Aspects of management of depression in primary care - use of a self-assessment instrument

Sammanfattning: Aim: The general aim of this thesis was to evaluate effects of recurrent use of a self-assessment instrument in general practitioner (GP) consultations with the patient with depression in the primary care clinical context. Does the use of self-assessment instruments have an effect on depression course, as well as quality of life, well-being, anti-depressant medication use, sick leave, work ability, and health care use in a long-term perspective? Introduction: Depression is a common mental disorder and leading cause of disability and is among the most common reasons for sick leave. Primary health care is the first line of care, and where 70% of all patients with depression are managed without referral to specialist psychiatry. As a tool to enhance accuracy and enable the GP to diagnose suspected depressions, there are recommendations to use some kind of structured interview. Self-assessment instruments such as MADRS-S (Montgomery Asberg Depression Rating Scale- Self rating) are well known in Swedish primary care, but not regularly used. MADRS-S is especially sensitive to change and is therefore suitable for measuring the effect of depression treatment. There are today no recommendations in guidelines to use MADRS-S or any other assessment tool on a regular basis; there are too few studies of good quality to provide enough evidence to defend its use. More studies are needed that evaluate structured use of such instruments and where outcomes are measured in long-term follow-up. Methods: Paper I (n=258) was a randomized controlled study, evaluating the effects of recurrent use of MADRS-S in the depressed patient during regular GP consultations. Outcomes were measured by BDI-II, EQ-5D, GHQ-12, and medication use. Paper II used results from self-assessments from patients with depression in 2 RCT studies (PRI-SMA and PRIM-NET), where the patients assessed their symptoms with both MADRS-S and BDI-II. The total scores were compared between MADRS-S and BDI-II. Paper III (n=9) invited patients with depression who had assessed their symptoms with MADRS-S to discuss their perceptions of such use in focus group discussions. The collected data were then analyzed with Malterud’s systematic text condensation. Paper IV (n=183) evaluated the effects of recurrent use of MADRS-S in the depressed patient during regular GP consultations on work ability, job strain, sick leave, quality of life, and social support. Results: Paper I showed no significant differences between the intervention and control group in depression severity reduction or remission rate, change in quality of life, psychological well-being, sedative prescriptions, or sick leave during the entire 12-month follow-up. However, significantly more patients in the intervention group continued anti-depressants until the 6 month follow-up (86/125 vs 78/133, p < 0.05). Paper II showed a good correlation between the two instruments (MADRS-S and BDI-II): 0.66 and 0.62. The reliability was also good for both MADRS-S (Cronbach α: 0.76 for both cohorts) and BDI-II items (Cronbach α: 0.88 and 0.85). Paper III showed that three categories emerged from the analysis: (i) confirmation; MADRS-S shows that I have depression and how serious it is, (ii) centeredness; the most important thing is for the GP to listen to and take me seriously and (iii) clarification; MADRS-S helps me understand why I need treatment for depression. Paper IV showed a significantly steeper increase of WAI at 3 months in the intervention group, although this levelled off at 6 and 12 months. In both groups approximately 20% showed decreased job strain with no significant difference between intervention and control groups. Sick leave did not show any significant difference. Social support was perceived as positive in a significantly higher frequency at 12 months in the intervention group compared to the control group (p= 0.009). Conclusion: The studies in this thesis have expanded knowledge of use of self-assessment instruments in the management of depression in primary care with regard to a number of aspects. Using a self-assessment instrument in recurrent consultations can strengthen the patient’s perceptions concerning confirmation, centeredness, and clarification. The use of a self-assessment instrument increases the adherence to anti-depressant medication, WAI, and the perception of positive social support. However, the use does not reinforce beneficial effects concerning depression course, quality of life, or sick-leave. Implication: It is important for GPs and nurses in primary care to have knowledge of the possible effects of the use of a self-assessment instrument and to explore during contact with the individual with depression, whether the individual is positive to the use of a self-assessment instrument. Further, the MADRS-S instrument corresponds well to the BDI-II instrument in all domains and could be used as a reliable instrument to follow a person’s course of depression with the knowledge that it yields indications comparable to the BDI-II. The use of depression self-rating scales should perhaps not be mandatory in primary health care but rather left to the discretion of the GP and the patient.