Depressive Disorders in Primary Health Care

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http://urn.fi/URN:ISBN:978-951-740-815-8
Title: Depressive Disorders in Primary Health Care
Author: Vuorilehto, Maria
Contributor: Department of Mental health and Alcohol Research, National Public Health Institute, Helsinki, Finland
University of Helsinki, Faculty of Medicine, Institute of Clinical Medicine, Department of Psychiatry
Thesis level: Doctoral dissertation (article-based)
Belongs to series: URN:ISSN:1458-6290
Abstract: The Vantaa Primary Care Depression Study (PC-VDS) is a naturalistic and prospective cohort study concerning primary care patients with depressive disorders. It forms a collaborative research project between the Department of Mental and Alcohol Research of the National Public Health Institute, and the Primary Health Care Organization of the City of Vantaa. The aim is to obtain a comprehensive view on clinically significant depression in primary care, and to compare depressive patients in primary care and in secondary level psychiatric care in terms of clinical characteristics. Consecutive patients (N=1111) in three primary care health centres were screened for depression with the PRIME-MD, and positive cases interviewed by telephone. Cases with current depressive symptoms were diagnosed face-to-face with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P). A cohort of 137 patients with unipolar depressive disorders, comprising all patients with at least two depressive symptoms and clinically significant distress or disability, was recruited. The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), medical records, rating scales, interview and a retrospective life-chart were used to obtain comprehensive cross-sectional and retrospective longitudinal information. For investigation of suicidal behaviour the Scale for Suicidal Ideation (SSI), patient records and the interview were used. The methodology was designed to be comparable to The Vantaa Depression Study (VDS) conducted in secondary level psychiatric care. Comparison of major depressive disorder (MDD) patients aged 20-59 from primary care in PC-VDS (N=79) was conducted with new psychiatric outpatients (N =223) and inpatients (N =46) in VDS. The PC-VDS cohort was prospectively followed up at 3, 6 and 18 months. Altogether 123 patients (90%) completed the follow-up. Duration of the index episode and the timing of relapses or recurrences were examined using a life-chart. The retrospective investigation revealed current MDD in most (66%), and lifetime MDD in nearly all (90%) cases of clinically significant depressive syndromes. Two thirds of the “subsyndromal” cases had a history of major depressive episode (MDE), although they were currently either in partial remission or a potential prodromal phase. Recurrences and chronicity were common. The picture of depression was complicated by Axis I co-morbidity in 59%, Axis II in 52% and chronic Axis III disorders in 47%; only 12% had no co-morbidity. Within their lifetimes, one third (37%) had seriously considered suicide, and one sixth (17%) had attempted it. Suicidal behaviour clustered in patients with moderate to severe MDD, co-morbidity with personality disorders, and a history of treatment in psychiatric care. The majority had received treatment for depression, but suicidal ideation had mostly remained unrecognised. The comparison of patients with MDD in primary care to those in psychiatric care revealed that the majority of suicidal or psychotic patients were receiving psychiatric treatment, and the patients with the most severe symptoms and functional limitations were hospitalized. In other clinical aspects, patients with MDD in primary care were surprisingly similar to psychiatric outpatients. Mental health contacts earlier in the current MDE were common among primary care patients. The 18-month prospective investigation with a life-chart methodology verified the chronic and recurrent nature of depression in primary care. Only one-quarter of patients with MDD achieved and maintained full remission during the follow-up, while another quarter failed to remit at all. The remaining patients suffered either from residual symptoms or recurrences. While severity of depression was the strongest predictor of recovery, presence of co-morbid substance use disorders, chronic medical illness and cluster C personality disorders all contributed to an adverse outcome. In clinical decision making, beside severity of depression and co-morbidity, history of previous MDD should not be ignored by primary care doctors while depression there is usually severe enough to indicate at least follow-up, and concerning those with residual symptoms, evaluation of their current treatment. Moreover, recognition of suicidal behaviour among depressed patients should also be improved. In order to improve outcome of depression in primary care, the often chronic and recurrent nature of depression should be taken into account in organizing the care. According to literature management programs of a chronic disease, with enhancement of the role of case managers and greater integration of primary and specialist care, have been successful. Optimum ways of allocating resources between treatment providers as well as within health centres should be found.Melkein 90 prosentilla terveyskeskuksen depressiopotilaista oli tämän tutkimuksen mukaan toipumista hidastavia muitakin psykiatrisia tai kroonisia fyysisiä sairauksia. Niinpä puolentoista vuoden kuluttua, uusintatutkimuksessa, neljännes potilaista sairasti yhä samaa depressiota. Puolet potilaista oli toipunut vain osittain tai depressio oli jo uusiutunut. Erityisen huonoa toipuminen oli päihdeongelmaisilla tai fyysisesti sairailla potilailla sekä niillä, joiden riippuvaiset, estyneet ja vaativat persoonallisuuden piirteet ylläpitivät masentuneisuutta. Yli tuhat satunnaista vantaalaista potilasta vastasi masennusoirekyselyyn käydessään terveyskeskuslääkärin vastaanotolla v. 2002. Ne, joilla oli masennusoireita, haastateltiin puhelimitse, ja heistä ne 137 potilasta, jotka olivat jo yli kaksi viikkoa kärsineet vähintään kahdesta vakavan masennustilan oireesta, valittiin lopulliseen tutkimusryhmään. Tutkimuspotilaiden mielenterveyteen ja fyysiseen terveydeen liittyvät diagnoosit kartoitettiin haastattelumenetelmällä ja sairauskertomuksista. Lisäksi selvitettiin saatua hoitoa, masennuksen kestoa ja toistumista sekä mahdollisia itsetuhoajatuksia ja itsemurhayrityksiä. Tavoitteena oli luoda aiempaa kattavampi käsitys terveyskeskuspotilaiden depressiosta. Lisäksi tutkimuksessa verrattiin depressioon liittyviä eroja ja yhteneväisyyksiä vantaalaisten terveyskeskuspotilaiden ja Peijaksen psykiatristen poliklinikoiden sekä sairaalan potilaiden välillä, joita oli aikaisemmin tutkittu samoin menetelmin. Vakavan masennustilan diagnoosi edellyttää viittä samanaikaista oiretta; melkein kaikilla tutkimusryhmän potilailla diagnoosin kriteerit olivat täyttyneet joskus, kaksi kolmasosaa sairasti parast’ aikaa vakavaa masennustilaa. Valtaosalla se oli jo toistuvaa, viidenneksellä se oli kroonista. Monet tutkimusryhmän potilaat olivat olleet myös psykiatrisessa hoidossa, mutta he olivat siirtyneet terveyskeskuksen hoitoon huonosti toipuneina. Terveyskeskuspotilaiden ja psykiatriseten poliklinikoiden potilaiden depressio osoittautui hyvin samankaltaiseksi. Sen sijaan erona sairaalapotilaisiin harvalla terveyskeskuspotilaalla depressio oli vaikea-asteista tai psykoottistasoista eivätkä itsemurhayritykset olleet yhtä tavallisia kuin sairaalapotilailla. Itsetuhoiset ajatukset olivat yleisiä terveyskeskuksen depressiopotilailla, mutta ne olivat tavallisesti jääneet lääkäreiltä tunnistamatta. Potilaista 17 prosenttia oli yrittänyt itsemurhaa elämänsä aikana, he olivat yleensä vaikeimmin sairaita ja heidän hoitoonsa oli panostettu. Tämän tutkimuksen perusteella terveyskeskuspotilaiden lievätkin depressio-oireet saattavat itse asiassa olla merkki huonosti parantuneesta vakavasta masennustilasta, jonka hoitoa pitäisi tehostaa. Itsemurhien ehkäisyn kannalta depressiopotilaiden itsetuhoisiin ajatuksiin kiinnitetään liian vähän huomita. Hoidon kehittämisessä pitää huomioida depression runsas uusiutuminen ja kroonistuminen terveyskeskuspotilailla. Työnjakoa ja yhteistyötä perusterveydenhuollon ja erikoissairaanhoidon välillä tulisi selkeyttää.
URI: URN:ISBN:978-951-740-815-8
http://hdl.handle.net/10138/22769
Date: 2008-05-16
Subject: lääketiede
Rights: This publication is copyrighted. You may download, display and print it for Your own personal use. Commercial use is prohibited.


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