Mark Haddad

Depression in adults with a chronic physical health problem: Treatment and management

The NHS National Institute for Health and Clinical Excellence (NICE, 2009) publication – Depression in adults with a chronic physical health problem: treatment and management – is a clinical practice guideline for the UK which partially updates and extends the earlier depression management in primary and secondary care guideline (NICE, 2004). Like other clinical guidelines, it has been systematically developed from the best available research evidence to assist clinicians and patients, and service commissioners and providers in making decisions about the most appropriate treatment and service organisation for this important area of health care need. The National Collaborating Centre for Mental Health (one of a number of centres established by NICE for the purpose of clinical guideline development) together with a guideline development group, comprising health and social care professionals, lay and patient representatives, and technical experts, worked on the guidance. The process from initial scope preparation to the production of the final guideline took over two years. As with other NICE recommendations, the development of this guidance has involved extensive stakeholder consultations at the initial scoping phase that defined the aspects of care covered and to whom it would apply, and later when the draft guideline was prepared. The aim of this editorial is to bring this important document to the attention of nurses and midwives worldwide who work with depression sufferers.

Case identification of depression in patients with chronic physical health problems: a diagnostic accuracy meta-analysis of 113 studies

BACKGROUND Depression is more likely in patients with chronic physical illness, and is associated with increased rates of disability and mortality. Effective treatment of depression may reduce morbidity and mortality. The use of two stem questions for case finding in diabetes and coronary heart disease is advocated in the Quality and Outcomes Framework, and has become normalised into primary care. AIM To define the most effective tool for use in consultations to detect depression in people with chronic physical illness. DESIGN Meta-analysis. METHOD The following data sources were searched: CENTRAL, CINAHL, Embase, HMIC, MEDLINE, PsycINFO, Web of Knowledge, from inception to July 2009. Three authors selected studies that examined identification tools and used an interview-based ICD (International Classification of Diseases) or DSM (Diagnostic and statistical Manual of Mental Disorders) diagnosis of depression as reference standard. At least two authors independently extracted study characteristics and outcome data and assessed methodological quality. RESULTS A total of 113 studies met the eligibility criteria, providing data on 20,826 participants. It was found that two stem questions, PHQ-9 (Patient Health Questionnaire), the Zung, and GHQ-28 (General Health Questionnaire) were the optimal measures for case identification, but no method was sufficiently accurate to recommend as a definitive case-finding tool. Limitations were the moderate-to-high heterogeneity for most scales and the facts that few studies used ICD diagnoses as the reference standard, and that a variety of methods were used to determine DSM diagnoses. CONCLUSION Assessing both validity and ease of use, the two stem questions are the preferred method. However, clinicians should not rely on the two-questions approach alone, but should be confident to engage in a more detailed clinical assessment of patients who score positively.

The detection of psychological problems by General Practitioners--influence of ethnicity and other demographic variables.

Abstract.Background:Common mental illness in Black Africans and Black Caribbeans has been relatively little studied in the UK. Previous studies of the detection of psychological problems by General Practitioners (GPs) in these groups have been inconclusive.Aims:The aim of this study was to investigate the prevalence, detection and management of psychological problems in General Practice among Black Caribbeans and Black Africans compared to White English attenders and to examine the relative contribution of other sociodemographic factors to these main outcome variables.Method:Consecutive attenders aged 16–65 years at 18 General Practitioners in South-East London completed the General Health Questionnaire (GHQ-12) before seeing the GP. The GPs rated the current emotional state of the patients at the end of each consultation. Comparison of the GHQ and GP ratings was used to compute the detection indices.Results:A total of 1211 patients aged 16–65 years were approached to take part in the study. Of the patients, 75 (6 %) declined or were not able to complete the GHQ. In all, 994 individuals had both GP and GHQ ratings. There was an overall probable prevalence of 37%, of which 73% were identified as cases by the GPs. Black African patients had lower rates of common mental disorders, were less likely to be detected as psychiatric cases by the GP and less likely to receive active management for their psychological problems than Black Caribbean and White English patients. Rates of prevalence, detection and management were similar between Black Caribbean and White English patients. In the multivariate analysis, ethnicity, employment and age all played a significant independent role in predicting probable prevalence. The patients’ reported decision to talk to their GP about psychological problems was the main predictor of detection. Ethnicity did not independently predict detection, but Black African cases were less likely to say that they would talk to their GP about psychological problems. GPs’ identification indices mirrored probable prevalence, suggesting that GPs were more sensitive to detecting psychiatric illness in individuals belonging to groups which commonly presented as symptomatic.Conclusions:The findings suggest that in General Practice the prevalence of common mental disorders, their detection and management in Black Caribbeans are similar to those in White English, but that Black Africans have lower prevalence, are less likely to be detected and are less likely to receive active management. The study of GP consulters presents problems for the interpretation of these results and it may be that Black Africans with psychological problems are less likely than their Caribbean and English counterparts to attend their GP, and less willing to speak to them about these problems when they do. Future similar studies should distinguish Black African and Black Caribbean subjects in their analyses, as categories such as ‘Afro-Caribbean’ may mask important differences in attitudes and illness behaviour.

Detecting Depression in Patients with Coronary Heart Disease: a Diagnostic Evaluation of the PHQ-9 and HADS-D in Primary Care, Findings From the UPBEAT-UK Study

Objective People with coronary heart disease (CHD) are at heightened risk of depression, and this co-occurrence of conditions is associated with poorer outcomes including raised mortality. This study compares the diagnostic accuracy of two depression case finding instruments in CHD patients relative to a diagnostic standard, the revised Clinical Interview Schedule (CIS-R). Methods The Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the CIS-R depression module were administered to 803 patients identified from the CHD registers of GP practices in Greater London. Results Of 730 recruited patients without previously identified depression, 32 (4.4%) met ICD-10 depressive episode criteria according to the CIS-R. For the PHQ-9 and HADS-D lower cut-points than those routinely recommended were associated with improved case identifying properties. The PHQ-9 appeared the superior instrument using a cut-point of ≥8 (sensitivity=94%; specificity=84%). Using categorical scoring the PHQ-9 was 59% sensitive and 95% specific. For the HADS-D using cut-point ≥5, sensitivity was 81% and specificity was 77%. Areas under the curves (AUC) (standard error) were 0.95 (0.01) and 0.88 (0.02) for the PHQ-9 and HADS-D, and 0.91 (0.02) for PHQ-9 using the categorical algorithm. Statistically significant differences between AUCs of the PHQ-9 and the HADS-D favoured the former. Severity ratings compared across measures indicated inconsistency between recommended bandings: the PHQ-9 categorised a larger proportion of participants with mild and moderate depression. Conclusion This is the first large-scale investigation of the accuracy of these commonly used measures within a primary care CHD population. Our results suggest that although both scales have acceptable abilities and can be used as case identification instruments for depression in patients with CHD, the PHQ-9 appeared diagnostically superior. Importantly, optimal cut-off points for depression identification in this population appear to differ from standard values, and severity ratings differ between these measures.

The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study.

Background Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression. Methods Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables. Result 1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000. Conclusions Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU. Trial Registration Controlled-Trials.com ISRCTN21615909

The development and psychometric properties of a measure of clinicians’ attitudes to depression: the revised Depression Attitude Questionnaire (R-DAQ)

BackgroundDepression is a common mental disorder associated with substantial disability. It is inadequately recognised and managed, and clinicians’ attitudes to this condition and its treatment may play a part in this. Most research in this area has used the Depression Attitude Questionnaire (DAQ), but analyses have shown this measure to exhibit problems in psychometric properties and suitability for the health professionals and settings where depression recognition may occur.MethodsWe revised the DAQ using a pooled review of findings from studies using this measure, together with a Delphi study which sought the opinions of a panel of relevant experts based in the UK, USA, Australia, and European countries (n = 24) using 3 rounds of questioning to consider attitude dimensions, content, and item wording. After item generation, revision and consensus (agreement >70%) using the Delphi panel, the revised DAQ (R-DAQ) was tested with 1193 health care providers to determine its psychometric properties. Finally the test-retest reliability of the R-DAQ was examined with 38 participants.ResultsThe 22-item R-DAQ scale showed good internal consistency: Cronbach’s alpha coefficient was 0.84; and satisfactory test-retest reliability: intraclass correlation coefficient was 0.62 (95% C.I. 0.37 to 0.78). Exploratory factor analysis favoured a three-factor structure (professional confidence, therapeutic optimism/pessimism, and a generalist perspective), which accounted for 45.3% of the variance.ConclusionsThe R-DAQ provides a revised tool for examining clinicians’ views and understanding of depression. It addresses important weaknesses in the original measure whilst retaining items and dimensions that appeared valid. This revised scale is likely to be useful in examining attitudes across the health professional workforce and beyond the confines of the UK, and may be valuable for the purpose of evaluating training that aims to address clinicians’ attitudes to depression. It incorporates key dimensions of attitudes with a modest number of items making it applicable to use in busy clinical settings.

A pilot randomised controlled trial of personalised care for depressed patients with symptomatic coronary heart disease in South London general practices: the UPBEAT-UK RCT protocol and recruitment

BackgroundCommunity studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings.MethodsThis pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care.81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire.Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant’s physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant’s mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient’s self efficacy to solve their problems.Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation.DiscussionThis practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care.Trial registrationISRCTN21615909.

The UPBEAT depression and coronary heart disease programme: using the UK medical research council framework to design a nurse-led complex intervention for use in primary care

BackgroundDepression is common in coronary heart disease (CHD) and increases the incidence of coronary symptoms and death in CHD patients. Interventions feasible for use in primary care are needed to improve both mood and cardiac outcomes. The UPBEAT-UK programme of research has been funded by the NHS National Institute for Health Research (NIHR) to explore the relationship between CHD and depression and to develop a new intervention for use in primary care.MethodsUsing the Medical Research Council (MRC) guidelines for developing and evaluating complex interventions, we conducted a systematic review and qualitative research to develop a primary care-based nurse-led intervention to improve mood and cardiac outcomes in patients with CHD and depression. Iterative literature review was used to synthesise our empirical work and to identify evidence and theory to inform the intervention.ResultsWe developed a primary care-based nurse-led personalised care intervention which utilises elements of case management to promote self management. Following biopsychosocial assessment, a personalised care plan is devised. Nurses trained in behaviour change techniques facilitate patients to address the problems important to them. Identification and utilisation of existing resources is promoted. Nurse time is conserved through telephone follow up.ConclusionsApplication of the MRC framework for complex interventions has allowed us to develop an evidence based intervention informed by patient and clinician preferences and established theory. The feasibility and acceptability of this intervention is now being tested further in an exploratory trial.

Beliefs and attitudes of French family practitioners toward depression: the impact of training in mental health

Objective: To study, in a sample of French Family Practitioners (FPs), beliefs and attitudes toward depression and how they vary according to training received in mental health. Methods: The Depression Attitude Questionnaire (DAQ) was completed by 468 FPs from all regions of France, recruited by pharmaceutical company representatives to attend focus groups on the management of depression in general practice. Results: A three-factor model was derived from the DAQ, accounting for 37.7% of the total variance. The correlations between individual items of each component varied from 0.4 to 0.65, with an overall internal consistency of 0.47 (Cronbachs alpha). FPs had an overall neutral position on component 1, professional ease, a positive view on the origins of depression and its amenability to change (component 2), and a belief in the necessity of medication and the benefit of antidepressant therapy (component 3). Training in mental health, specifically through continuing medical education and postgraduate psychiatric hospital training, was significantly and positively associated with both professional ease and a medication approach to treating depression. Conclusion: This study is the first description of the beliefs and attitudes of French FPs toward depression using a standardized measure, the DAQ, despite the instruments limited psychometric properties. It shows the positive effect of training in mental health on attitudes toward depression.

Managing complex problems: treatment for common mental disorders in the UK

AIMS This paper aims to describe current trends in the UK primary care management of common mental disorders and explore the appropriateness of differing management approaches in light of the course and common complications of these disorders. METHODS It highlights key findings concerning the course and comorbidity of depression to indicate that depression and associated mental illnesses may often form part of more complex patterns of ill health and that these conditions have a clear potential for chronicity. A narrative review of studies providing detail of depression prevalence in selected comorbid conditions is presented for this purpose. CONCLUSION The presentation and course of common mental disorders indicate organizational changes in health service delivery, and--for a sizeable patient group--the use of chronic disease management strategies.