Patients' and practice nurses' perceptions of depression in patients with type 2 diabetes and/or coronary heart disease screened for subthreshold depression

Enhancement of Preoperative Mental Health Assessment Through Clinical Nurse Specialist Project Leadership

PURPOSE/OBJECTIVES

The aim of the project was to discern whether a collaborative, consultative-rich, clinical nurse specialist-led project could increase completion rates of a patient health questionnaire for depression and a generalized anxiety disorder questionnaire with appropriate referrals in adult patients in the ambulatory and hospital settings of a robust cardiovascular surgery practice before cardiovascular surgery.

DESCRIPTION OF PROJECT

The Define, Measure, Analyze, Improve, Control implementation methodology guided this quality improvement project. The workflow was analyzed in collaboration with stakeholders, and barriers to and facilitators of questionnaire completion were identified. Interpreter services partnerships were enhanced and used for patients with a preferred language other than English. Weekly data analysis assessed ongoing questionnaire completion rates.

OUTCOME

Documented completion rates of questionnaires improved across ambulatory and hospital settings by 15%. Patients with a preferred language other than English had an 80-percentage-point increase in documented questionnaire completion.

CONCLUSION

Clinical nurse specialists are poised to lead projects because of their use of the collaborative and consultative core competencies. A formal electronic health record report was established for monitoring outcomes. Embedding questionnaire administration within the standard workflow of ambulatory and hospital staff makes administering questionnaires preoperatively a sustainable practice in both settings.

Experiences and care needs of post-discharge patients who underwent cardiac surgery: A qualitative study

AIM

This study clarifies the physical, psychological, and social forms of distress in, and care needs of, cardiac surgery patients, including optimal times for supporting them in their post-hospital discharge daily lives.

METHODS

Semi-structured qualitative interviews were conducted. Participants included 12 adults (11 male and one female, mean age = 66.5 years) who had undergone cardiac surgery, experienced intensive care, and received outpatient care at the first post-discharge visit (around 2 ~ 3 weeks after discharge), around 3 months after discharge, and between 3 months and 1 year after discharge. Verbatim transcripts were analyzed based on similarities and differences for codes based on assessment items, and subcategories and categories were generated.

RESULTS

After surgery, patients experienced physical, psychological, and social distress. First, they experienced physical pain shortly after discharge. Moreover, as they recovered at home, a gap between their sense of their recovery and the perceptions of those around them about their recovery often persisted, which led to psychological and social distress. Patients gained a sense of safety through "assurance of physical recovery" and security through "shared subjective distress."

CONCLUSIONS

Post-cardiac surgery patients seek reassurance and safety by sharing experiences owing to daily life distress. Our findings could help provide better support to meet the care needs of such patients.

A primary care psychoeducational group intervention for patients with depression and physical comorbidity: A qualitative study with a gender perspective

OBJECTIVE

To explore the experiences and emotions of individuals with depression and physical comorbidity within the context of psychoeducational group interventions led by primary care nurses in Catalunya (Spain).

METHOD

A psychoeducational group intervention was conducted in the first semester of 2019 with 13 primary care teams (rural/urban) and 95 participants with depression and physical comorbidity. The qualitative research and phenomenological perspective were based on 13 field diaries and 7 semi-structured interviews carried out with the observer nurses. The interviews were recorded and transcribed. Codes were identified by segmenting the text into citations/verbatim accounts and emerging categories/subcategories by regrouping the codes. The results were triangulated among the researchers to identify and compare similarities and differences.

RESULTS

Four major themes were found: (a) gender differences; (b) coping strategies and changes observed during the intervention; (c) functions of the group as a therapeutic element; and (d) the nurses' perceptions of the group experience. Gender differences were identified in relation to experiences and emotions.

CONCLUSIONS

As some patients acquired skills/behaviours during the intervention that helped them initiate changes and the nurses were satisfied with the intervention, it is important to include this information when planning effective interventions for patients with this profile.

General practice management of depression among patients with coronary heart disease in Australia

BACKGROUND

Incident depression is associated with coronary heart disease (CHD) and increased morbidity and mortality. Treatment of depression with antidepressants and psychotherapy can be beneficial for these patients to reduce the risk of further CHD events. Ongoing management of CHD and depression mainly occurs in the community, but little is known about the identification and care of patients with comorbid CHD and depression in general practice. This study explores the prescription of antidepressants for these patients by sociodemographic variables.

METHODS

This is an open cohort study with de-identified data based on electronic medical records of 880,900 regular patients aged 40 + years from a national general practice database in Australia (MedicineInsight). Data from 2011-2018 was used to classify patients as newly recorded CHD (CHD recorded in 2018 but not in previous years), previously recorded CHD (CHD recorded between 2011-2017) or no recorded history of CHD. Antidepressant prescribing in 2018 considered active ingredients and commercial brand names. The association between sociodemographic variables and antidepressant prescribing was tabulated according to the CHD status.

RESULTS

The proportion of current depression among patients with newly recorded CHD was 11.4% (95%CI 10.3-12.6), 10.5% among those with previously recorded CHD (95%CI 10.0-11.1) and 9.6% among those with no recorded history of CHD (95%CI 9.2-10.1). Antidepressant prescribing was slightly higher among those with newly recorded CHD (76.4%; 95%CI 72.1-80.6) than among those with previously recorded CHD (71.6%; 95%CI 69.9-73.2) or no history of CHD (69.5%; 95%CI 68.6-70.4). Among males with newly recorded CHD and depression, antidepressant prescribing was more frequent in major cities or inner regional areas (~ 81%) than in outer/remote Australia (66.6%; 95% CI 52.8-80.4%).

CONCLUSIONS

Although antidepressant prescribing was slightly greater in those with newly recorded CHD compared to those with depression alone, its clinical significance is uncertain. Much larger differences in prescribing were seen by geographic location and could be addressed by innovations in clinical practice.

Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy

BACKGROUND

Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption.

METHODS

We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients.

RESULTS

We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support.

CONCLUSIONS

We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

Barriers and enablers to screening and diagnosing diabetes distress and depression in people with type 2 diabetes mellitus: A qualitative evidence synthesis

AIM

Synthesise qualitative evidence of healthcare professionals' (HCP) experiences of diabetes distress and depression screening in people with type 2 diabetes (T2DM) in primary care to identify HCP barriers and enablers to screening implementation.

METHODS

Searched six electronic databases in October 2020 for qualitative studies exploring HCPs' experiences of diabetes distress and depression screening in T2DM populations. Applying a best-fit framework synthesis, data were coded to the theoretical domains framework (TDF), followed by thematic analysis of data that did not fit the TDF. Study quality and confidence in findings were assessed using CASP and GRADE-CERQual respectively.

FINDINGS

Of 4942 unique records identified, 10 articles were included. We identified fifteen barriers and enablers in 8 TDF domains and 1 new domain; people with T2DM factors. One barrier (poor awareness about the rationale for screening) and 2 enablers (perceived impacts on T2DM care, receiving financial reimbursement) were assessed as findings of high confidence.

CONCLUSION

HCPs experience many barriers and enablers to diabetes distress and depression screening among people with T2DM in primary care. Future interventions and policies should ensure HCPs understand the rationale for screening, highlight the benefits of screening, resource screening appropriately and address HCP group specific barriers.

Understanding care needs of cancer patients with depressive symptoms: The importance of patients' recognition of depressive symptoms

Objective

The majority of cancer patients with depressive symptoms does not perceive a need for psychological care. Reasons for this are still unclear. We examined the mediating role of cancer patients' perceptions of depressive symptoms in the relationship between depressive symptoms and perceived need for psychological care.

Methods

For this cross‐sectional study, we recruited 127 Dutch cancer patients with moderate to severe levels of depressive symptoms (Patient Health Questionnaire [PHQ]‐9≥10) who did not receive professional psychological care. Depressive symptoms were measured with the PHQ‐9 questionnaire, by using three different depression score operationalizations. We used mediation analyses to test the mediating role of patients' illness perceptions (measured with subscales of the Brief Illness Perception Questionnaire) in the relation between depressive symptoms and need for care.

Results

Whilst results did not show significant direct associations between depressive symptoms and perceived need for psychological care, we found positive indirect effects of severity (B = 0.07, SE = 0.04, p < 0.02), meeting the DSM‐5 diagnosis (B = 0.45, SE = 0.26, p < 0.02) and having relatively more affective symptoms (B = 2.37, SE = 1.10, p < 0.02) on need for care through the identity perception.

Conclusions

Including assessments of patients' recognition of depressive symptoms and their perceptions of depression treatment efficacy might improve depression screening in cancer patients by more accurately identifying those with a need for psychological care. Moreover, improving patients' knowledge and recognition of symptoms as being depressive symptoms might be a possible target point in increasing care needs and hereby optimizing the uptake of psychological care in cancer patients with depressive symptoms.

Life goal reconstruction for people with chronic health conditions: Feasibility of a brief internet-based writing intervention using a minimally monitored delivery

Examination of people's narratives after significant life changes revealed that engaging in current and future goal reconstruction was associated with higher levels of well-being while a failure to disengage from "what might have been" was associated with lower levels of well-being. This work led to the development of a life goal writing intervention that has received empirical support with most studies conducted among nonclinical populations. This study aims to assess the feasibility of a brief and minimally monitored internet-delivered writing therapy developed to facilitate life goal reconstruction among adults diagnosed with various chronic health conditions. Sixteen adults showing mild to moderate levels of anxiety or depression were recruited and a single group pretest/post-test design used. The 5-week program is comprised of psychoeducation, five weekly 30-min writing sessions, automated emails and symptom monitoring. Feasibility outcome measures included attrition, treatment adherence, acceptability and preliminary effectiveness. Primary outcome measures were The Patient Health Questionnaire -9 (PHQ-9) and the Generalized Anxiety Disorder -7 (GAD-7). Attrition was low (12%) and adherence high (93%). All but one study completer reported they would recommend the program. Mixed effects models revealed a significant and large reduction from pre-treatment to post-treatment on the PHQ-9 and GAD-7 and remission rates of 67% and 64% respectively. These findings suggest that it would be feasible to proceed to a larger trial. The brief duration of the intervention combined to a minimally monitored delivery may lend itself to implementation in routine clinical care milieus such as hospital settings.

A reduced state of being: The role of culture in illness perceptions of young adults diagnosed with depressive disorders in Singapore

Illness perceptions form a key part of common-sense models which are used widely to explain variations in patient behaviours in healthcare. Despite the pervasiveness of depressive disorders worldwide and in young adults, illness perceptions of depressive disorders have not yet been well understood. Moreover, while a high proportion of cases of depressive disorders reside in South-east Asia, few have explored illness perceptions that are culturally relevant to this region. To address these limitations, this study aimed to understand illness perceptions of young adults diagnosed with depressive disorders. Face-to-face semi-structured interviews were conducted among Chinese, Malay, and Indian young adults aged 20 to 35 years old, who were seeking treatment at a psychiatric hospital. Data reached saturation after 33 interviews (10 to 12 interviews per ethnic group) and five themes emerged from the thematic analysis: 1) A reduced state of being experienced at a point of goal disengagement, 2) the accumulation of chronic stressors in a system that demands success and discourages the pursuit of personally meaningful goals, 3) a wide range of symptoms that are uncontrollable and disabling, 4) poor decision making resulting in wasted opportunities, with some positive takeaways, and 5) accepting the chronicity of depression. Young adults typically experienced depression as a reduced state of being and it was thought of cognitively as an entity that may be a part of or separate from the self. Over and beyond these aspects of cognitive representations was the emergence of themes depicting conflicts and dilemmas between the self and the social environment that threatened self-identity and autonomy. Addressing these conflicts in therapy would therefore be of utmost relevance for young adults recovering from depressive disorders in the local setting.

Investigating patients´ views on screening for depression in cardiac practice: A qualitative interview study

OBJECTIVE

Recommendations on screening for depression in patients with coronary heart disease (CHD) are highly debated. While recent research has prioritized efficacy studies, little is known about what is potentially required for screening to be efficacious. Expanding our knowledge of how patients with CHD view screening is likely to pose a first step towards addressing this gap. We aimed to investigate patients ́ views on routine screening for depression in cardiac practice.

METHODS

This exploratory, qualitative study was conducted among 12 patients with CHD, who completed semi-structured interviews. We used a purposive sampling strategy to include patients within a range of ages, gender and self-reported depression. Thematic analysis was carried out.

RESULTS

We identified four main themes: Acceptance, utility, barriers and expectations. Patients in this sample appeared to be in favor of standardized routine screening for depression in cardiac practice, if the rationale was disclosed. Patients reported that standardized screening addresses holistic care demands, promotes validation of individual symptom burden and legitimizes the display of psychological distress in cardiac practice. Yet, skepticism towards the validity of screening instruments and perceived stigmatization could pose a main barrier to screening efficacy. Patients expected to receive feedback on results and consecutive recommendations.

CONCLUSION

We found that depression screening is endorsed by patients with CHD in this study sample. Standardized routine screening procedures could serve as a useful tool to combat stigmatization, and encourage patients to display symptoms of depression towards cardiologists. The efficacy of depression screening could potentially be enhanced by tailoring the screening process towards patients´ needs.

Lessons learned from an attempted randomized-controlled feasibility trial on "WIDeCAD" - An internet-based depression treatment for people living with coronary artery disease (CAD)

Despite the high prevalence of comorbid depression in people living with coronary artery disease (CAD), uptake of psychological treatment is generally low. This study was designed to investigate the feasibility of an internet-based cognitive-behavioral (iCBT) depression intervention for people with CAD and depressive symptoms.

METHODS

People with CAD and depressive symptoms (PHQ-9 ≥ 5) were randomly assigned to the eight modules comprising iCBT (N = 18), or waitlist-control (N = 16). Measures were taken at baseline (t1) and at post-treatment (eight weeks after randomization, t2). Feasibility-related outcomes were recruitment strategy, study attrition, intervention dropout, satisfaction, negative effects as well as the potential of the intervention to affect likely outcomes in a future full-scale trial (depression, anxiety, quality of life, fear of progression). Data analyses were based on intention-to-treat principles. Linear regression models were used to detect between group differences. Linear Mixed Models were used to model potential changes over time.

RESULTS

This trial was terminated prior to a-priori defined sample size has been reached given low recruitment success as well as high intervention dropout (88%) and study attrition (23%). On average, participants in the intervention group completed M = 2.78 (SD = 3.23) modules. Participants in the waitlist control group barely started one module (M = 0.82, SD = 1.81). The satisfaction with the intervention was low (M = 20.6, SD = 0.88). Participants reported no negative effects attributed to the iCBT. Differences between groups with regard to depression, anxiety, fear of progression and quality of life remained non-significant (p > 0.05).

CONCLUSION

This trial failed to recruit a sufficient number of participants. Future work should explore potential pitfalls with regards to the reach and persuasiveness of internet interventions for people living with CAD. The study gives important indications for future studies with regard to the need for new ideas to reach and treat people with CAD and depression.

Effectiveness of a Psychoeducational Group Intervention Carried Out by Nurses for Patients with Depression and Physical Comorbidity in Primary Care: Randomized Clinical Trial

The association between physical illness and depression implies a poorer management of chronic disease and a lower response to antidepressant treatments. Our study evaluates the effectiveness of a psychoeducational group intervention led by Primary Care (PC) nurses, aimed at patients of this kind. It is a randomized, multicenter clinical trial with intervention (IG) and control groups (CG), blind response variables, and a one year follow-up. The study included 380 patients ≥50 years of age from 18 PC teams. The participants presented depression (BDI-II > 12) and a physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma. The IG (n = 204) received the psychoeducational intervention (12 weekly sessions of 90 min), and the CG (n = 176) had standard care. The patients were evaluated at baseline, and at 4 and 12 months. The main outcome measures were clinical remission of depressive symptoms (BDI-II ≤ 13) and therapeutic response (reduction of depressive symptoms by 50%). Remission was not significant at four months. At 12 months it was 53.9% in the IG and 41.5% in the CG. (OR = 0.61, 95% CI, 0.49–0.76). At 4 months the response in the IG (OR = 0.59, 95% CI, 0.44–0.78) was significant, but not at 12 months. The psychoeducational group intervention led by PC nurses for individuals with depression and physical comorbidity has been shown to be effective for remission at long-term and for therapeutic response at short-term.

A Web-Based Mental Health Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The Springboard Trial): 12-Month Outcomes of a Randomized Controlled Trial

BACKGROUND

People with type 2 diabetes mellitus (T2DM) often experience mental health symptoms that exacerbate illness and increase mortality risk. Access to psychological support is low in people with T2DM. Detection of depression is variable in primary care and can be further hampered by mental health stigma. Electronic mental health (eMH) programs may provide an accessible, private, nonstigmatizing mental health solution for this group.

OBJECTIVE

This study aims to evaluate the efficacy over 12 months of follow-up of an eMH program (myCompass) for improving social and occupational functioning in a community sample of people with T2DM and self-reported mild-to-moderate depressive symptoms. myCompass is a fully automated and self-guided web-based public health program for people with depression or anxiety. The effects of myCompass on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior were also examined.

METHODS

Adults with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited via online advertisements, community organizations, and general practices. Screening, consent, and self-report questionnaires were administered online. Eligible participants were randomized to receive either myCompass (n=391) or an attention control generic health literacy program (Healthy Lifestyles; n=379) for 8 weeks. At baseline and at 3, 6, and 12 months postintervention, participants completed the Work and Social Adjustment Scale, the Patient Health Questionnaire-9 item, the Diabetes Distress Scale, the Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Glycosylated hemoglobin measurements were obtained at baseline and 6 and 12 months postintervention.

RESULTS

A total of 38.9% (304/780) of the trial participants completed all postintervention assessments. myCompass users logged in on an average of 6 times and completed an average of 0.29 modules. Healthy Lifestyles users logged in on an average of 4 times and completed an average of 1.37 modules. At baseline, the mean scores on several outcome measures, including the primary outcome of work and social functioning, were close to the normal range, despite a varied and extensive recruitment process. Intention-to-treat analyses revealed slightly greater improvement at 12 months in work and social functioning for the Healthy Lifestyles group relative to the myCompass group. All participants reported equivalent improvements in depression anxiety, diabetes distress, diabetes self-management, and glycemic control across the trial.

CONCLUSIONS

The Healthy Lifestyles group reported higher ratings of social and occupational functioning than the myCompass group, but no differences were observed for any secondary outcome. Although these findings should be interpreted in light of the near-floor symptom scores at baseline, the trial yields important insights into how people with T2DM might be engaged in eMH programs and the challenges of focusing specifically on mental health. Several avenues emerge for continued investigation into how best to deal with the growing mental health burden in adults with T2DM.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true.