RESUMEN
BACKGROUND: Most practice guidelines recommend maintenance antidepressant treatment for recurrent major depressive disorder. However, the degree to which such guidance is actually followed in primary health care has remained obscure. We investigated the provision of maintenance antidepressant treatment within a representative primary care five-year cohort study. METHODS: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up. A graphic life chart enabling evaluation of the longitudinal course of episodes plus duration of pharmacotherapies was used. In accordance with national guidelines, an indication for maintenance treatment was defined to exist after three or more lifetime major depressive episodes (MDEs); maintenance treatment was to commence four months after onset of full remission. RESULTS: Of the cohort patients, 34% (46/137) had three or more lifetime MDEs, thus indicating the requirement for maintenance pharmacotherapy. Of these, half (54%, 25/46) received maintenance treatment, for only 29% (489/1670) of the months indicated. CONCLUSIONS: In this cohort of depressed primary care patients, half of patients with indications for maintenance treatment actually received it, and only for a fraction of the time indicated. Antidepressant maintenance treatment for the prevention of recurrences is unlikely to be subject to large-scale actualization as recommended, which may significantly undermine the potential public health benefits of treatment.
Asunto(s)
Antidepresivos/uso terapéutico , Trastorno Depresivo Mayor/tratamiento farmacológico , Trastorno Depresivo Mayor/prevención & control , Atención Primaria de Salud/estadística & datos numéricos , Prevención Secundaria/estadística & datos numéricos , Adulto , Anciano , Trastorno Depresivo Mayor/epidemiología , Trastorno Depresivo Mayor/psicología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Recurrencia , Inducción de RemisiónRESUMEN
BACKGROUND: Depressive disorders are known to impair health-related quality of life (HRQoL) both in the short and long term. However, the determinants of long-term HRQoL outcomes in primary care patients with depressive disorders remain unclear. METHODS: In a primary care cohort study of patients with depressive disorders, 82% of 137 patients were prospectively followed up for five years. Psychiatric disorders were diagnosed with SCID-I/P and SCID-II interviews; clinical, psychosocial and socio-economic factors were investigated by rating scales and questionnaires plus medical and psychiatric records. HRQoL was measured with the generic 15D instrument at baseline and five years, and compared with an age-standardized general population sample (n=3707) at five years. RESULTS: Depression affected the 15D total score and almost all dimensions at both time points. At the end of follow-up, HRQoL of patients in major depressive episode (MDE) was particularly low, and the association between severity of depression (Beck Depression Inventory [BDI]) and HRQoL was very strong (r=-0.804). The most significant predictors for change in HRQoL were changes in BDI and Beck Anxiety Inventory (BAI) scores. The mean 15D score of depressive primary care patients at five years was much worse than in the age-standardized general population, reaching normal range only among patients who were in clinical remission and had virtually no symptoms. CONCLUSIONS: Among depressive primary care patients, presence of current depressive symptoms markedly reduces HRQoL, with symptoms of concurrent anxiety also having a marked impact. For HRQoL to normalize, current depressive and anxiety symptoms must be virtually absent.
Asunto(s)
Calidad de Vida , Adulto , Anciano , Ansiedad/diagnóstico , Estudios de Cohortes , Trastorno Depresivo/diagnóstico , Trastorno Depresivo/epidemiología , Trastorno Depresivo/psicología , Femenino , Finlandia/epidemiología , Humanos , Entrevista Psicológica , Masculino , Persona de Mediana Edad , Atención Primaria de Salud/métodos , Atención Primaria de Salud/estadística & datos numéricos , Escalas de Valoración Psiquiátrica , Encuestas y CuestionariosRESUMEN
BACKGROUND: Response styles theory of depression postulates that rumination is a central factor in occurrence, severity and maintaining of depression. High neuroticism has been associated with tendency to ruminate. We investigated associations of response styles and neuroticism with severity and chronicity of depression in a primary care cohort study. METHODS: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up with a graphic life chart enabling evaluation of the longitudinal course of episodes. Neuroticism was measured with the Eysenck Personality Inventory (EPI-Q). Response styles were investigated at five years using the Response Styles Questionnaire (RSQ-43). RESULTS: At five years, rumination correlated significantly with scores of Hamilton Depression Rating Scale (r=0.54), Beck Depression Inventory (r=0.61), Beck Anxiety Inventory (r=0.50), Beck Hopelessness Scale (r=0.51) and Neuroticism (r=0.58). Rumination correlated also with proportion of follow-up time spent depressed (r=0.38). In multivariate regression, high rumination was significantly predicted by current depressive symptoms and neuroticism, but not by anxiety symptoms or preceding duration of depressive episodes. CONCLUSIONS: Among primary care patients with depression, rumination correlated with current severity of depressive symptoms, but the association with preceding episode duration remained uncertain. The association between neuroticism and rumination was strong. The findings are consistent with rumination as a state-related phenomenon, which is also strongly intertwined with traits predisposing to depression.
Asunto(s)
Trastorno Depresivo , Atención Primaria de Salud , Adulto , Ansiedad/psicología , Trastornos de Ansiedad/diagnóstico , Depresión/psicología , Trastorno Depresivo/diagnóstico , Trastorno Depresivo/epidemiología , Trastorno Depresivo/psicología , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Femenino , Finlandia/epidemiología , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neuroticismo , Inventario de Personalidad , Atención Primaria de Salud/métodos , Atención Primaria de Salud/estadística & datos numéricos , Estudios Prospectivos , Escalas de Valoración Psiquiátrica , Distribución Aleatoria , Factores Socioeconómicos , Estadística como Asunto , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To study prevalence of and predictors for functional and work disability among primary care (PC) patients with depressive disorders in prospective long-term follow-up. METHODS: The Vantaa Primary Care Depression Study followed up prospectively 137 patients with depressive disorders for 5 years with a life chart. Information on level of functioning in general and in different dimensions, employment, sick leaves and disability pensions were obtained from interviews and patient records. RESULTS: Level of functioning and work ability were strongly associated with time spent depressed and/or current severity of depression. Patients who belonged to the labour force at baseline spent one-third of the follow-up off work due to depression; two-thirds were granted sick leaves, and one-tenth a disability pension due to depression. Longer duration of depression, co-morbid disorders and having received social assistance predicted dropping out from work. CONCLUSION: Duration of depressive episodes appears decisive for long-term disability among PC patients with depression. Patients spent one-third of the follow-up off work due to depression, and remaining outside the labour force is a common outcome. Psychiatric and somatic co-morbidities, education and socio-economic means influence the level of functioning and ability to work, but are not equally important for all areas of life.
Asunto(s)
Trastorno Depresivo Mayor/psicología , Personas con Discapacidad , Empleo , Atención Primaria de Salud/estadística & datos numéricos , Adulto , Comorbilidad , Trastorno Depresivo Mayor/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pensiones , Prevalencia , Estudios Prospectivos , Jubilación , Ausencia por Enfermedad , Factores de TiempoRESUMEN
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
BACKGROUND: No previous study has prospectively investigated incidence and risk factors for suicide attempts among primary care patients with depression. METHOD: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients was screened for depression, and Structured Clinical Interviews for DSM-IV used to diagnose Axis I and II disorders. A total of 137 patients were diagnosed with a DSM-IV depressive disorder. Altogether, 82% of patients completed the 5-year follow-up. Information on timing of suicide attempts, plus major depressive episodes (MDEs) and partial or full remission, or periods of substance abuse were examined with life charts. Incidence of suicide attempts and their stable and time-varying risk factors (phases of depression/substance abuse) were investigated using Cox proportional hazard and Poisson regression models. RESULTS: During the follow-up there were 22 discrete suicide attempts by 14/134 (10.4%) patients. The incidence rates were 0, 5.8 and 107 during full or partial remission or MDEs, or 22.2 and 142 per 1000 patient-years during no or active substance abuse, respectively. In Cox models, current MDE (hazard ratio 33.5, 95% confidence interval 3.6-309.7) was the only significant independent risk factor. Primary care doctors were rarely aware of the suicide attempts. CONCLUSIONS: Of the primary care patients with depressive disorders, one-tenth attempted suicide in 5 years. However, risk of suicidal acts was almost exclusively confined to MDEs, with or without concurrent active substance abuse. Suicide prevention among primary care patients with depression should focus on active treatment of major depressive disorder and co-morbid substance use, and awareness of suicide risk.
Asunto(s)
Trastorno Depresivo Mayor/epidemiología , Atención Primaria de Salud , Intento de Suicidio/estadística & datos numéricos , Adulto , Comorbilidad , Trastorno Depresivo/epidemiología , Femenino , Finlandia/epidemiología , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Atención Primaria de Salud/estadística & datos numéricos , Estudios Prospectivos , Factores de Riesgo , Trastornos Relacionados con Sustancias/epidemiología , Factores de TiempoRESUMEN
BACKGROUND: How different ways of assessing suicidal ideation influence its prevalence, correlates and predictive validity among patients with major depressive disorder (MDD) remains unclear. METHODS: Within the Vantaa Primary Care Depression Study (PC-VDS, 91 patients) and the Vantaa Depression Study (VDS, 153 psychiatric out-and 41 inpatients), suicidal ideation was assessed with the Scale for Suicidal Ideation (SSI), Hamilton Depression Scale (HAM-D) item 3 and Beck Depression Inventory (BDI) item 9, and by asking whether patients had seriously considered suicide during the episode. The positive and negative predictive values (PPV, NPV) for suicide attempts during a six-month follow-up were investigated. RESULTS: Depending on the setting, 56-88% of patients had suicidal ideation in some of the assessments, but only 8-44% in all of them. Agreement ranged from negligible to moderate (kappa 0.06-0.64), being lowest among primary care patients. The correlates of suicidal ideation overlapped. No assessment had optimal sensitivity, specificity, PPV and NPV. Nevertheless, PPVs ranged up to 43%. CONCLUSIONS: Which MDD patient is classified as having suicidal ideation depends strongly on the method of assessment, with the greatest variation likely in primary care. Differences in assessments may cause inconsistency in risk factors. Predicting suicide attempts is difficult, but not futile.
Asunto(s)
Trastorno Depresivo Mayor/epidemiología , Escalas de Valoración Psiquiátrica , Ideación Suicida , Suicidio/estadística & datos numéricos , Adulto , Estudios de Cohortes , Trastorno Depresivo Mayor/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Factores de Riesgo , Sensibilidad y Especificidad , Suicidio/psicologíaRESUMEN
PURPOSE: We evaluate for the first time the associations of brain white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) with neuropsychological variables among middle-aged bipolar I (BPI), II (BPII) and major depressive disorder (MDD) patients and controls using a path model. METHODS: Thirteen BPI, 15 BPII, 16 MDD patients, and 21 controls underwent brain MRI and a neuropsychological examination. Two experienced neuroradiologists evaluated WMHs on the MRI scans. We constructed structural equation models to test the strength of the associations between deep WMH (DWMH) grade, neuropsychological performance and diagnostic group. RESULTS: Belonging in the BPI group as opposed to the control group predicted higher DWMH grade (coefficient estimate 1.13, P=0.012). The DWMH grade independently predicted worse performance on the Visual Span Forward test (coefficient estimate -0.48, P=0.002). Group effects of BPI and MDD were significant in predicting poorer performance on the Digit Symbol test (coefficient estimate -5.57, P=0.016 and coefficient estimate -5.66, P=0.034, respectively). LIMITATIONS: Because of the small number of study subjects in groups, the negative results must be considered with caution. CONCLUSIONS: Only BPI patients had an increased risk for DWMHs. DWMHs were independently associated with deficits in visual attention.
Asunto(s)
Trastorno Bipolar/patología , Encéfalo/patología , Trastornos del Conocimiento/patología , Trastorno Depresivo Mayor/patología , Adulto , Atención , Trastorno Bipolar/fisiopatología , Trastorno Bipolar/psicología , Encéfalo/fisiopatología , Estudios de Casos y Controles , Trastorno Depresivo Mayor/fisiopatología , Trastorno Depresivo Mayor/psicología , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neuroimagen , Pruebas NeuropsicológicasRESUMEN
OBJECTIVE: To study, whether temperament and character remain stable over time and whether they differ between patients with and without personality disorder (PD) and between patients with specific PDs. METHODS: Patients with (n=225) or without (n=285) PD from Jorvi Bipolar Study, Vantaa Depression Study (VDS) and Vantaa Primary Care Depression Study were interviewed at baseline and at 18 months, and in the VDS also at 5 years. A general population comparison group (n=264) was surveyed by mail. RESULTS: Compared with non-PD patients, PD patients scored lower on self-directedness and cooperativeness. Cluster B and C PDs associated with high Novelty Seeking and Harm Avoidance, respectively. In logistic regression models, sensitivity and specificity of Temperament and Character Inventory (TCI) dimensions for presence of any PD were 53% and 75%, and for specific PDs from 11% to 41% and from 92% to 100%, respectively. The 18-month test-retest correlations of TCI-R dimensions ranged from 0.58 to 0.82. CONCLUSIONS: Medium-term temporal stability of TCI in a clinical population appears good. Character scores differ markedly between PD and non-PD patients, whereas temperament scores differ only somewhat between the specific PDs. However, the TCI dimensions capture only a portion of the differences between PD and non-PD patients.
Asunto(s)
Carácter , Trastornos de la Personalidad/psicología , Temperamento , Adulto , Anciano , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Inventario de PersonalidadRESUMEN
BACKGROUND: Whether temperament and character differ between bipolar disorder (BD) and major depressive disorder (MDD) patients and general population subjects, or between BD I and BD II patients, remains unclear. METHOD: BD patients (n=191) from the Jorvi Bipolar Study and MDD patients (n=266) from the Vantaa Depression Study (VDS) and the Vantaa Primary Care Depression Study were interviewed at baseline, at 6 and 18 months, and in the VDS at 5 years. A general population comparison group (n=264) was surveyed by mail. BD patients' scores on the Temperament and Character Inventory-Revised were compared at an index interview, when levels of depression and mania were lowest, with scores of MDD patients and controls. BD I (n=99) and BD II (n=92) patients were compared. RESULTS: Compared with controls, both BD and MDD patients had higher harm avoidance [odds ratio (OR) 1.027, p<0.001 and OR 1.047, p<0.001, respectively] and lower persistence (OR 0.983, p=0.006 and OR 0.968, p<0.001, respectively) scores. Moreover, BD patients had lower self-directedness (OR 0.979, p=0.003), MDD patients lower reward dependence (OR 0.976, p=0.002) and self-transcendence (OR 0.966, p<0.001) scores. BD patients scored lower in harm avoidance (OR 0.980, p=0.002) and higher in novelty seeking (OR 1.027, p<0.001) and self-transcendence (OR 1.028, p<0.001) than MDD patients. No differences existed between BD I and II patients. CONCLUSIONS: The patterns of temperament and character dimensions differed less between BD and MDD patients, than patients from their controls. The most pronounced difference was higher novelty seeking in BD than MDD patients. The dimensions investigated are unlikely to differ between BD I and BD II patients.
Asunto(s)
Trastorno Bipolar/psicología , Carácter , Trastorno Depresivo Mayor/psicología , Temperamento , Adulto , Análisis de Varianza , Distribución de Chi-Cuadrado , Femenino , Humanos , Entrevista Psicológica , Modelos Logísticos , Masculino , Inventario de Personalidad , Escalas de Valoración PsiquiátricaRESUMEN
Post-natal depression is a major mental health problem in many western countries. The children of depressed parents face an elevated risk of depression before reaching adulthood. In primary health care, there is an obvious need to improve competence in mental health among those working with mothers and their children. In this practice development project the aim was to improve recognition and treatment of post-natal depression in primary health care in City of Vantaa, Finland. Mothers scoring 13 points or more on Edinburgh Postnatal Depression Scale were asked to participate in a cognitive behavioural therapy-based and goal-orientated session with a mental health nurse. Based on analysis of 166 mothers it can be concluded that one or two sessions with a mental health nurse were sufficient for over 50% of the mothers, and 68% of the mothers were able to get post-natal depression care in the same clinic where their children are monitored without a need for specialized psychiatric services. In addition, the appropriate use of antidepressant medication was enhanced.
Asunto(s)
Instituciones de Atención Ambulatoria , Servicios de Salud del Niño , Depresión Posparto/diagnóstico , Depresión Posparto/terapia , Tamizaje Masivo/métodos , Adulto , Terapia Cognitivo-Conductual , Conducta Cooperativa , Depresión Posparto/enfermería , Femenino , Finlandia , Humanos , Recién Nacido , Tamizaje Masivo/enfermería , Enfermería Psiquiátrica/métodos , Psiquiatría/métodos , Enfermería en Salud Pública/métodos , Resultado del Tratamiento , Adulto JovenRESUMEN
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
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.