Depression and primary care

Primary care has the lead role in reducing the burden of common mental disorders in Australia. This supplement adds to the evidence base needed to achieve it

Harvey A Whiteford MPH, FRANZCP, FAFPHM

Objective: To identify reports in the “grey literature” of programs conducted in Australian primary care to improve depression and anxiety outcomes, and to examine these reports for evidence of effectiveness.Methods: A systematic search was undertaken for grey literature reports using primary health care research databases, community and professional websites, clearinghouse sources, government reports, and reports from the Australian General Practice Network. Reports were included if they related to programs targeting depression or anxiety, contained qualitative or quantitative effectiveness data, and were published during 1995–2006.Results: In total, 642 reports were identified, of which 43 met inclusion criteria. Of the 43 programs described, 30 were delivered in general practice, five in the community or residential care, three in schools, and five were Internet or computer based. Nine programs were also reported in the formal “black” literature, but most, including the Better Outcomes in Mental Health Care initiative, were not. Limited data on effectiveness or patient outcomes were available in the grey literature.Conclusions: There is currently no single service that identifies, describes and catalogues the range and effectiveness of mental health initiatives in Australia. There may be a role for a mental health information “clearinghouse” to facilitate dissemination and education, and to promote collaboration among researchers, practitioners, consumers and policymakers. Innovative schemes to disseminate evidence-based models and to encourage the collection of data on patient outcomes in such programs are needed.

Helen Christensen PhD, MPsychol(Hons) · Kathleen M Griffiths PhD · Amelia Gulliver BScPsych(Hons), BA

Objective: To examine whether there was a reduction in demand for psychological services provided through the Access to Allied Psychological Services (ATAPS) projects after the introduction of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) program, and whether any such reduction was greater in urban than rural areas.Design and setting: A Division-level correlation analysis examining the relationship between the monthly number of sessions provided by allied health professionals through the ATAPS projects run by Divisions of General Practice, and allied health professional services reimbursed by Medicare Australia under the Better Access program, between 1 November 2006 and 31 March 2007.Main outcome measures: Uptake of each program, assessed by the number of sessions provided.Results: Overall, despite dramatic uptake of the Better Access program in the first 5 months after its introduction, the demand for ATAPS services was not reduced. The correlations between the numbers of sessions provided by both programs overall (r = − 0.078; P = 0.074) and in rural Divisions (r = 0.024; P = 0.703) were not significant. However, there was a significant negative correlation between the numbers of sessions provided by both programs in urban Divisions (r = − 0.142; P = 0.019).Conclusions: For the first 5 months of the Better Access program, the two programs seemed to operate relatively independently of each other in terms of service provision, but in urban Divisions there was a move towards services provided through the Better Access program. Early indications are that the two programs are providing complementary services and are working together to address a previously unmet need for mental health care.

Justine R Fletcher BPsych, MPsych · Bridget Bassilios BSc, GradDipPsych, DPsych · Fay Kohn DEd, MA, GradDipTESOL · Lucio Naccarella BSc(Hons), GradDipMHS, PhD · Grant A Blashki MB BS, MD, FRACGP · Philip M Burgess MA, PhD, FAPS · Jane E Pirkis MPsych, MAppEpid, PhD

Objective: To create a taxonomy of distress and depression for use in primary care, that mirrors the thinking and practice of experienced general practitioners.Design: Qualitative study, using an ethnomethodological approach, with observation of videotaped routine GP–patient consultations and in-depth interviews with GPs.Setting and participants: The study was conducted in metropolitan Melbourne in 2005. Fourteen GPs conducted 36 patient consultations where depression was a focus; nine GPs participated in in-depth interviews to elicit details of how they recognised and diagnosed depression in their patients.Results: GPs consider distress and depression in three steps. In the first step, a change in a group of symptoms and signs is observed (eg, facial expression, loss of drive). The second step categorises the syndrome according to whether or not there is an identifiable environmental cause (reactive or “endogenous”), with the final step categorising the reactive syndromes according to their most prominent symptoms: either anxiety and worry, or helplessness and hopelessness. The resulting taxonomy includes: endogenous depression (a chronic and perhaps characterological depression characterised by a lack of interest and motivation); anxious depressive reaction (stress or worry); and hopeless depressive reaction (demoralisation).Conclusion: This simple and parsimonious taxonomy has validity based on its derivation from within the primary care setting.

David M Clarke PhD, FRACGP, FRANZCP · Kay Cook MSc, PhD · Graeme C Smith MB BS, MD, FRANZCP · Leon Piterman MMed, MEdSt, FRACGP

Objectives: To assess the characteristics of people with common mental health problems who are recognised by their general practitioner, and those who are not.Design: Two different case-finding techniques (brief self-report and structured diagnostic interview) were compared with GPs’ independent assessments of patients’ presentations as psychological and/or medical.Setting and participants: 371 patients in general practices in metropolitan Sydney and rural New South Wales, with follow-up telephone interview as soon as possible after the GP visit. The study was conducted from 2001 to 2003.Main outcome measures: Overall rates of disorder, measured by the 12-item Somatic and Psychological HEalth REport (SPHERE-12), and anxiety, depression and somatisation diagnostic categories of the Composite International Diagnostic Interview – Auto; rates of disability, assessed by the 12-item Short-Form (SF-12) General Health Survey’s mental (MCS) and physical component scales; GP ratings of patients’ psychological problems, and intended treatments.Results: The SPHERE-12 showed the highest rate of case detection and greater agreement with GP assessments of psychological reasons for presentation. Patients who presented with somatic symptoms alone were most likely to be overlooked by GPs: none of the 57 patients identified by SPHERE-12 with a somatic disorder were identified by GPs as psychological presentations. Specificity for the SPHERE-12 psychological scale changed from 72% to 93%, and from 84% to 96% for the combined psychological and somatic scale, when the criterion of an SF-12 MCS score ≤ 40 was added.Conclusion: Low rates of recognition of psychological problems by GPs, and infrequent treatment for those presenting with somatic symptoms, indicate a need for building GPs skills in the assessment and management of somatisation. The SPHERE-12 may be a useful screening tool for primary care if followed by further questioning and other methods to assess diagnosis and severity to target appropriate treatment.

Kay A Wilhelm MD, FRANZCP · Adam W Finch MPsychol · Tracey A Davenport BA(Hons), eMBA · Ian B Hickie MD, FRANZCP

Objectives: To report the baseline characteristics of the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) study cohort and discuss the implications for depression care in general practice.Design: A prospective longitudinal study beginning in January 2005.Participants and setting: Adult patients with depressive symptoms identified via screening with the Center for Epidemiologic Studies Depression Scale (CES-D ≥ 16) in 30 randomly selected Victorian general practices.Main outcome measure: Depression status on the Patient Health Questionnaire (PHQ).Results: 789 patients form the cohort (71% women). At baseline, 47% were married, 21% lived alone, 36% received a pension or benefit, 15% were unable to work, 23% reported hazardous drinking, 32% were smokers, 39% used antidepressants and 19% used sedatives. 27% satisfied criteria for current major depressive syndrome (MDS) on the PHQ, while 52% had “persistent” depressive symptoms, and 22% had “transient” depressive symptoms, lasting at most a few weeks. Of those satisfying criteria for MDS, 49% were also classified with an anxiety syndrome, 40% reported childhood sexual abuse, 57% reported childhood physical abuse, 42% had at some time been afraid of their partner, and 72% reported a chronic physical condition; 84% were receiving mental health care (either taking antidepressants or seeing a health practitioner specifically for mental health care) compared with 66% of those with persistent depressive symptoms and 57% with transient depressive symptoms.Conclusion: This method of screening for depressive symptoms in general practice identifies a group of patients with substantial multiple comorbidities — psychiatric, physical and social problems coexist with depressive symptoms, raising challenges for the management of depression in general practice.

Jane M Gunn PhD, FRACGP, MB BS · Gail P Gilchrist PhD, GradDipAlc · Patty Chondros MSc(Stats), GradDipEpi · Melina Ramp MSc(AppStats), GradDipPsych, BA(SocSci) · Kelsey L Hegarty PhD, FRACGP, MB BS · Grant A Blashki MB BS, MD, FRACGP · Dimity C Pond PhD, FRACGP, MB BS · Mike Kyrios PhD, MPsych, PgradDipEduPsych · Helen E Herrman MD, FAFPHM, FRANZCP

The Mood Assessment Program (MAP) is a computerised assessment and diagnostic program developed at the Black Dog Institute, Sydney, to assist with diagnostic subtyping and management of mood disorders. MAP decision rules capture the applied research, informed by clinical expertise, that has been undertaken over the past two decades. Preliminary validation studies suggest the MAP possesses acceptable validity for key diagnostic decisions, including determination of polarity and depressive subtype, and the presence or absence of the principal anxiety disorders. The MAP provides a rich set of information to help the practitioner derive a broad formulation and so shape a management plan in conjunction with broad treatment guidelines. The program will be rolled out over the next 6 months as a formal evaluative tool for wide assessment and application by general practitioners, and subsequently to assist a broader range of health practitioners.

Gordon B Parker PhD, DSc, FRANZCP · Kathryn Fletcher BSc(PsychHons) · Matthew P Hyett BSc, PGDipPsych

Objective: To evaluate the impact of an educational intervention on general practitioners’ skills in cognitive behavioural strategies (CBS).Design: Randomised controlled trial, with baseline and post-training measurement of GP competency in CBS using standardised simulated patient consultations, conducted between January 2005 and December 2006.Participants and setting: 55 GPs in Victoria with a special interest in mental health issues.Intervention: A 20-hour multifaceted educational program facilitated by mental health experts, incorporating rehearsal of CBS and provision of resources such as patient education material and worksheets.Main outcome measures: Objective ratings of videotaped consultations of a standardised simulated patient using the Cognitive Therapy Scale.Results: 32 doctors completed all phases of the intervention and the evaluation protocol. The intervention group showed greater improvements than the control group in both general therapeutic and specific CBS skills after the training.Conclusion: Competency in CBS in highly motivated GPs can be improved by a brief training intervention.Trial registration: International Standard Randomised Controlled Trial Number ISRCTN62481969.

Grant A Blashki MB BS, MD, FRACGP · Leon Piterman MMed, MEdSt, FRACGP · Graham N Meadows MD, MRCPsych, FRANZCP · David M Clarke PhD, FRACGP, FRANZCP · Vasuki Prabaharan PhD, MSc(Applied Statistics), GradDip(Applied Statistics) · Jane M Gunn PhD, FRACGP, MB BS · Fiona K Judd MD, DPM, FRANZCP

Objective: To evaluate the diagnosis of patients with somatisation disorders in primary care, and the effectiveness of coordinated care and evidence-based care planning on psychiatric symptoms and quality of life for these patients.Design, setting and participants: This was a project of the SA HealthPlus Coordinated Care Trial, comprising a randomised controlled trial of 124 subjects recruited by general practitioners in southern Adelaide. Eligible patients had a GP diagnosis of somatisation, including unexplained physical symptoms as part of anxiety, chronic pain or somatoform disorders. Diagnoses were checked using the Composite International Diagnostic Interview (CIDI). The study was conducted from December 1997 to December 1999.Intervention: A care plan including treatment for depression and anxiety disorders, a containment strategy for somatisation, and service coordinator-assisted self-management. Control patients received standard treatment.Main outcome measures: Psychiatric symptoms; quality of life; medication use; and depression, anxiety and hostility scores.Results: Compared with CIDI diagnoses, mood disorders in patients were underdiagnosed by GPs (64 v 31), particularly major depression (46 v 1). At 12 months, the intervention group showed reductions in depression (P = 0.002), guilt (P = 0.006) and anxiety (state, P = 0.043; trait, P = 0.001). Compared with the control group, physical role functioning improved for the intervention group (P = 0.006), and their medication use decreased by 8.9%.Conclusions: Conservative management, treatment of depression, and case management by service coordinators is effective in managing somatising patients in primary care. GPs require training in the diagnosis of depression and how to say “no” to patients with unexplained physical symptoms who request further unnecessary investigations or referrals.

Rene G Pols FRANZCP, FAFPHM, FFPMANZCA · Malcolm W Battersby PhD, FRANZCP, FAChAM

Objectives: To determine the effectiveness of “Keeping the blues away” (KBA), a manualised depression relapse prevention program for general practice, in reducing the relapse of depression compared with usual care (with the aim of halving the relapse rate), and in reducing depression severity and improving the process of care.Design and setting: A cluster randomised controlled trial conducted in 2004–2005 in South Australian general practices.Participants: 43 general practitioners from 23 urban and rural practices recruited 110 patients with depression (age range, 18–75 years).Intervention: GP training manual or patient manual and relaxation CD; 20 hours of training on depression, the study protocol, assessment tools and skills.Main outcome measures: Relative risk (RR) of depression relapse; depression severity and quality of life scores.Results: There were no significant differences in relapse rates between the groups (χ21 = 1.51; P = 0.23), although there was a non-significant tendency for relapse to be reduced in the KBA group (RR = 0.77; 95% CI, 0.50–2.05). Older patients (≥ 50 years) in the KBA group showed a significantly lower probability of relapse than those in the control group (P = 0.018). There was a decrease in depression scores in both groups. KBA participants had more severe depression at baseline, and the reduction in severity in those with symptoms for > 6 months was nearly significant (P = 0.06). KBA was positively received by GPs and patients.Conclusions: Although this pilot study of a small sample did not achieve its primary outcome of reducing depression relapse by 50%, KBA was found to be a promising program for older patients and for those with more severe or persistent symptoms.

Catherine A Howell BM BS, FRACGP, MHSM · Deborah A Turnbull BA(Hons), MPsych(Clin), PhD · Justin J Beilby MB BS, MD, FRACGP · Charlotte A Marshall BA(Hons), MPsych(Clin), MAPS · Nancy Briggs BSc, MA(Psych), PhD · Wendy L Newbury RN

Objective: To identify the health and mental health information needs of people with coronary heart disease (CHD), with and without comorbid depression.Design and setting: A qualitative study conducted in Melbourne in 2006, using thematic analysis of semi-structured interviews on the types of health information that patients with CHD considered useful to assist with the management of their illness. Structured clinical interviews were used to assess current and prior depressive episodes in these patients.Participants: 14 general practice patients (eight with current or prior history of major depression) who had experienced myocardial infarction, coronary artery bypass graft surgery, angioplasty or angina (confirmed via testing).Results: Four themes relating to information on how patients could manage their cardiovascular health and improve their psychosocial wellbeing emerged: psychosocial; physical activity; medical; and information for family. The most prominent information needs included identification and management of risk-related physical symptoms, and psychosocial information, most notably to enhance patients’ social support. Patients considered this information important for alleviating health anxiety and negative affect.Conclusion: This small patient sample endorsed the need for health and mental health information on a range of psychosocial and physical health topics. Participants desired specific types of information to assist with the self-management of their health and to assuage their health concerns.

Ciaran Pier PhD, BA(Hons)(Psych) · Kerrie A Shandley MPsych(Health), GradDip(Psych), BSc · Julie L Fisher PhD, MBusInfoSys, GradDipComputersInEducation · Frada Burstein MSc(ApplMath), PhD · Mark R Nelson PhD, FRACGP · Leon Piterman MMed, MEdSt, FRACGP