Aspects of common mental disorders in primary care

Abstract

Depression and anxiety disorders are common in the general population. Primary care is the first line of care for people with common mental disorders. This doctoral project investigated aspects of common mental disorders, including diagnostic procedures and interventions in primary care.

Study I was an observational study of 480 people in the regions of Stockholm and Västra Götaland on sick leave for common mental disorders. It used structured psychiatric interviews (M.I.N.I.) and symptom severity scales (MADRS-S, KEDS) to investigate the relationship between sick leave certificate diagnoses for common mental disorders and diagnoses made in the psychiatric interviews. It also examined length of sick leave by diagnoses on certificates, interview diagnoses, and symptom severity. Many participants fulfilled the criteria for mental disorders other than the sick leave certificate diagnosis. For example, 76% on sick leave for stress-induced exhaustion disorder (SED) and 67% on sick leave for anxiety disorder fulfilled the criteria for depression (p=0.041). Diagnoses on certificates were not associated with sick leave length. Fulfilling SED criteria was associated with longer sick leave (144 vs. 84 days, p<0.001), as were more severe symptoms. Thus, sick leave certificate diagnoses do not reflect the diagnoses obtained in structured psychiatric interviews. This could mirror the changing and overlapping nature of the symptoms of common mental disorders and suggests that findings based on sick leave certificate diagnoses should be interpreted with caution. The association between longer sick leave and more severe symptoms or fulfilling SED criteria is clinically relevant and worth further study.

Study II used data from the PRIM-CARE cluster randomized controlled trial (RCT) at 23 primary care centers (11 intervention, 12 control) in Västra Götaland and Dalarna to compare the 12- and 24-month effectiveness of care managers to usual care for primary care patients with depression (n=376: 192 intervention, 184 control). Patients with care managers had less severe symptoms (MADRS-S, p=0.02) and higher quality of life (EQ-5D, p=0.01) at 12 months. Improvements in patients without care managers meant that this was no longer the case at 24 months (MADRS-S, p=0.83, EQ-5D, p=0.88). Responses to a study-specific postal questionnaire at 24 months showed that patients with care managers were more confident that they could get information (53% vs 38%; p=0.02) and professional emotional support (51% vs 40%; p=0.05). Care managers for primary care patients with depression therefore seem superior to usual care in the long term, as it took up to 24 months for patients without care managers to achieve the same improvements as patients with care managers achieved in 6 months and maintained long-term. Moreover, patients with care managers had more confidence in future care.

Study III explored the views and experiences of general practitioners (GPs) who worked with the care managers in the PRIM-CARE study to better understand the GPs’ perspectives on this organizational change. Transcripts from five focus-group discussions with GPs were analyzed with qualitative content analysis. GPs thought care managers could ensure care quality while freeing GPs from case management. They could also feel concern about role overlap, think that care managers should be assigned to patients who need them the most, and express the belief that transition to a chronic care model required change. In summary, GPs could see benefits to assigning care managers to patients with depression. However, they expressed concern about role overlap and emphasized the need to clarify care managers’ role in the care team.

Study IV was an RCT pilot trial that investigated the feasibility and effectiveness of two cognitive behavioral therapy (CBT) protocols for generalized anxiety disorder (GAD) in primary care, intolerance-of-uncertainty therapy (IUT) and meta-cognitive therapy (MCT). Feasibility measures included recruitment, drop-out, patients’ perceptions of participation and treatment, and therapists’ competence in and adherence to protocol. Effectiveness measures, assessed at pre-treatment, post-treatment, and 6 months, included worry, depressive symptoms, functional impairment, and quality of life. The recruitment process was smooth, dropout was low, and patients were satisfied with treatment (scale 0-6, median 5.17, SD 1.09). Therapists’ competence and adherence to protocol were rated weak to mediocre. Both therapies effectively reduced worry with large effect sizes (Cohen’s d IUT = -2.69, 95% confidence interval [-3.63, -1.76] and Cohen’s d MCT = -3.78 [-4.68, -2.90]). MCT resulted in statistically superior improvements (d = -2.03 [-3.31, -0.75]). Results were maintained at 6 months. It is thus feasible to conduct an RCT comparing IUT and MCT in primary care patients with GAD. Both treatments effectively reduce worry, but MCT seems superior. A full-scale RCT is required to confirm these findings.