A rapidly growing body of research suggests that depression in primary care may differ from that in psychiatry in its nature, severity, comorbidity, and responsiveness to treatment. The Michigan Depression Project is a long-term series of studies designed to explore the twin assumptions that depressed primary care patients are similar to depressed psychiatric patients and that identical treatment will benefit both groups. Major findings are (1) criterion-based diagnosis of major depressive disorder in primary care includes many patients with mild depression and little to no impairment; (2) the onset of depression among family practice patients-but not psychiatric patients-is usually preceded by a severe life event; (3) in primary care, outcome for patients with undetected depression appears to be comparable to that for those with detected depression; and (4) family physicians appear to employ historical cues in assigning the diagnosis of depression to distressed and impaired patients. The results of the Michigan Depression Project and the recent work of other researchers suggest that the challenges facing primary care physicians in the diagnosis and treatment of depressed patients are daunting. These challenges lead to a set of consultative skills and behaviors on the part of psychiatrists that may be different than generally expected. One-time, stand-alone psychiatric consultations are often needed, because neither the primary care physician nor the patient desires the psychiatric care to be "carved out" from the continuing care of a set of chronic problems. Future intervention studies should compare subgroups of patients who appear most in need of treatment (on the basis of functional impact) with those who are mildly depressed and barely meet diagnostic criteria. These studies will help primary care physicians focus their energies and therapies where they will have the most benefit in treating what is clearly a common and important, but still poorly understood, problem in primary care medical practice.
"We assumed that with this smaller number of sessions dropout would be less likely. We also assumed that a less intense type of treatment would be sufficient, because of the usually less severe nature of major depressive disorders in general practice . The aim was to complete the therapy within five months. "
[Show abstract][Hide abstract] ABSTRACT: Interpersonal Psychotherapy (IPT) is recommended in most depression treatment guidelines and proved to be a suitable treatment for elderly depressed patients. Despite the favorable results of IPT in research populations, the dissemination to general practice is surprisingly limited. Little is known about uptake and satisfaction when this therapy is introduced into real-life general practice.
Motivation and evaluation of patients, GPs and therapists were recorded and organizational barriers described alongside a randomized controlled trial. IPT, given by mental health workers, was compared with usual general practitioner (GP) care. Included were patients (> or =55 years) who met the DSM-IV criteria for major depressive disorder.
Patients were motivated for the psychotherapy intervention: of the 205 eligible patients, 143 (70%) entered the study, and of the 69 patients who were offered IPT, 77% complied with the treatment. IPT proved to be an attractive therapy for patients as well as for therapists from mental health organizations. General practitioners evaluated the intervention positively afterwards, mainly because of the time-limited and structured approach. Organizational barriers: no IPT therapists were available; an IPT trainer and supervisor had to be trained and training materials had to be developed and translated. Additionally, there was a lack of office space in some general practices; for therapists from private practices it was not feasible to participate because of financial reasons. IPT was superior to usual care in patients with moderate to severe depression.
As we succeeded in delivering IPT in primary care practice, and as IPT was superior to usual care, there are grounds to support the implementation of IPT for depressed elderly patients within general practice, as long as the practices have room for the therapists and financial barriers can be overcome. Consolidation may be achieved by making this intervention available through practice nurses or community psychiatric nurses who deliver IPT as part of a more comprehensive depression management program.
BMC Family Practice 02/2007; 8(1):52. DOI:10.1186/1471-2296-8-52 · 1.67 Impact Factor
"Projects to improve depression management have reported that simple guideline implementation and educational strategies were generally ineffective. In short term evaluation, effective strategies were those with broad interventions that incorporated clinical education, enhanced team work and a greater integration between primary care and psychiatry [46-50]. "
[Show abstract][Hide abstract] ABSTRACT: The way GPs work does not appear to be adapted to the needs of depressive patients. Therefore we wanted to examine Swedish GPs' conceptions of depressive disorders and their treatment and GPs' ideas of factors that may influence their manner of work with depressive patients.
A postal questionnaire to a stratified sample of 617 Swedish GPs.
Most respondents assumed antidepressive drugs effective and did not assume that psychotherapy can replace drugs in depression treatment though many of them looked at psychotherapy as an essential complement. Nearly all respondents thought that clinical experiences had great importance in decision situations, but patients' own preferences and official clinical guidelines were also regarded as essential. As influences on their work, almost all surveyed GPs regarded experiences from general practice very important, and a majority also emphasised experiences from private life. Courses arranged by pharmaceutical companies were seen as essential sources of knowledge. A majority thought that psychiatrists did not provide sufficient help, while most respondents perceived they were well backed up by colleagues.
GPs tend to emphasize experiences, both from clinical work and private life, and overlook influences of collegial dealings and ongoing CME as well as the effects of the pharmaceutical companies' marketing activities. Many GPs appear to need more evidence based knowledge about depressive disorders. Interventions to improve depression management have to be supporting and interactive, and should be combined with organisational reforms to improve co-operation with psychiatrists.
BMC Family Practice 06/2005; 6(1):21. DOI:10.1186/1471-2296-6-21 · 1.67 Impact Factor
Austin Granatowicz, Caroline I Piatek, Elizabeth Moschiano, Ihab El-Hemaidi, Joel D Armitage, Mojtaba Akhtari
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