Research PaperPharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity
Introduction
Treatment of depression is a major challenge for primary care (PC). Altogether 30 million Europeans are estimated to suffer from depression, and depression is likely to be the most important illness in Europe in terms of disability-adjusted life-years (Wittchen et al., 2011). Marked efforts have been made to improve recognition, treatment, and outcome of depression in PC. These include education of PC doctors (Sikorski et al., 2012), use of depression screens (Thombs et al., 2012), and application of service delivery models such as collaborative (Sighinolfi et al., 2014, Community Preventive Services Task Force, 2012) or stepped (Firth et al., 2015) care. Furthermore, a large-scale national initiative to promote psychological treatment in PC in the UK (Clark, 2011) and guidelines produced by national health care organizations (Leitlinien, 2015, National Board of Health and Welfare, 2010, NICE, 2010) or professional societies (American Psychiatric Association (APA), 2010, Cleare et al., 2015, Kennedy et al., 2009, The Finnish Medical Society Duodecim and Finnish Psychiatric Association, 2014 have been implemented. In addition, over the last 25 years, use of antidepressants (ADs) has risen in Europe, which at least on an ecological level is associated with a decline in suicide mortality (Gusmao et al., 2013). However, evidence for a major positive change in terms of public health is limited and uncertain.
General population studies consistently show that the majority of individuals suffering from depression either do not seek treatment or receive adequate care (Demyttenaere, 2003, Gabilondo et al., 2011, Hamalainen et al., 2009, Kessler et al., 2003, Wang et al., 2005). In epidemiological studies, a significant proportion of individuals with depressive syndromes do not perceive themselves as suffering from a mental disorder (Hamalainen et al., 2004). Both anosognosia and the often somatic complaints in PC (Vuorilehto et al., 2005) are obstacles to recognition of depression. The likelihood for recognition increases with depression severity (Thompson et al., 2001). The quality of treatments is central from the point of view of public health. However, limited comprehensive studies exist in PC, mainly focusing on pharmacotherapy and follow-up monitoring (Coyne et al., 1997, Gilchrist and Gunn, 2007, Limosin et al., 2004, Lin et al., 2000, Ronalds et al., 1997, Rost et al., 1995, Rost et al., 1998, Simon et al., 2001, Simon et al., 2004). Besides reports from the UK Improved Access to Psychological Therapies (IAPT) project (Richards and Borglin, 2011), few clinical epidemiological studies exists on the availability, type, and quality of psychological treatments. While national guidelines commonly instruct referral to specialized psychiatric care, the actual patterns of referral have seldom been investigated.
Whatever the treatment modality, patient adherence is crucial for any benefits to materialize (Chong et al., 2011, Lynch et al., 2011, Raue et al., 2009, Thompson et al., 2000a). Depending on their attitudes, patients may immediately decline treatment, ostensibly accept it but not start, discontinue at a later phase, or participate too irregularly for any benefit to be gained (Melartin et al., 2005). Thus, the adherence to treatment is likely to play an important role in the adequacy of treatment (Chong et al., 2011, Lynch et al., 2011, Raue et al., 2009, Thompson et al., 2000a, 2000b). However, most studies address the issue by reporting on the quality of care merely in terms of treatment provision, neglecting the potential shortcomings due to poor adherence. Moreover, not all patients believe that ADs are helpful (Edlund et al., 2008), and some prefer no treatment to an unacceptable treatment modality (Morey et al., 2007). Adherence to the chosen treatment modality may be less than optimal if a patient is obliged to use a modality that he/she does not desire (Raue et al., 2009). The few PC studies investigating adherence mainly focus on pharmacotherapy, although psychological treatments in PC are known to be equally effective for mild or moderate depression (Cuijpers et al., 2009) and are often preferred (Raue et al., 2009, van Schaik et al., 2004, Vuorilehto et al., 2007). Moreover, most reports are based on treatment trials with selected patient populations. Despite chronicity and the recurrent nature of depression necessitating continuity of care, naturalistic studies comprise only short follow-ups of acute depression. According to these studies, a significant proportion of patients fail to start an AD prescribed. Discontinuation is very common at the beginning of pharmacotherapy, especially among young patients, a fact of which the clinician is often unaware (Bambauer et al., 2007, Demyttenaere, 2003, Hunot et al., 2007, Lin et al., 1995, Maddox et al., 1994, Simon et al., 1993). Thus, although patient adherence is a precondition for any treatment benefits, the role of attitudes towards treatments and the types of adherence problems encountered in PC have been relatively poorly studied.
Overall, despite abundant guidance, specific treatments and service delivery models, knowledge of actual treatment provision for depression in PC is fragmentary and crude. In this study, we followed 100 PC patients with MDD for 18 months and observed their treatment. We investigated their contacts with PC doctors, the pharmacological and psychosocial treatments offered, and the factors predicting treatment provision. We also examined treatment attitudes, different types of adherence problems encountered, and factors related to referral to psychiatric services.
Section snippets
Methods
The Vantaa Primary Care Depression Study (PC-VDS) is a naturalistic and prospective cohort study on depressive disorders. The study protocol was approved by the pertinent ethics committee in December 2001. The PC-VDS forms a collaborative research project between the Department of Mental and Alcohol Research of the National Institute of Health and Welfare and the City of Vantaa, Finland. The catchment area comprises a population of 63 400, served by 30 general practitioners with
Follow-up contacts with PC doctor
During IE after baseline (median duration 16 months), patients contacted their PC doctors for any health reason a median of five times (25–75% percentiles 2–9). Less than one-half (median 2; 25–75% percentiles 1–5) of these contacts included monitoring of depression, and thus, could be regarded as a follow-up contact for depression. The third of patients [38% (38/100)] with three or more follow-up contacts for depression were in univariate analyses younger (43.0 years vs. 48.6 years) and at
Discussion
When observing 100 PC patients with MDD for 18 months we documented that over time the vast majority were offered some type of treatment, mostly an AD (82%), and often only an AD. One-half of the patients were offered some type of psychosocial treatment, guideline-concordant or not. However, a significant proportion of patients who were offered treatment, either never started, discontinued, or did not sufficiently adhere to it for a variety of reasons. Both suboptimal patient adherence and
Conclusions
In this PC study, we found several foci of improvement in treating depression. While pharmacotherapy was offered to most patients, monitoring of outcome and support for adherence were suboptimal, with patients making their own decisions about continuing with the offered treatment. Also the available forms of PS failed to form an integral part of the treatment process. Finally, collaboration between PC and specialist care failed to form genuine steps in the intensity of treatment).
Conflict of interest
The authors have no conflicts of interest to report.
Acknowledgements
This study was supported by a grant from the Finnish Medical Society Duodecim.
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