Primary care patients with common mental disorders : quality of life, sick leave and effects of group therapy

Background: Depression, Anxiety and Stress-Related Disorders, Common Mental Disorders (CMDs) are common among patients in primary health care, with many left untreated or even undiagnosed. CMDs are associated with high societal costs, and are the main cause of increasing Sick Leave among patients in primary health care. Effective treatments are not widely available in primary care. In addition, the associations between Clinical and Treatment-Related Factors, Patient Variables, Sick Leave and the Quality of Life are not well investigated. Research is needed in order to identify factors related to Health Outcomes, as well as to develop treatments that are well suited for primary care settings.

Aims: The objective of the present thesis was to investigate the following: (a) The effects of two different group interventions for CMD in a primary care setting (Paper I), (b) the effects on active treatments on Sick Leave in a primary care setting (Paper II), (c) patient characteristics and their associations with the Quality of Life (QoL) (Paper III) and (d) how patient variables compared to treatments can predict QoL-one year after treatment (Paper IV).

Methods: One large-scale randomized controlled trial (RCT) was conducted. In Paper I, a group intervention with a Transdiagnostic Manual based on Cognitive Behavioral Treatment(CBT) + Care as Usual(CAU) (n= 80) was compared to group with Multimodal Intervention(MMI) led by assistant nurses + CAU (n= 84) and CAU (n=81). Paper II compared treatment effects of group CBT + CAU (n=45) and MMI + CAU (n=58) compared to CAU (n=61) on Sick Leave. In Paper III, associations between patient variables and QoL were examined using a linear regression model. Paper IV examined associations between patient variables, treatment effects of group CBT + CAU, MMI + CAU or CAU and QoL one year after treatment, using a linear regression model. We used the Mental Component Summary (MCS) and the Physical Summary Score (PCS) of short form 36 (SF-36) to measure QoL.

Results: Study 1: the MMI + CAU group was significantly more improved than the CBT + CAU and CAU groups. The CBT + CAU group was significantly more improved than the CAU group. Study 2: The mean number of Sick Leave days decreased after randomization and the CBT and MMI interventions did not result in lower odds for sick listing compared with CAU. Study 3: Depressive Disorders and symptoms had the strongest effects on MCS. Study IV: background factors such as being employed, being born outside Sweden as well as having a Personality Disorder (PD) were strong predictors for QoL one year after treatment. The strongest positive predictor of MCS one year after treatment was the Group Treatment MMI.

Conclusions: Transdiagnostic Group Treatment led by assistant nurses in a primary care setting can be effective for patients with CMD. Reduction in Psychological Symptoms and increased Well-Being did not seem to have effect on Sick Leave. For primary care patients with mild to moderate Mental Illness, Mood Disorder and Depressive Symptoms were the strongest factors associated with negative influence on MCS. Effective Treatment and Being Employed had the strongest positive impact on QoL one year after treatment. PD had the strongest negative impact together with Being Born Outside Sweden. Increased priority for treatment of CMD in primary care is of great importance.

List of scientific papers

I. Ejeby K, Savitskij R, Öst L-G, Ekbom A, Brandt L, Ramnerö J, Åsberg M, Backlund L G. Randomized controlled trial of transdiagnostic group treatments for primary care patients with common mental disorders. Family Practice. 2013; 3, 273-280.
https://doi.org/10.1093/fampra/cmu006

II. Ejeby K, Savitskij R, Öst L-G, Ekbom A, Brandt L, Ramnerö J, Åsberg M, Backlund, L G. Symptom reduction due to psychosocial interventions is not accompanied by a reduction in sick leave: Results from a randomized controlled trial in primary care. Scandinavian Journal of Primary Health Care. 204; 32: 67-72.
https://doi.org/10.3109/02813432.2014.909163

III. Ejeby K, Öst L-G, Ekbom A, Gustavsson P, Ramnerö J, Backlund L G. Factors associated with quality of life for primary care patients with mental disorders. [Manuscript]

IV. Ejeby K, Öst L-G, Ekbom A, Gustavsson P, Ramnerö J, Backlund L G. Long-Term Effects on the Quality of Life of Primary Care Patients With Mental Disorders: Psychological Treatments Versus Patient Characteristics. [Manuscript]