Depression Flashcards
What are some barriers to the diagnosis of depression?
Docherty, 1997
- Patient’s lack of awareness and understanding of the nature of the disease
- Variability of the clinical presentation
- Presence of comorbid medical disorders
— E.g. hypothyroidism
- Fear of the stigma attached to depression
- Ashamed to admit to psychological symptoms
- Physician’s lack of knowledge about the diagnosis and lack of training in its management
— Reduces the physician’s ability to render a diagnosis and successfully treat the illness
- Barriers from the system:
— Financing of care under capitated systems
— Time available to care for patients
— Continuity of the physician/patient relationship
Whitebird, Solberg, Margolis, Asche, Trangle, Wineman – 2013
- Interviewed 82 physicians and administrative leaders of 41 medical groups
— What is preventing the organisational changes needed to improve the treatment of depression?
- US study (Minnesota) – applicability to UK? Especially due to differences between our healthcare system and the proportion of budget spent on mental health
— Possible ethnocentric bias
- Some identified barriers to improving care:
— External contextual problems including:
— Reimbursement
— Scarce resources
— Access to/communication with speciality mental health
— Individual attitudes
— Physician and patient resistance
— Internal care process barriers
— Organisational and condition complexity
— Difficulty standardising and measuring care
Coventry, Hays and Chew-Graham – 2011
- 29 people interviewed
— 19 healthcare professionals, 7 service users and 3 carers
— Small sample size
— Under-representation of patients and carers – they should be at least in equal proportion to the HCPs
- Qualitative data hence difficult to put data together to draw overall conclusions
- Barriers to detecting and managing depression in people with long term conditions in primary care:
— If practitioners/patients conceptualise depression as a common and understandable response to the losses associated with LTCs
— It is often normalised – may stop individuals from actively seeking help
— Encouragement (through QOF) of reductionist approaches to case finding in people with CHD and diabetes
— Uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management
What are some potential solutions for barriers to improved organisation of care?
Von Korff, Katon, Unützer, Wells, Wagner. 2001
- Aligning efforts to improve depression care with broader strategies for improving care of other chronic conditions
- Increasing the availability of depression case management services in primary care
- Developing registries and reminder systems to ensure active follow up of depressed patients
- – This is an important one – when a person is in a depressive state of mind, they may not realise how much help they can receive by attending appointments and hence gentle reminders may encourage them to attend. However, it is also important that a person wants to attend a therapy session (willingness to engage improves outcome) so this scheme must be careful that it does not force people to attend unwillingly.
- Achieving agreement on how depression outcomes should be measured to provide outcomes-based performance standards
- Providing greater support from mental health specialists for management of depressed patients by primary care providers
- Campaigns to reduce the stigma associated with treatment of depressive illness
- – Stigma is a huge barrier to accessing help. Improving the general public’s awareness and understanding of mental health problems may be a step towards addressing this stigma
- Increased dissemination of interventions that activate and empower patients managing a depressive illness
- – With a strong evidence base (requires up to date research)
- – However this requires a lot of investment since many of the effective interventions (such as CBT) are time and money consuming
- Redefining the lack of time of Primary care providers for high quality depression care as issues in organisation of care and provider training
- Development of incentives for high quality depression care
- – Could this lead to over-diagnosis or even excessive treatment (e.g. Treatment of mild depression with anti-depressants or psychotherapy, which is unnecessary)
What are healthcare practitioners’ attitudes towards the management of depression?
Barley, Murray, tylee, 2011
- Systematic literature search of studies of gps and practice nurses’ attitudes to the management of depression
- Only included studies since 2000 – appropriate since this is an area with lots of improvements hence earlier studies likely to be out of date
- Included 17 studies
- – 7 qual, 10 quan = good proportion since will give more info about the attitudes and help you to understand how/why they have/haven’t changed
- – But difficult to collect the data together to form a conclusion due to the use of both types of data
- Results found that gps and practice nurses are unsure of the exact nature of the relationship between mood and social problems and are unsure of their role in managing it
- In some clinicians:
- – Ambivalent attitudes to working with depressed people
- – Lack of confidence
- – The use of a limited number of management options
- – A belief that a diagnosis of depression is stigmatising
What influences GPs’ decisions about a diagnosis of depression?
Malhi et al, 2013
- 1760 gps participated in an educational program (RADAR) which focused on the diagnosis and management of clinical depression
— Large sample size which is really good – reduces the risk of confounding factors
- The GPs identified a maximum of 4 patients whom they diagnosed with depression and answered questions regarding their diagnostic decision making process for each patient
- Results = assessment of depression severity was influenced more by somatic symptoms collectively than emotional symptoms
— Suicidal thoughts, risk of self harm, lack of enjoyment and difficulty with activities = strongest predictors of a diagnosis of severe depression
- However, GPs chose to partake in this program – this could suggest that they are more interested in mental health and hence may have better diagnostic skills for depression (due to interest and extra research) than those who have not participated
— Hence this may be not be representative
Schumann, Schneider, Kantert, Löwe, Linde – 2011
- Systematic review of qualitative studies to investigate how family practitioners diagnose depression and what their concepts of depression are and the perceived barriers are when diagnosing depression
- 13 studies included
— 239 primary care providers included in total
— Acceptable number of studies
- FPs use approaches to diagnose depression that are usually based on their knowledge of the patients long term history, an established patient-doctor relationship and a rule-out algorithm of other diagnoses
- Uses studies from a range of countries – mainly “western countries” which could lead to ethnocentric bias
What are the effects of improvement in depression diagnosis and treatment?
Hickie, 2007
- If increased treatment has led to demonstratable benefits and is cost effective, then depression is not yet being over-diagnosed
- Increased treatment of depression reduces suicide
- – Hall WD, Mant A, Mitchell PB, Rendle VA, Hickie IB, McManus P, 2003
- – Ludwig J, Marcotte DE, 2005
- Increased treatment of depression increases productivity
- – Simon GE, Revicki D, Heiligenstein J, Grothaus L, VonKorff M, Katon WJ, Hylan TR, 2000
- The provision of appropriate medical and psychological care is also cost effective
- – Sanderson K, Andrews G, Corry J, Lapsley H, 2003
- The increased rate of diagnosis has had other benefits:
- – Reduced stigma
- – Removal of structural impediments to employment and health benefits
- – Increased access to life insurance
- – Improved physical health outcomes
- – Reduced secondary alcohol and drug misuse
- – Wider public understanding of the risks and benefits of coming forward for care
- – Pirkis J, Hickie I, Young L, Burns J, Highet N, Davenport T.
Why is depression over-diagnosed?
Parker, 2007
- Lack of a reliable and valid diagnostic model
- Marketing of treatments beyond their true utility in a climate of heightened expectations
Why could over-diagnosis of depression be a problem?
Parker, 2007
- False positive detection of depression may result in ineffective and inappropriate treatments
What evidence is there to support the use of anti-depressants in the treatment of depression?
DeRubeis et al., 2005
- Found that there was a significant advantage for medication relative to placebo
- But a non-significant trend for cognitive therapy relative to placebo
- Concluded that cognitive therapy can be as effective as medications for the initial treatment of moderate to severe major depression
— But the degree of effectiveness may depend on a high level of therapist experience/expertise
- Involved 240 patients aged 18 to 70 with moderate to severe depression
- Double blinding – patient and pharmacotherapist
- Random assignment of participants to 1 of 3 groups:
— 16 weeks of medications (n=160)
— 16 weeks of cognitive therapy (n=60)
— 8 weeks of pill placebo (n=60)
• After the 8 weeks they were offered treatment without cost
- Lowest remission rate = CT
- Response rate at 16 weeks = same for ADM and CT
Barbui et al, 2011
- Systematic review and meta-analysis of double blind randomised controlled trials comparing antidepressants or benzodiazepines vs placebo in adults with minor depression
- There is unlikely to be a clinically important advantage for anti-depressants over placebo in individuals with minor depression
— Data from 3 studies showed no statistically significant difference between anti-depressants and placebo
- There is no evidence available for benzodiazepanes so it is not possible to determine their potential therapeutic role in this condition
- Intention-to-treat analysis
- Included only 6 studies
— Overall quality of these studies was graded as low
— But confidence intervals were not very wide
— All studies had short-term follow-up
— Incomplete data reporting was a major issue
What evidence is there to support the use of CT in the treatment of depression?
Cuijpers et al., 2013
- Meta-analysis: RCTs comparing CBT to control groups, other psychotherapies and pharmacotherapy
— 115 studies included
- No indication that CBT was more or less effective than other psychotherapies or pharmacotherapy
— Combined treatment was significantly more effective than pharmacotherapy
- CBT’s effects may have been overestimated until now
- Prior psychotherapy had an enduring effect that was at least as efficacious as continuing patients on medications and that held for the prevention of relapse and possibly recurrence
— But was striking how rapidly even recovered patients experienced a recurrence when medications were withdrawn
— In contrast, CT provided evidence of sustained benefit
— BA may have an enduring effect that approaches that produced by CT
- Was conducted in the setting where BA was first developed
— Possible investigator allegiance may have biased the study
- Did not maintain the blinding for follow-up after the first year
Luty et al., 2007
- 177 participants
- No difference between CBT and IPT in the sample as a whole
— But CBT more effective than IPT in severe depression
— The response was comparable with that for mild and moderate depression
Dobson et al., 2008
- Uses participants from the Dimidjian et al. (2006)
— 188 participants
— 16 weeks of ADM = 100
• Half were continued on medication
• Half were withdrawn onto pill-placebo at the beginning of the first year of follow-up
— 16 weeks of cognitive therapy = 45
— 16 weeks of behavioural activation = 43
- Differences between behavioural activation and cognitive therapy were small in magnitude
— Not significantly different across the full 2-year follow-up
— Each was at least as efficacious as continuation medication
- Patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication
- Patients treated with medication but withdrawn onto pill-placebo had more relapse through 1 year of follow-up, compared to patients who received prior behavioural activation, prior cognitive therapy or continued medication
- There is little evidence that having taken medication does anything to alter the risk factors that lead to subsequent relapse and recurrence
— Most patients with chronic or recurrent depression are encouraged to stay on medication indefinitely
- The cost estimates in the Hollon et al (2005) study favoured prior CT by the time of 1 year of follow up
— Suggests that CT is as clinically efficacious as antidepressants and more cost-effective in the long term
— The cumulative costs of continued medications proved to be more expensive
- Little evidence of a preventative effect for continuation medication
— But was striking how rapidly even recovered patients experienced a recurrence when medications were withdrawn
— In contrast, CT provided evidence of sustained benefit
— BA may have an enduring effect that approaches that produced by CT
- Was conducted in the setting where BA was first developed
— Possible investigator allegiance may have biased the study
- Did not maintain the blinding for follow-up after the first year
What evidence is there to support the use of IPT in the treatment of depression?
Cuijpers et al., 2011
- Meta-analysis: RCTs comparing IPT with no treatment, usual care, other psychological treatments
- Combination maintenance treatment with pharmacotherapy and IPT was more effective in preventing relapse than pharmacotherapy alone
- Included 38 studies
- – The studies had relatively high methodological quality
- Compared with control groups, there was a moderate to large effect of IPT in the acute treatment of depression
- Also found some indications that IPT had less efficacy than SSRI pharmacotherapy
- Did not find that IPT had greater efficacy than other psychotherapies, including CBT
- – But the number of studies was too small to draw definite conclusions
What evidence is there to support the use of behavioural activation in the treatment of depression?
Ekers et al., 2014
- Meta-analysis = randomised trials of behavioural activation for depression vs controls or anti-depressant medication
- Supports the evidence base indicating that behavioural activation is an effective treatment for depression
- The relative small set of techniques necessary for effective delivery of BA may be possible to acquire after 5 days
- Used 25 studies
— But most were low quality
— And many were small
- BA is superior to controls and has a small but significant short term superiority to antidepressant medication
— But when low quality studies were removed from the analysis these differences disappeared
— Suggests caution for interpreting results
Dimidjian et al., 2006
- Study participants = 241 adults with major depressive disorder
— 66% female – gynocentric bias
- Randomisation to 1 of 4 groups: behavioural activation, cognitive therapy, antidepressant medication or pill placebo
- Study shows that BA is more efficacious than CT
— For severely depressed patients
— It is comparable in efficacy to antidepressants
— Challenges the assumption that directly modifying negative beliefs is essential for change
— Raises the possibility that elements of the expanded BA model may offer more robust interventions for depression
- BA brought a significantly greater percentage of participants to remission and retained a greater percentage of participants in treatment
— Compared to anti-depressants
- In BA patients learn to identify patterns of avoidance and to respond with activation
- Suggests that BA may be a viable alternative to antidepressants
- BA would be a more exportable treatment that is easier to implement and train than CT or other more complex interventions
— If so, the public health advantages would be significant
- Was conducted in the setting where BA was first developed
— Possible investigator allegiance may have biased the study
- Lack of competency ratings for BA therapists
What evidence is there to support the use of problem solving in the treatment of depression?
Mynors-Wallis et al., 2000
- 151 participants
— Problem solving with GP = 39
— Problem solving with nurse = 41
— Medication alone = 36
— Combination treatment = 35
— Drop out = 35
- The combination of problem solving treatment and antidepressant medication was no more effective than either treatment alone
- No difference in outcome irrespective of who delivered the problem solving treatment
- Problem solving treatment is an effective treatment for depressive disorders in primary care
— Can be delivered by suitably trained practice nurses or GPs
— It is most likely to benefit patients who have a depressive disorder of moderate severity and who wish to participate in an active psychological treatment
- Lack of placebo use in study
Mynors-Wallis, 1995
- Difference in score on the Hamilton rating scale for depression between problem solving and placebo treatments was significant
— But the difference between problem solving and amitriptyline was not significant
- Concludes that problem solving treatment is effective, feasible and acceptable to patients
- Very small study – 91 patients only
— High drop out rate between the 6 and 12 week assessment due to poor recovery rate for placebo group
- Problem solving was more effective than placebo and as effective as amitriptyline in treating major depression in primary care
- Patients’ satisfaction with problem solving was high
What evidence is there to support the use of combined treatment (CT + ADM) in the treatment of depression?
Hollon et al., 2014
- Participants = 452 adult outpatients (in US)
- Treatment was continued for up to 42 months until recovery was achieved
- Combined treatment (ADM + CT) enhanced the rate of recovery compared to treatment with ADM alone
- – The advantage was limited to patients with severe, non-chronic MDD
- Remission rates did not significantly differ
- Relied on exploratory analyses to examine the joint effects of severity and chronicity
- Absence of another psychotherapy or psychotherapy control, in combination with medications, to test for the specificity of CT in accounting for the combined treatment advantage
- Lack of blinding for patients and providers
What is the prevalence of depression in the UK?
2.6 in 100 people in the UK have depression every year - The Health and Social Care Information Centre, 2009
Women are almost twice as vulnerable to periods of major depression as men, regardless of cultural background – Nolen-Hoeksema, 2002
Gender differences: coping style
Hanninen and Aro, 1996
- The capacity to manage negative life events well is often referred to as resilience
- Women scored lower than men on a resilience scale
- Questionnaire data from 890 female and 766 male Finnish 22 year old adults
- Coping methods associated with depression: (dysfunctional methods)
— Self blame
— Venting anger on others
— Seeking comfort in sweets
— Drinking beer
- Women resorted much more often than men to dysfunctional ways of coping, except drinking
- Women showed more depressive symptoms than men
- Low resilience was associated with dysfunctional coping
Blalock and Joiner, 2000
- A coping style associated with depression is cognitive avoidance
— Involves denial and minimisation of stressors
— Associated with increases in depression in women, but not in men
Nolen-Hoeksema and Girgus, 1994
- For women, the significant predictors of recovery appeared to be the availability of close supports and their satisfaction with support
- For men, predictors of recovery included living in a marital relationship, absence of negative social interactions and number of friends/acquaintances
