Epidemiological data are reviewed on the prevalence, course, socio-demographic correlates, and societal costs of major depression throughout the world. Major depression is estimated in these surveys to be a commonly occurring disorder. Although estimates of lifetime prevalence and course vary substantially across countries for reasons that could involve both substantive and methodological processes, the cross-national data are clear in documenting meaningful lifetime prevalence with wide variation in age-of-onset and high risk of lifelong chronic-recurrent persistence. A number of sociodemographic correlates of major depression are found consistently across countries, and cross-national data also document associations with numerous adverse outcomes, including difficulties in role transitions (e.g., low education, high teen childbearing, marital disruption, unstable employment), reduced role functioning (e.g., low marital quality, low work performance, low earnings), elevated risk of onset, persistence and...

https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-031912-114409

The epidemiology of depression across cultures

Background Depression is common in primary care but is suboptimally managed. Collaborative care, that is, structured care involving a greater role of nonmedical specialists to augment primary care, has emerged as a potentially effective candidate intervention to improve quality of primary care and patient outcomes. Methods To quantify the short-term and longer-term effectiveness of collaborative care compared with standard care and to understand mechanisms of action by exploring between-study heterogeneity, we conducted a systematic review of randomized controlled trials that compared collaborative care with usual primary care in patients with depression. We searched MEDLINE (from the beginning of 1966), EMBASE (from the beginning of 1980), CINAHL (from the beginning of 1980), PsycINFO (from the beginning of 1980), the Cochrane Library (from the beginning of 1966), and DARE (Database of Abstracts of Reviews of Effectiveness) (from the beginning of 1985) databases from study inception to February 6, 2006. Results We found 37 randomized studies including 12 355 patients with depression receiving primary care. Random effects meta-analysis showed that depression outcomes were improved at 6 months (standardized mean difference, 0.25; 95% confidence interval, 0.18-0.32), and evidence of longer-term benefit was found for up to 5 years (standardized mean difference, 0.15; 95% confidence interval, 0.001-0.31). When exploring determinants of effectiveness, effect size was directly related to medication compliance and to the professional background and method of supervision of case managers. The addition of brief psychotherapy did not substantially improve outcome, nor did increased numbers of sessions. Cumulative meta-analysis showed that sufficient evidence had emerged by 2000 to demonstrate the statistically significant benefit of collaborative care. Conclusions Collaborative care is more effective than standard care in improving depression outcomes in the short and longer terms. Future research needs to address the implementation of collaborative care, particularly in settings other than the United States.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/411326/ioi60143_2314_2321.pdf

Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.

Background: Depression is common in primary care but is suboptimally managed. Collaborative care, that is, structured care involving a greater role of nonmedical specialists to augment primary care, has emerged as a potentially effective candidate intervention to improve quality of primary care and patient outcomes. Methods: To quantify the short-term and longer-term effectiveness of collaborative care compared with standard care and to understand mechanisms of action by exploring between-study heterogeneity, we conducted a systematic review of randomized controlled trials that compared collaborative care with usual primary care in patients with depression. We searched MEDLINE (from the beginning of 1966), EMBASE (from the beginning of 1980), CINAHL (from the beginning of 1980), PsycINFO (from the beginning of 1980), the Cochrane Library (from the beginning of 1966), and DARE (Database of Abstracts of Reviews of Effectiveness) (from the beginning of 1985) databases from study inception to February 6, 2006. Results: We found 37 randomized studies including 12 355 patients with depression receiving primary care. Random effects meta-analysis showed that depression outcomes were improved at 6 months (standardized mean difference, 0.25;95% confidence interval, 0.18-0.32), and evidence of longer-term benefit was found for up to 5 years (standardized mean difference, 0.15; 95% confidence interval, 0.001-0.31). When exploring determinants of effectiveness, effect size was directly related to medication compliance and to the professional background and method of supervision of case managers. The addition of brief psychotherapy did not substantially improve outcome, nor did increased numbers of sessions. Cumulative meta-analysis showed that sufficient evidence had emerged by 2000 to demonstrate the statistically significant benefit of collaborative care. Conclusions: Collaborative care is more effective than standard care in improving depression outcomes in the short and longer terms. Future research needs to address the implementation of collaborative care, particularly in settings other than the United States.

Collaborative care for depression : A cumulative meta-analysis and review of longer-term outcomes. Commentary

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines. Objectives To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit. Randomized or quasi-randomized controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters were used. Sixty-five trials met the inclusion criteria. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, >24,000 participants, risk ratio (RR) for cessation at longest follow up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Two studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that provided access to a hotline two detected a significant benefit and one did not. Telephone counselling not initiated by calls to helplines also increased quitting (44 studies, >24,000 participants, RR 1.29, 95% CI 1.20 to 1.38). In the subgroup of studies offering 1-2 calls the effect was small and not significant. A further seven studies were too diverse to contribute to meta-analyses and are discussed separately.

Telephone counselling for smoking cessation.

BACKGROUND Mixed methods or multimethod research holds potential for rigorous, methodologically sound investigations in primary care. The objective of this study was to use criteria from the literature to evaluate 5 mixed methods studies in primary care and to advance 3 models useful for designing such investigations. METHODS We fi rst identifi ed criteria from the social and behavioral sciences to analyze mixed methods studies in primary care research. We then used the criteria to evaluate 5 mixed methods investigations published in primary care research journals. RESULTS Of the 5 studies analyzed, 3 included a rationale for mixing based on the need to develop a quantitative instrument from qualitative data or to converge information to best understand the research topic. Quantitative data collection involved structured interviews, observational checklists, and chart audits that were analyzed using descriptive and inferential statistical procedures. Qualitative data consisted of semistructured interviews and fi eld observations that were analyzed using coding to develop themes and categories. The studies showed diverse forms of priority: equal priority, qualitative priority, and quantitative priority. Data collection involved quantitative and qualitative data gathered both concurrently and sequentially. The integration of the quantitative and qualitative data in these studies occurred between data analysis from one phase and data collection from a subsequent phase, while analyzing the data, and when reporting the results. DISCUSSION We recommend instrument-building, triangulation, and data transformation models for mixed methods designs as useful frameworks to add rigor to investigations in primary care. We also discuss the limitations of our study and the need for future research.

https://www.annfammed.org/content/annalsfm/2/1/7.full.pdf

Designing A Mixed Methods Study In Primary Care

Objective: To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years.

Setting and Subjects: Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening.

Research Design: Practices were stratified by depression treatment patterns before randomization to enhanced or usual care. After delivering brief training, enhanced care clinicians provided improved depression management over 24 months. The research team evaluated productivity and absenteeism at baseline, 6, 12, 18, and 24 months in 326 patients who reported full-or part-time work at one or more completed waves.

Results: Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years. Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over 2 years at an estimated annual value of $1982 per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over 2 years at an estimated annual value of $619 per depressed full-time equivalent.

Conclusions: This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees.

/pdf/the-effect-of-improving-primary-care-depression-management-10yniojwnj.pdf

The effect of improving primary care depression management on employee absenteeism and productivity. A randomized trial.

OBJECTIVE AND DESIGN: This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression.

/pdf/barriers-to-initiating-depression-treatment-in-primary-care-19rapcaesp.pdf

Barriers to Initiating Depression Treatment in Primary Care Practice

Objectives: To evaluate the long term effect of ongoing intervention to improve treatment of depression in primary care. Design: Randomised controlled trial. Setting: Twelve primary care practices across the United States. Participants: 211 adults beginning a new treatment episode for major depression; 94% of patients assigned to ongoing intervention participated. Intervention: Practices assigned to ongoing intervention encouraged participating patients to engage in active treatment, using practice nurses to provide care management over 24 months. Main outcome measures: Patients9 report of remission and functioning. Results: Ongoing intervention significantly improved both symptoms and functioning at 24 months, increasing remission by 33 percentage points (95% confidence interval 7% to 46%), improving emotional functioning by 24 points (11 to 38) and physical functioning by 17 points (6 to 28). By 24 months, 74% of patients in enhanced care reported remission, with emotional functioning exceeding 90% of population norms and physical functioning approaching 75% of population norms.
 Conclusions: Ongoing intervention increased remission rates and improved indicators of emotional and physical functioning. Studies are needed to compare the cost effectiveness of ongoing depression management with other chronic disease treatment routinely undertaken by primary care.

https://www.bmj.com/content/bmj/325/7370/934.full.pdf

Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

Objective: This study used statewide administrative data sets to estimate the prevalence of tobacco use among persons with mental illnesses who were accessing public-sector mental health care in Colorado and to determine the relationships between tobacco use and primary diagnosis and alcohol and drug use. Methods: This study utilized the Colorado Client Assessment Record to examine predictors of tobacco use among 111,984 persons with mental illnesses who were receiving services in the public mental health system. Results: Thirty-nine percent of the sample (N=43,508) used tobacco. Multiple logistic regression analysis found that schizophrenia, schizoaffective disorder, and bipolar disorder (p<.001 for all), and depression or dysthymia (p<.01) were associated with greater tobacco use than other diagnoses. Significant differences in tobacco use existed across gender, age group, race or ethnicity, and substance use categories. Conclusions: Findings suggest that an administrative database is a low-burden means of identifying persons at high risk of tobacco use to inform resource allocation. (Psychiatric Services 57: 1035–1038, 2006)

Predictors of tobacco use among persons with mental illnesses in a statewide population

Persons with mental illnesses use tobacco at significantly higher and heavier rates than the general population, and suffer greater tobacco- related morbidity and mortality. However, there are few existing tobacco cessation interventions for these individuals. This study examined two tobacco cessation interventions, a telephonic quitline intervention (counseling and nicotine replacement therapy) and a community-based group counseling intervention with adults currently receiving community mental health services. At 6-month follow-up, both groups demonstrated significantly reduced tobacco use, but participants who received both quitline services and the group counseling intervention were significantly more likely to have a 50% tobacco use reduction. Across groups, the overall intent-to-treat cessation rate was 7%. Tobacco dependence, depression symptoms, and psychotic symptoms decreased significantly for all treatment groups, while health and mental health functioning increased. Findings suggest that common community tobacco cessation services are effective for this population.

Miriam Dickinson

Papers

The effect of improving primary care depression management on employee absenteeism and productivity. A randomized trial.

Barriers to Initiating Depression Treatment in Primary Care Practice

Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

Predictors of tobacco use among persons with mental illnesses in a statewide population

Smoking reduction for persons with mental illnesses: 6-month results from community-based interventions.