists after acute myocardial infarction remain unrecognized.

Satisfaction with mental health services in older primary care patients

OBJECTIVE

This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems.

METHODS

A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment.

RESULTS

Older adult patients' satisfaction with IC (mean: 3.4, standard deviation [SD]: 0.60) was significantly higher than that with ESR (mean: 3.2, SD: 0.78), but the absolute difference was modest. Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction. Stigma toward mental illness was negatively associated with satisfaction with mental health services.

CONCLUSIONS

Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics.

Improved detection and pharmacotherapy of major depression from 1989 to 2001 in psychiatric outpatient care in Finland

There have been several reports of non-detection and undertreatment of major depression during the past decades. In this study, we investigated how accurately major depression was assessed, diagnosed and treated according to gold standards, and whether any trend could be found from 1989 to 2001 in Finland. In total, documents of 4447 patients were retrospectively checked at most four times to find the patients fulfilling the study criteria. Finally, 531 patients were included in the study. The major finding of the study was the improved diagnostic assessment of patients with major depression seen in psychiatric settings. However, a systematic and comprehensive approach in asking about and recording subtyping, severity and comorbidity of depression was insufficient. Another major finding of the study was the improved pharmacotherapy of patients with major depression. It seems to be relevant that problems in the quality of care for depression in psychiatric settings are now more likely to be related to suboptimal intensity and monitoring of treatment than to mere lack of treatment.

Managed care and systems cost-effectiveness: treatment for depression

OBJECTIVE

The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care.

DATA SOURCES/STUDY SETTING

The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico.

STUDY DESIGN

Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression.

DATA COLLECTION/EXTRACTION METHODS

Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population.

PRINCIPAL FINDINGS

System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness.

CONCLUSION

Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.

Increased recognition of depression in primary care. Comparison between primary-care physician and ICD-10 diagnosis of depression

BACKGROUND

Underrecognition and undertreatment of depression in primary care has been regarded as a major public health problem. In contrast, some studies found that among patients labeled as depressed by primary-care physicians (PCPs), a relevant proportion do not satisfy international diagnostic criteria for depression. The aims of this study are: (1) to assess disparity between PCP diagnosis and research diagnosis of depression; (2) to compare antidepressant treatment in concordant and discordant cases of depression.

METHODS

Data are gathered from a national survey on depressive disorders in primary care, conducted with the collaboration of 191 PCPs. Three hundred and sixty-one PCP patients were evaluated, and their psychiatric diagnosis was established by the 'unaided' PCPs and by using a research interview for depression.

RESULTS

PCPs recognized 79.4% of cases of depression and prescribed antidepressants to 40.9% of them. Yet, 45.0% of patients labeled as depressed by the PCPs were not cases of depression according to ICD-10 criteria; 26.9% of false-positive cases received an antidepressant. Globally, 35% of antidepressants for 'depression' were prescribed to false-positive cases.

CONCLUSIONS

Underrecognition and undertreatment of depression in primary care seem to be less alarming. Conversely, PCP diagnoses of depression appear to be more inclusive than psychiatric diagnostic criteria. A possible consequence of this apparently more inclusive diagnostic threshold may be an excessive use of antidepressants. These changes require a corresponding change in research, toward efficacy and safety of the treatment of milder cases, and in education, toward the distinction between the management of mild and severe cases of depression.

Racial and ethnic differences in the mental health problems and use of mental health care

OBJECTIVES

We compared rates of mental health problems and use of mental health care across multiple racial and ethnic groups using secondary data from a large, nationally representative survey.

METHODS

We pooled cross-sectional data from the 2001-2003 National Surveys on Drug Use and Health. Our sample included 134,875 adults classified as white, African American, American Indian/Alaskan Native, Asian, Mexican, Central and South American, Puerto Rican, other Hispanic-Latino, or those with multiple race and ethnicities. For each group, we estimate the past year probability of: (1) having 1 or more mental health symptoms in the past year, (2) having serious mental illness in the past year, (3) using mental health care, (4) using mental health care conditional on having mental health problems, (5) reporting unmet need for mental health care, and (6) reporting unmet need for mental health care conditional on having mental health problems.

RESULTS

We found significantly higher rates of mental health problems and higher self-reported unmet need relative to whites among American Indian/Alaskan Natives and lower rates of mental health problems and use of mental health care among African American, Asian, Mexican, Central and South American, and other Hispanic-Latino groups. These differences generally were robust to the inclusion of clinical and socio demographic covariates.

CONCLUSIONS

Overall, our study shows wide variation in mental health morbidity and use of mental health care across racial and ethnic groups in the United States. These results can help to focus efforts aimed at understanding the underlying causes of the differences we observe.

[Psychotropic drug use and mental psychiatric disorders in France; results of the general population ESEMeD/MHEDEA 2000 epidemiological study]

INTRODUCTION

The use of psychotropic drugs is high in France and has increased over the last two decades. To date, no national study evaluating psychotropic drug use in the context of the diagnosis of psychiatric disorders has been performed. Such data has now been generated in the ESEMeD/MHEDEA 2000 study, which has allowed comparison of the situation in France with that in five other European countries (Germany, Belgium, Spain, the Netherlands and Italy).

OBJECTIVES

1) To describe the declared use of psychotropic drugs (globally and by therapeutic class) in order to evaluate annual prevalence, treatment duration and demographic factors associated with use. 2) To estimate the proportion of subjects with an anxiety disorder, mood disorder or alcohol-related disorder (abuse or dependence) that have been appropriately treated with an antidepressant or anxiolytic drug. 3) to evaluate the proportion of psychotropic drug users who fulfil diagnostic criteria for these three classes of psychiatric disorder.

METHODS

This was a transversal survey carried out between 2001 and 2003 of non-institutionalised subjects aged 18 or over in the general population of Germany (n = 3,555), Belgium (n = 2,419), Spain (n = 5,473), France (n = 2,894), the Netherlands (n = 2,372) and Italy (n = 4,712). In France, the sampling source used was a randomly generated list of telephone numbers. Subjects were interviewed at home by professional interviewers. The WMH-CIDI questionnaire was used.

RESULTS

In France, 21% of subjects interviewed (n = 580) had taken at least one psychotropic drug during the year. For 19%, this was an anxiolytic or hypnotic (AX-HY), for 6.0% an antidepressant (AD), for 0.8% an antipsychotic (AP) and for 0.4% a mood regulating drug (TY). The distribution of users of AX-HY according to treatment duration was the following: 44% (1 to 15 days), 13% (16 to 30 days), 14% (1 to 3 months), 6.7% (3 to 6 months) and 23% (> 6 months). For users of ADs, the distribution was: 21% (1 to 15 days), 7.8% (16 to 30 days), 18% (1 to 3 months), 12% (3 to 6 months) and 42% (> 6 months). For subjects fulfilling diagnostic criteria for a mood disorder in the previous year or over their lifetime, 43% and 29% respectively had taken an AX-HY in the last twelve months and 29% and 16% an AD. For those who fulfilled diagnostic criteria for an anxiety disorder in the previous year or over their lifetime, the use of an AX-HY, in the last twelve months, concerned 43% and 30% of subjects respectively, whilst that of AD concerned 16% and 14%. For previous year or lifetime alcohol-related disorders, AX-HY use, in the last twelve months, concerned 63% and 22% of subjects respectively and use of ADs 9.3% and 7.2%. Amongst users of AX-HY in the last twelve months, a previous year or lifetime diagnosis of mood disorders was made for 16% and 39% of subjects respectively. Amongst users of ADs, the respective prevalence was 31% and 64%. A twelve-month and lifetime diagnosis of anxiety disorders was identified in 22% and 37% of users of AX-HY and among 27% and 50% of users of AD respectively. A twelve-month and lifetime diagnosis of alcohol-related disorders was found in 2.5% and 6.6% of users of AX-HY and among 1.1% and 7.8% of users of AD respectively. 68% of users of AX-HY had fulfilled none of these diagnostic criteria in the previous 12 months and 46% had never fulfilled them in their lifetime. With respect to AD users, the proportion who did not meet these diagnostic criteria in the previous 12 months was 56%, compared to 20% over their lifetime. Comparison of the French data from the study with those of the entire European sample showed that the annual prevalence of AX-HY and AD use was higher in France with mean treatment durations that were shorter. For antipsychotics and mood regulators, no clear differences were observed between France and the six countries of the study taken together.

DISCUSSION

Over the last two decades, use of AX-HY seems to have decreased in France, even though it remains higher than that observed in the other European countries participating in this study. This high use can be explained in part by the observation that, in around half the cases, it corresponds to occasional use. In contrast, the use of antidepressants has increased. In subjects with recent mood disorders or anxiety disorders, the use of AX-HY remains higher than that of antidepressants. Finally among users of AX-HY, only half of them had presented a mood disorder, anxiety disorder or alcohol use disorder during their lifetime, whereas this proportion rose to 80% for users of antidepressants.

Suboptimal antidepressant use in the elderly

Ongoing changes in available agents and health care delivery systems have made it imperative to study the quality of antidepressant use in vulnerable and traditionally underserved elderly. We conducted a retrospective cohort study among 12,130 new antidepressant users aged > or =65 years with a recent diagnosis of depression in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly Program from January 1, 1994, to December 31, 1999. Additional use information was available through Medicare data. Potentially hazardous antidepressant regimens were defined as use of highly anticholinergic agents or daily dosages in excess of geriatric prescribing guidelines. Low-intensity regimens were defined by lower than recommended daily dosages, too-short durations of therapy, or lack of follow-up. Of all elderly antidepressant users, 43.3% were taking suboptimal regimens. Potentially hazardous regimens were used by 11.9%, including 7.3% taking highly anticholinergic agents and 5.3% using excessively high daily dosages. Low-intensity regimens were used by 34.8% of patients, including 7.6% with excessively low daily dosages, 19.3% with short durations of therapy, and 14.8% with inadequate follow-up. Potentially hazardous regimens were associated with ages 65 to 74 years, nursing home residence, cancer diagnoses, less comorbidity, use of other psychiatric medications, making more physician visits, and earlier calendar years. Low-intensity regimens were associated with ages > or =85 years, nonwhite race, greater comorbidity, fewer physician visits or inpatient days in the baseline 6 months, and not using other psychiatric medications. Suboptimal antidepressant use remains common in the elderly, especially the use of inadequately intensive regimens. Interventions are needed to improve the quality and outcomes of antidepressant use in this vulnerable population.

Cultural differences in conceptual models of depression

Members of ethnic minority groups are less likely than white middle class people to seek professional treatment for depression and other mental health problems. One explanation is that the former conceptualize depressive symptoms as social problems or emotional reactions to situations, while the latter are more apt to view depression as a disease requiring professional treatment. Though considerable evidence supports this hypothesis, it is rarely explored directly through cross-cultural comparisons. The present study compares conceptual models of depressive symptoms in two diverse cultural groups in New York City (USA): 36 South Asian (SA) immigrants and 37 European Americans (EA) were presented with a vignette describing depressive symptoms and participated in a semi-structured interview designed to elicit representational models of the symptoms. Results indicate pervasive differences in representational models across the two groups. SA participants identified the "problem" in the vignette in largely social and moral terms. Suggestions for management and health seeking in this group emphasized self-management and lay referral strategies. EAs, by contrast, often proposed alternate, sometimes contradictory, explanatory models for the depressive symptoms. One model emphasized biological explanations ranging from "hormonal imbalance" to "neurological problem." The second model resembled the "situational stress" or "life problem" model described by SAs. The implications of these findings, and directions for future research, are discussed.

La santé mentale : état des lieux et problématique

The prevalence of mental disorders makes mental health a significant public health problem given that they affect more that one in four people during their life span. Four of the five main causes for Years lost due to Disability (YLD) for 15-44 year olds' are mental disorders. Various effective treatments are available; however, their use poses a few noteworthy problems. This article puts forth an inventory on the principal mental disorders recognised at the international and national levels and extracts and highlights the main challenges associated with mental health care from the scientific literature. The synthesis concludes with a presentation of recommendations made in order to confront these difficulties and by outlining some of the national actions currently under preparation.

Effects of Pharmaceutical Promotion on Adherence to the Treatment Guidelines for Depression

OBJECTIVES

We sought to examine the impact of direct-to-consumer advertising (DTCA) and pharmaceutical promotion to physicians on the likelihood that (1) an individual diagnosed with depression received antidepressant medication and that (2) antidepressant medication was used for the appropriate duration.

RESEARCH DESIGN AND SUBJECTS

A quasiexperimental design was used to examine treatment patterns of 30,621 depressed individuals whose insurance claims were included in the MarketScan database from 1997 through 2000. The main explanatory variables were spending on DTCA, detailing to physicians, and free samples for 6 antidepressant medications.

RESULTS

Individuals diagnosed with depression during periods when class-level antidepressant DTCA spending was highest (cumulative spending more than US 18.5 million dollars) had 32% higher relative odds of initiating medication therapy compared with those diagnosed during periods when DTCA spending was lowest (P < 0.0001). Free samples of medications dispensed to physicians had no effect on odds of initiating antidepressant use. Class-level DTCA spending on antidepressants had a small positive effect on the duration of antidepressant use, whereas DTCA spending for the specific medication taken by an individual had no effect on treatment duration. Detailing spending at the class or product level had no significant effect on duration of treatment with an antidepressant medication.

CONCLUSIONS

Our results suggest that DTCA of antidepressants was associated with an increase in the number of people diagnosed with depression who initiated medication therapy. DTCA was associated with a small increase in the number of individuals treated with antidepressants who received the appropriate duration of therapy. Promotion to physicians was not associated with either the initiation of treatment with an antidepressant or with the duration of therapy.

Knowledge About Recommended Treatment and Management of Major Depressive Disorder, Panic Disorder, and Generalized Anxiety Disorder Among Family Physicians

BACKGROUND: Concerns have been raised about whether primary care physicians appropriately manage mental disorders. We assessed family physicians' knowledge of appropriate management of major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD). METHOD: Active members of the Texas Academy of Family Physicians (N = 3553) were mailed a questionnaire in 2002 asking them to indicate which treatments they felt were effective for MDD, panic disorder, and GAD and also to indicate how they had treated their last patient with each disorder. Their treatment strategies were then compared with current guidelines. RESULTS: 574 physicians (16%) responded. The percentage of respondents scoring at or above 80% for knowledge of effective treatments was 88.3% for MDD, 16.8% for panic disorder, and 12.5% for GAD (p <.001 for MDD vs. panic disorder or GAD). Only 0.3% of MDD patients, 1.4% of panic disorder patients, and 4.0% of GAD patients were not prescribed at least 1 of the effective treatments. Referral rates to mental health providers were high for all 3 conditions. CONCLUSIONS: There were significant gaps in physician knowledge of current guidelines on treating panic disorder and GAD, but not MDD. However, most patients with one of the disorders were either referred to a mental health provider or treated with an effective modality.

Trends in elderly patients' office visits for the treatment of depression according to physician specialty: 1985-1999

Changes from 1985 to 1999 in diagnosis of depression and prescription of antidepressant medications during visits by elderly patients to primary care physicians, psychiatrists, and other specialists were examined. Using nationally representative surveys of office-based practices, estimates of the proportion of office visits by elderly patients during which a physician diagnosed depression or prescribed an antidepressant medication were obtained. Between 1985 and 1993-1994, a significant increase in the rate of depression diagnosis was seen, but no change was observed between 1993-1994 and 1998-1999. Rates of prescribing of antidepressants more than doubled between 1985 and 1998-1999. The majority of depression visits and visits where an antidepressant was prescribed were to primary care physicians in all time periods examined. Primary care depression treatment initiatives should place greater emphasis on elderly patients.

Improving care for minorities: can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial

OBJECTIVE

Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities.

STUDY SETTING

The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. STUDY DEIGN: Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians).

DATA EXTRACTION METHODS

Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups.

PRINCIPAL FINDINGS

At baseline, all ethnic groups Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8-20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients.

CONCLUSIONS

Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities.

The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients

BACKGROUND

Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment.

METHODS

A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling.

RESULTS

African Americans (adjusted OR, 0.30; 95% CI 0.19-0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26-0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35-1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08-9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression.

CONCLUSIONS

African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients' cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Sociological influences on antidepressant prescribing

This study examined how patient characteristics, physician characteristics, the physician's interaction with the health care system, and the physician's interaction with the patient influenced whether patients with a depression diagnosis received an antidepressant prescription and whether they received a SSRI antidepressant, a non-SSRI antidepressant, or both. The 1998 National Ambulatory Medical Care Survey (NAMCS), in the USA, was used for the analysis. Logistic regression was used to examine what characteristics influenced whether a patient with a depression diagnosis received an antidepressant prescription. Next, a multinomial logistic regression model was applied to examine the relative risk of using one type of antidepressant versus another among antidepressant users while correcting for possible sample selections using the Heckman selection model. Sixty-seven percent of patients with a depression diagnosis received an antidepressant. Patients who were seeing providers who were not primary care physicians or psychiatrists, self-paying patients, and patients with neurotic depression were significantly less likely to receive an antidepressant prescription. Patients with depression listed as their first diagnosis were significantly more likely to receive an antidepressant prescription. Patients seeing a psychiatrist were more likely than patients seeing a primary care physician to receive a non-SSRI antidepressant than a SSRI antidepressant. Patients belonging to an HMO that had capitated visits were over four times more likely to receive non-SSRI antidepressants than SSRI antidepressants. Patients with major depression were significantly more likely to receive a non-SSRI antidepressant. Patients with depression as their primary diagnosis and patients who saw psychiatrists were significantly more likely to receive both SSRI and non-SSRI antidepressants rather than just SSRI antidepressants. Patient characteristics, physician characteristics, the physician's interaction with the health care system, and the physician's interaction with the patient all influenced antidepressant prescribing. An especially important finding was that insurance status influenced whether patients received an antidepressant. Health care providers need to take the time to help patients without insurance obtain antidepressant medication if it is needed.

Low dosage tricyclic antidepressants for depression

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWER'S CONCLUSIONS

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

The economic burden of depression and the cost-effectiveness of treatment

Cost-of-illness research has shown that depression is associated with an enormous economic burden, in the order of tens of billions of dollars each year in the US alone. The largest component of this economic burden derives from lost work productivity due to depression. A large body of literature indicates that the causes of the economic burden of depression, including impaired work performance, would respond both to improvement in depressive symptomatology and to standard treatments for depression. Despite this, the economic burden of depression persists, partly because of the widespread underuse and poor quality use of otherwise efficacious and tolerable depression treatments. Recent effectiveness studies conducted in primary care have shown that a variety of models, which enhance care of depression through aggressive outreach and improved quality of treatments, are highly effective in clinical terms and in some cases on work performance outcomes as well. Economic analyses accompanying these effectiveness studies have also shown that these quality improvement interventions are cost efficient. Unfortunately, widespread uptake of these enhanced treatment programmes for depression has not occurred in primary care due to barriers at the level of primary care physicians, healthcare systems, and purchasers of healthcare. Further research is needed to overcome these barriers to providing high-quality care for depression and to ultimately reduce the enormous adverse economic impact of depression disorders.

Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression

BACKGROUND AND OBJECTIVES

To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients' outcomes 12, 18, and 24 months following baseline.

RESEARCH DESIGN

Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions.

SUBJECTS

In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months.

MEASURES

Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview.

RESULTS

Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively; P = 0.01). The intervention had no significant impact on insured patients' MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively; P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively; P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care.

CONCLUSIONS

The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention's impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study's intervention.

Narrowing the gap in treatment of depression

OBJECTIVE

Although effective treatments for depression exist, under or non-treatment of depression is common. Efforts were made in the early 1990s to improve recognition and treatment of depression, with many of those efforts targeted at groups most vulnerable to under-treatment. The purpose of this study is to assess treatment rates in 1993-1994 and 1996-1997.

METHOD

Using nationally representative surveys of office-based practice covering the years 1993, 1994, 1996, and 1997, we obtained estimates of visits by adults in which depression was diagnosed and a prescription for antidepressant medication and/or psychotherapy was provided or ordered.

RESULTS

The proportion of physician office visits in which a depression diagnosis was recorded did not change from 1993-1994 (3.48 percent) to 1996-1997 (3.40 percent). However, the rate of antidepressant prescription or psychotherapy rose from 74.2 percent of visits with a depression diagnosis in 1993-1994 to 82.3 percent of these visits in 1996-1997. Significantly lower rates of treatment for depression during office visits made by African American patients, elderly patients, and patients on Medicaid occurred in 1993-1994, but were not evident in 1996-1997, reflecting improved rates of depression treatment in these populations.

CONCLUSIONS

Although rates of diagnosis of depression during office visits have not increased, treatment rates for depression are improving among those who are diagnosed, including groups of people who historically were less likely to be offered treatment. Additional efforts to improve recognition and diagnosis of depression in ambulatory medical practice and to improve dissemination of treatment are needed.

Understanding the causal relationship between patient-reported interpersonal and technical quality of care for depression

OBJECTIVES

Patient ratings of their health care experience have become increasingly important as indicators of interpersonal quality of care. Currently the link between technical and interpersonal quality of care indicators is not well understood. The goal of this study was to examine the temporal relationship between technical quality of care for depression and interpersonal quality of care by examining their association over time.

METHODS

A cross-lagged (longitudinal) path analytic model was estimated to examine the causal relationship between two measures of interpersonal quality of care and technical quality of care among 697 respondents participating in the 18 and 24 month assessments of Partners in Care (PIC). Measures of age, gender, number of chronic diseases, indicators of anxiety and depression, recent service utilization, and stability of the doctor-patient relationship were included as covariates.

RESULTS

After controlling for study design and relevant patient characteristics, one significant cross-lagged effect was found: that from one measure of interpersonal quality (patient satisfaction) to technical quality (standardized coefficient = 0.18), but not from quality to satisfaction.

CONCLUSION

Results of these analyses indicate that patients who report high satisfaction with care are more likely to receive higher technical quality depression care 6 months later as compared with those who are less satisfied. This implies that one pathway to improving technical quality of care may be through increasing patients' satisfaction.

Evidence review: efficacy and effectiveness of antidepressant treatment in primary care

This review considers evidence for the efficacy of pharmacotherapy among primary care patients with depressive disorders and reviews knowledge regarding the effectiveness of current practice. Strong evidence supports the efficacy of antidepressant pharmacotherapy for primary care patients with major depression and dysthymia with some evidence for pharmacotherapy of less severe depression. In general, available antidepressants appear equal in both efficacy and effectiveness. Treatment selection for any individual patient remains largely empirical, with few clinical characteristics predicting better or worse response to specific treatments. Strong evidence supports continuation treatment (i.e., at least six months of pharmacotherapy) for all patients and maintenance treatment (i.e., at least 24 months of pharmacotherapy) for those with chronic or recurrent depression. Unfortunately, few patients in primary care or specialty practice receive recommended levels of pharmacotherapy or recommended frequency of follow-up care. A number of recent studies have evaluated strategies to improve the quality of antidepressant treatment in primary care. Educational programs (including academic detailing and continuous quality improvement) have had little impact on patient outcomes. Key elements of effective care improvement programs include specific, evidence-based treatment protocols, organized patient education and active follow-up care.

Identify bipolar spectrum disorders

Patients with bipolar spectrum disorders commonly present with depressive symptoms to primary care clinicians. This article details bipolar spectrum disorder assessment, treatment, and treatment response. By intervening early in the course of depressive and hypomanic episodes, you can help decrease the morbidity and suffering associated with bipolar spectrum disorders.