RESUMEN
BACKGROUND: Primary health care provides treatment for most patients with depression. Despite their importance for organizing services, long-term course of depression and risk factors for poor outcome in primary care are not well known. METHOD: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients representing primary care patients in a Finnish city was screened for depression with the Primary Care Evaluation of Mental Disorders. SCID-I/P and SCID-II interviews were used to diagnose Axis I and II disorders. The 137 patients with DSM-IV depressive disorder were prospectively followed up at 3, 6, 18 and 60 months. Altogether, 82% of patients completed the 5-year follow-up, including 102 patients with a research diagnosis of major depressive disorder (MDD) at baseline. Duration of the index episode, recurrences, time spent in major depressive episodes (MDEs) and partial or full remission were examined with a life-chart. RESULTS: Of the MDD patients, 70% reached full remission, in a median time of 20 months. One-third had at least one recurrence. The patients spent 34% of the follow-up time in MDEs, 24% in partial remission and 42% in full remission. Baseline severity of depression and substance use co-morbidity predicted time spent in MDEs. CONCLUSIONS: This prospective, naturalistic, long-term study of a representative cohort of primary care patients with depression indicated slow or incomplete recovery and a commonly recurrent course, which need to be taken into account when developing primary care services. Severity of depressive symptoms and substance use co-morbidity should be systematically evaluated in planning treatment.
Asunto(s)
Trastorno Depresivo Mayor/terapia , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Adulto , Anciano , Comorbilidad , Trastorno Depresivo Mayor/epidemiología , Femenino , Finlandia/epidemiología , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Adulto JovenRESUMEN
OBJECTIVE: There is a scarcity of prospective long-term studies on work disability caused by depression. We investigated predictors for disability pension among psychiatric patients with MDD. METHOD: The Vantaa Depression Study followed up prospectively 269 psychiatric in- and out-patients with DSM-IV MDD for 5 years with a life chart, including 230 (91.3%) patients belonging to labour force. Information on disability pensions was obtained from interviews, patient records and registers. RESULTS: Within 5 years, 20% of the patients belonging to labour force at baseline were granted a disability pension. In multivariate analyses, the significant baseline predictors for granted disability pension were age ≥50 years (HR = 3.91, P < 0.001), subjective inability to work (HR = 2.14, P = 0.008) and introversion (HR = 1.08, P = 0.049). When follow-up variables were included, the predictors were age more than 50 (OR = 6.25, P < 0.001), proportion of time spent depressed (OR = 14.6, P < 0.001), number of comorbid somatic disorders (OR = 1.47, P = 0.013) and lack of vocational education (OR = 2.38, P = 0.032). CONCLUSION: Of psychiatric patients with depression, one-fifth were granted a disability pension within 5 years. Future disability pension can be predicted by baseline older age, personality factors, functional disability, lack of vocational education and comorbid somatic disorders. Longitudinally, accumulation of time spent depressed appears decisive for pensioning.
Asunto(s)
Comorbilidad , Trastorno Depresivo Mayor/fisiopatología , Personas con Discapacidad/psicología , Empleo/estadística & datos numéricos , Pensiones/estadística & datos numéricos , Adulto , Factores de Edad , Trastorno Depresivo Mayor/psicología , Personas con Discapacidad/estadística & datos numéricos , Empleo/psicología , Femenino , Finlandia , Estudios de Seguimiento , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: Depressive disorders are known to often be chronic and recurrent both in the general population and in psychiatric settings. However, despite its importance for public health and services, the outcome of depression in primary care is not well known. METHOD: In The Vantaa Primary Care Depression Study (PC-VDS), 1111 consecutive primary-care patients were screened for depression with the Prime-MD screen, and 137 diagnosed with DSM-IV depressive disorders by interviewing with the Structured Clinical Interview for DSM-IV (SCID)-I/P and SCID-II. This cohort was prospectively followed-up at 3, 6 and 18 months. Altogether 123 patients (90%) completed the 18-month follow-up, including 79 with major depressive disorder (MDD) and 44 with subsyndromal disorders. Duration of the index episode and the timing of relapses/recurrences were examined using a life-chart. RESULTS: Of the patients with MDD, only a quarter [25% (20/79)] achieved and remained in full remission, while another quarter [25% (20/79)] persisted in major depressive episode for 18 months. The remaining 49% (39/79) suffered from residual symptoms or recurrences. In Cox regression models, time to remission and recurrences were robustly predicted by severity of depression, and less consistently by co-morbid substance-use disorder, chronic medical illness or cluster C personality disorder. Of the subsyndromal patients, 25% (11/44) proceeded to MDD. CONCLUSIONS: This prospective medium-term study verified the high rate of recurrences and chronicity of depression also in primary care. Severity of depressive symptoms and co-morbidity are important predictors of outcome. Development of chronic disease management for depression is warranted in primary care.
Asunto(s)
Trastorno Depresivo Mayor/terapia , Trastorno Depresivo/terapia , Atención Primaria de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Escalas de Valoración Psiquiátrica , Recurrencia , Inducción de Remisión , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Major Depressive Disorder (MDD) is a major cause of long-term work disability. However, factors predicting this are not well known. METHOD: In the Vantaa Depression Study, predictors for being granted a disability pension during an 18-month follow-up were examined among the 186 psychiatric MDD in- and out-patients belonging to the labour force at baseline. RESULTS: The 21 patients (11.3%) granted a disability pension were significantly older, more hopeless, had worse social and occupational functioning, and spent more time depressed during follow-up. After adjusting for these predictors, being on sick leave at baseline still strongly predicted disability pension during follow-up. CONCLUSION: Disability pension is predicted by multiple sociodemographic and clinical factors. Baseline level of functioning and duration of depressive episodes are key clinical predictors. The positive and negative consequences of sick leave warrant closer attention.
Asunto(s)
Trastorno Depresivo Mayor/epidemiología , Trastorno Depresivo Mayor/psicología , Evaluación de la Discapacidad , Pensiones/estadística & datos numéricos , Adulto , Demografía , Trastorno Depresivo Mayor/diagnóstico , Femenino , Finlandia/epidemiología , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Most national suicide prevention strategies set improved detection and management of depression in primary health care into a central position. However, suicidal behaviour among primary-care patients with depressive disorders has been seldom investigated. METHOD: In the Vantaa Primary Care Depression Study, a total of 1119 primary-care patients in the City of Vantaa, Finland, aged 20 to 69 years, were screened for depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. Depressive disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and the 137 patients with depressive disorder were included in the study. Suicidal behaviour was investigated cross-sectionally and retrospectively in three time-frames: current, current depressive episode, and lifetime. Current suicidal ideation was measured with the Scale for Suicidal Ideation (SSI), and previous ideation and suicide attempts were evaluated based on interviews plus medical and psychiatric records. RESULTS: Within their lifetimes, 37% (51/137) of the patients had seriously considered suicide and 17% (23/137) attempted it. Lifetime suicidal behaviour was independently and strongly predicted by psychiatric treatment history and co-morbid personality disorder, and suicidal behaviour within the current episode was predicted most effectively by severity of depression. CONCLUSIONS: Based on these findings and their convergence with studies of completed suicides, prevention of suicidal behaviour in primary care should probably focus more on high-risk subgroups of depressed patients, including those with moderate to severe major depressive disorder, personality disorder or a history of psychiatric care. Recognition of suicidal behaviour should be improved. The complex psychopathology of these patients in primary care needs to be considered in targeting preventive efforts.
Asunto(s)
Síntomas Conductuales/psicología , Trastorno Depresivo Mayor/prevención & control , Trastorno Depresivo Mayor/psicología , Atención Primaria de Salud , Adulto , Trastorno Depresivo Mayor/diagnóstico , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Femenino , Finlandia , Humanos , Masculino , Servicios de Salud Mental , Persona de Mediana Edad , Trastornos de la PersonalidadRESUMEN
BACKGROUND: New antidepressants emerged and became widely used during the 1990s. The present study investigated quality-of-care problems in the treatment of depression in a current psychiatric setting. METHOD: We investigated the treatment received for depression by all 803 inpatients or outpatients with a clinical diagnosis of ICD-10 depressive episode or recurrent depressive disorder in 1996 in the Peijas Medical Care District, which provides psychiatric services for citizens of Vantaa, a city in southern Finland. RESULTS: Most patients (84%) in the sample were found to have received antidepressants, generally in adequate, albeit low, doses. Inadequate antidepressant treatment was common only with tricyclic antidepressants. Most patients received a single antidepressant for extended periods; only 22% had 2 or more antidepressant trials. During the treatment period, disability pension was granted to 19% of those not already pensioned, two thirds (67%) of whom had received only 1 antidepressant trial prior to being granted a pension. CONCLUSION: The present study supports the emerging perception of improved quality of pharmacotherapy in psychiatric settings, with the exception of treatment with tricyclic antidepressants. Problems of quality of care now appear to be related to the suboptimal intensity and monitoring of the treatment provided. which may eventually result in considerable costs to society due to permanent disability.