Is major depression adequately diagnosed and treated by general practitioners? Results from an epidemiological study

Sant Joan de Déu-SSM, Fundació Sant Joan de Déu, Barcelona, Spain.
General Hospital Psychiatry (Impact Factor: 2.61). 03/2010; 32(2):201-209. DOI: 10.1016/j.genhosppsych.2009.11.015
Source: PubMed


The aim of this study was to (1) to explore the validity of the depression diagnosis made by the general practitioner (GP) and factors associated with it, (2) to estimate rates of treatment adequacy for depression and factors associated with it and (3) to study how rates of treatment adequacy vary when using different assessment methods and criteria.
Epidemiological survey carried out in 77 primary care centres representative of Catalonia. A total of 3815 patients were assessed.
GPs identified 69 out of the 339 individuals who were diagnosed with a major depressive episode according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (sensitivity 0.22; kappa value: 0.16). The presence of emotional problems as the patients' primary complaint was associated with an increased probability of recognition. Rates of adequacy differed according to criteria: in the cases detected with the SCID-I interview, adequacy was 39.35% when using only patient self-reported data and 54.91% when taking into account data from the clinical chart. Rates of adequacy were higher when assessing adequacy among those considered depressed by the GP.
GPs adequately treat most of those whom they consider to be depressed. However, they fail to recognise depressed patients when compared to a psychiatric gold standard. Rates of treatment adequacy varied widely depending on the method used to assess them.

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    • "Depression is highly prevalent in the general population [1] and is set to become one of the three leading causes of burden of disease by 2030 [2]. The majority of patients suffering from depressive disorders is managed within the primary care setting and despite the availability of effective treatments [3], the quality of care provided by GPs remains often suboptimal [4] [5]. Hence, the development of more efficient, structured and multifaceted integration programmes between primary care and mental health services was suggested to be a crucial factor for improving the depression outcomes in primary care [3] [6]. "
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    ABSTRACT: Objectives: This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries. Methods: A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure. Results: The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care. Conclusions: The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.
    Full-text · Article · Aug 2014 · Journal of Psychosomatic Research
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    • "It is difficult to properly identify and diagnose patients with depression, and among patients under antidepressant treatment, there is no planned clinical monitoring and contacts after the start of the treatment are scarce and irregular. In this situation, you lose the opportunity to adjust the treatment to the patient's clinical status and to improve adherence to treatment (Pinto-Meza et al., 2008; Fernández et al., 2010). The clinical effectiveness and usefulness of disease management models for depression that involve changes in the various components of the care process (Thota et al., 2012) have been proved. "
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    ABSTRACT: Background A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring. Methods Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life. Trial registration: ISRCTN16384353. Results A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance. Limitations The number of patients lost (31%) before follow-up may have introduced a bias. Conclusions Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables.
    Full-text · Article · May 2014 · Journal of Affective Disorders
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    • "In fact, most individuals with depression are handled either solely in primary care or in primary care combined with other services (Aragonès et al., 2004). However, difficulties have been described in the management of depression in primary care, particularly with regard to ensuring that treatments are adhered to, proper patient follow-up and the continuity of care (Fernández et al., 2010; Pinto-Meza et al., 2008). There is evidence that collaborative care programmes designed to improve the management of depression based on the chronic Contents lists available at ScienceDirect journal homepage: "
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    ABSTRACT: Background Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care. Methods A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007–2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs). Results Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane. Limitations The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression. Conclusions The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.
    Full-text · Article · Apr 2014 · Journal of Affective Disorders
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