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1.  Psychiatrists’ approach to vascular risk assessment in Latin America 
World Journal of Psychiatry  2014;4(3):56-61.
AIM: To explore the way in which Latin American psychiatrists approach the screening of vascular risk factors in patients receiving antipsychotic medication.
METHODS: This was a descriptive, cross sectional study that surveyed Latin-American physicians to evaluate differences between groups divided in three main sections. The first section included demographic and professional data. The second section asked about the available medical resources: weighing scales, sphygmomanometer and measuring tape. Finally, the third section aimed at looking into the attitudes towards cardiovascular prevention. The latter was also divided into two subsections. In the first one, the questions were about weight, blood pressure and waist perimeter. In the second subsection the questions asked about the proportion of patients: (1) that suffered from overweight and/or obesity; (2) whose lipids and glycemia were controlled by the physician; (3) that were questioned by, and received information from the physician about smoking; and (4) that received recommendations from the physician to engage in regular physical activity. The participants were physicians, users of the medical website Intramed. The visitors were recruited by a banner that invited them to voluntarily access an online self-reported structured questionnaire with multiple options.
RESULTS: We surveyed 1185 general physicians and 792 psychiatrists. Regarding basic medical resources, a significantly higher proportion of general physicians claimed to have weighing scales (χ2 = 404.9; P < 0.001), sphygmomanometers (χ2 = 419.3; P < 0.001), and measuring tapes (χ2 = 336.5; P < 0.001). While general physicians measured overweight and metabolic indexes in the general population in a higher proportion than in patients treated with antipsychotics (Z = -11.91; P < 0.001), psychiatrists claimed to measure them in patients medicated with antipsychotics in a higher proportion than in the general population (Z = -3.26; P < 0.001). Also general physicians tended to evaluate smoking habits in the general population more than psychiatrists (Z = -7.02; P < 0.001), but psychiatrists evaluated smoking habits in patients medicated with antipsychotics more than general physicians did (Z = -2.25; P = 0.024). General physicians showed a significantly higher tendency to control blood pressure (χ2 = 334.987; P < 0.001), weight (χ2 = 435.636; P < 0.001) and waist perimeter (χ2 = 96.52; P < 0.001) themselves and they did so in all patients. General physicians suggested physical activity to all patients more frequently (Z = -2.23; P = 0.026), but psychiatrists recommended physical activity to patients medicated with antipsychotics more frequently (Z = -7.53; P < 0.001).
CONCLUSION: Psychiatrists usually check vascular risk factors in their patients, especially in those taking antipsychotics. General practitioners check them routinely without paying special attention to this population.
doi:10.5498/wjp.v4.i3.56
PMCID: PMC4171137  PMID: 25250222
Antipsychotics; Metabolic syndrome; Psychiatric patients; Schizophrenia; Vascular risk factors
2.  Attitudes toward depression among Japanese non-psychiatric medical doctors: a cross-sectional study 
BMC Research Notes  2012;5:441.
Background
Under-recognition of depression is common in many countries. Education of medical staff, focusing on their attitudes towards depression, may be necessary to change their behavior and enhance recognition of depression. Several studies have previously reported on attitudes toward depression among general physicians. However, little is known about attitudes of non-psychiatric doctors in Japan. In the present study, we surveyed non-psychiatric doctors’ attitude toward depression.
Methods
The inclusion criteria of participants in the present study were as follows: 1) Japanese non-psychiatric doctors and 2) attendees in educational opportunities regarding depression care. We conveniently approached two populations: 1) a workshop to depression care for non-psychiatric doctors and 2) a general physician-psychiatrist (G-P) network group. We contacted 367 subjects. Attitudes toward depression were measured using the Depression Attitude Questionnaire (DAQ), a 20-item self-report questionnaire developed for general physicians. We report scores of each DAQ item and factors derived from exploratory factor analysis.
Results
We received responses from 230 subjects, and we used DAQ data from 187 non-psychiatric doctors who met the inclusion criteria. All non-psychiatric doctors (n = 187) disagreed with "I feel comfortable in dealing with depressed patients' needs," while 60 % (n = 112) agreed with "Working with depressed patients is heavy going." Factor analysis indicated these items comprised a factor termed "Depression should be treated by psychiatrists" - to which 54 % of doctors (n = 101) agreed. Meanwhile, 67 % of doctors (n = 126) thought that nurses could be useful in depressed patient support. The three factors derived from the Japanese DAQ differed from models previously derived from British GP samples. The attitude of Japanese non-psychiatric doctors concerning whether depression should be treated by psychiatrists was markedly different to that of British GPs.
Conclusions
Japanese non-psychiatric doctors believe that depression care is beyond the scope of their duties. It is suggested that educational programs or guidelines for depression care developed in other countries such as the UK are not directly adaptable for Japanese non-psychiatric doctors. Developing a focused educational program that motivates non-psychiatric doctors to play a role in depression care is necessary to enhance recognition and treatment of depression in Japan.
doi:10.1186/1756-0500-5-441
PMCID: PMC3434090  PMID: 22894761
3.  What is depression? Psychiatrists’ and GPs’ experiences of diagnosis and the diagnostic process 
The diagnosis of depression is defined by psychiatrists, and guidelines for treatment of patients with depression are created in psychiatry. However, most patients with depression are treated exclusively in general practice. Psychiatrists point out that general practitioners’ (GPs’) treatment of depression is insufficient and a collaborative care (CC) model between general practice and psychiatry has been proposed to overcome this. However, for successful implementation, a CC model demands shared agreement about the concept of depression and the diagnostic process in the two sectors. We aimed to explore how depression is understood by GPs and clinical psychiatrists. We carried out qualitative in-depth interviews with 11 psychiatrists and 12 GPs. Analysis was made by Interpretative Phenomenological Analysis. We found that the two groups of physicians differed considerably in their views on the usefulness of the concept of depression and in their language and narrative styles when telling stories about depressed patients. The differences were captured in three polarities which expressed the range of experiences in the two groups. Psychiatrists considered the diagnosis of depression as a pragmatic and agreed construct and they did not question its validity. GPs thought depression was a “gray area” and questioned the clinical utility in general practice. Nevertheless, GPs felt a demand from psychiatry to make their diagnosis based on instruments created in psychiatry, whereas psychiatrists based their diagnosis on clinical impression but used instruments to assess severity. GPs were wholly skeptical about instruments which they felt could be misleading. The different understandings could possibly lead to a clash of interests in any proposed CC model. The findings provide fertile ground for organizational research into the actual implementation of cooperation between sectors to explore how differences are dealt with.
doi:10.3402/qhw.v9.24866
PMCID: PMC4224702  PMID: 25381757
Depression; clinical utility; rating scales; collaborative care; psychiatry; general practice
4.  Cross-sectional study of attitudes about suicide among psychiatrists in Shanghai 
BMC Psychiatry  2014;14:87.
Background
Attitudes and knowledge about suicide may influence psychiatrists’ management of suicidal patients but there has been little research about this issue in China.
Methods
We used the Scale of Public Attitudes about Suicide (SPAS) – a 47-item scale developed and validated in China – to assess knowledge about suicide and seven specific attitudes about suicide in a sample of 187 psychiatrists from six psychiatric hospitals in Shanghai. The results were compared to those of 548 urban community members (assessed in a previous study).
Results
Compared to urban community members, psychiatrists were more likely to believe that suicide can be prevented and that suicide is an important social problem but they had more stigmatizing beliefs about suicidal individuals and felt less empathy for them. The belief that suicide can be prevented was more common among female psychiatrists than male psychiatrists but male psychiatrists felt more empathy for suicidal individuals. Only 37% of the psychiatrists correctly agreed that talking about suicide-related issues with an individual would not precipitate suicidal behavior and only 41% correctly agreed that those who state that they intend to kill themselves may actually do so.
Conclusions
Many psychiatrists in Shanghai harbor negative attitudes about suicidal individuals and are concerned that directly addressing the issue with patients will increase the risk of suicide. Demographic factors, educational status and work experience are associated with psychiatrists’ attitudes about suicide and, thus, need to be considered when training psychiatrists about suicide prevention.
doi:10.1186/1471-244X-14-87
PMCID: PMC3987172  PMID: 24666549
Suicide; Attitudes; Psychiatrists; China
5.  General practitioners and psychiatrists: comparison of attitudes to depression using the depression attitude questionnaire. 
BACKGROUND. Variation in the management of depression may be linked to doctors' attitudes to depression. AIM. A study was undertaken comparing the attitudes to depression between general practitioners and psychiatrists. METHOD. A sample of 74 general practitioners and 65 psychiatrists in Wales was surveyed by postal questionnaire. Attitudes were assessed by the depression attitude questionnaire and patient management was assessed by a questionnaire on prescribing practice. RESULTS. General practitioners differed significantly from psychiatrists in attitudes, particularly in areas covering professional ease in dealing with patients with depression and identification of depression. Those general practitioners who reported use of low antidepressant doses were significantly more likely than general practitioners prescribing standard doses to believe in psychotherapeutic treatments. Users of short-term continuation therapy expressed a lack of therapeutic optimism and comfort in dealing with depressed patients. CONCLUSION. General practitioners and psychiatrists differ significantly in their attitudes to depression. The attitudes which vary among general practitioners reflect practice. The depression attitude questionnaire may prove useful in indicating how educational initiatives to improve primary care detection and management should be directed.
PMCID: PMC1239142  PMID: 7702889
6.  Physicians who experience sickness certification as a work environmental problem: where do they work and what specific problems do they have? A nationwide survey in Sweden 
BMJ Open  2012;2(2):e000704.
Objectives
In a recent study, 11% of the Swedish physicians below 65 years dealing with sickness certification tasks (SCT) experienced SCT to a great extent as a work environment problem (WEP). This study aimed at exploring which SCT problems those physicians experienced and if these problems varied between general practitioners (GPs), psychiatrists, orthopaedists and physicians working at other types of clinics.
Design
A cross-sectional nationwide questionnaire study.
Setting
All physicians working in Sweden in 2008.
Participants
The 1554 physicians <65 years old, working in a clinical setting, having SCT and stating SCT to a great extent being a WEP.
Outcome measures
Frequency of possibly problematic situations or lack of time, reasons for sickness certifying unnecessarily long, experience of difficulties in contacts with sickness insurance offices, and severity of experienced problems.
Results
In all, 79% of this group of physicians experienced SCT as problematic at least once weekly, significantly higher proportion among GPs (p<0.001) and psychiatrists (p=0.005). A majority (at most 68.3%) experienced lack of time daily, when handling SCT, the proportion being significantly higher among orthopaedists (p=0.003, 0.007 and 0.011 on three respective items about lack of time). Among psychiatrists, a significantly higher proportion (p<0.001) stated wanting a patient coordinator. Also, GPs agreed to a higher extent (p<0.001) to finding 14 different SCT tasks as ‘very problematic’.
Conclusions
The main problem among physicians who experience SCT to a great extent as a WEP was lack of time related to SCT. The proportion of physicians experiencing problems varied in many aspects significantly between the different work clinics; however, GPs were among the highest in most types of problems. The results indicate that measures for improving physicians' sickness certification practices should be focused on organisational as well as professional level and that the needs in these aspects differ between specialties.
Article summary
Article focus
A study of the minority of physicians who state sickness certification tasks to a great extent being a work environment problem.
What problems do these physicians experience in relation to sickness certification?
Do the experienced problems vary with type of work clinic/specialty?
Key messages
A vast majority of these physicians experienced daily lack of time when handling sickness certification tasks.
About half of these physicians found it very problematic to assess level of work incapacity, to manage the two roles as the patient's physician and as a medical expert, and to provide the Social Insurance Office with more extensive sickness certificates.
Measures for improving physicians' sickness certification practices should be focused on organisational as well as professional levels and might need to differ between specialties.
Strengths and limitations of this study
The study was based on a questionnaire sent to all 37 000 physicians in a whole country, and the response rate (61%) could be regarded as relatively high.
Only one question about work environment was included.
doi:10.1136/bmjopen-2011-000704
PMCID: PMC3293140  PMID: 22382120
7.  Experiences and barriers to implementation of clinical practice guideline for depression in Korea 
BMC Psychiatry  2013;13:150.
Background
Clinical guidelines can improve health-care delivery, but there are a number of challenges in adopting and implementing the current practice guidelines for depression. The aim of this study was to determine clinical experiences and perceived barriers to the implementation of these guidelines in psychiatric care.
Methods
A web-based survey was conducted with 386 psychiatric specialists to inquire about experiences and attitudes related to the depression guidelines and barriers influencing the use of the guidelines. Quantitative data were analyzed, and qualitative data were transcribed and coded manually.
Results
Almost three quarters of the psychiatrists (74.6%) were aware of the clinical guidelines for depression, and over half of participants (55.7%) had had clinical experiences with the guidelines in practice. The main reported advantages of the guidelines were that they helped in clinical decision making and provided informative resources for the patients and their caregivers. Despite this, some psychiatrists were making treatment decisions that were not in accordance with the depression guidelines. Lack of knowledge was the main obstacle to the implementation of guidelines assessed by the psychiatrists. Other complaints addressed difficulties in accessing the guidelines, lack of support for mental health services, and general attitudes toward guideline necessity. Overall, the responses suggested that adding a summary booklet, providing teaching sessions, and improving guidance delivery systems could be effective tools for increasing depression guideline usage.
Conclusion
Individual barriers, such as lack of awareness and lack of familiarity, and external barriers, such as the supplying system, can affect whether physicians’ implement the guidelines for the treatment of depression in Korea. These findings suggest that further medical education to disseminate guidelines contents could improve public health for depression.
doi:10.1186/1471-244X-13-150
PMCID: PMC3681685  PMID: 23705908
Depressive disorder; Practice guidelines; Health care surveys; Questionnaires
8.  Perceived competence and attitudes towards patients with suicidal behaviour: a survey of general practitioners, psychiatrists and internists 
Background
Competence and attitudes to suicidal behaviour among physicians are important to provide high-quality care for a large patient group. The aim was to study different physicians’ attitudes towards suicidal behaviour and their perceived competence to care for suicidal patients.
Methods
A random selection (n = 750) of all registered General Practitioners, Psychiatrists and Internists in Norway received a questionnaire. The response rate was 40%. The Understanding of Suicidal Patients Scale (USP; scores < 23 = positive attitude) and items about suicide in case of incurable illness from the Attitudes Towards Suicide Questionnaire were used. Five-point Likert scales were used to measure self-perceived competence, level of commitment, empathy and irritation felt towards patients with somatic and psychiatric diagnoses. Questions about training were included.
Results
The physicians held positive attitudes towards suicide attempters (USP = 20.3, 95% CI: 19.6–20.9). Internists and males were significantly less positive. There were no significant differences in the physicians in their attitudes toward suicide in case of incurable illness according to specialty. The physicians were most irritated and less committed to substance misuse patients. Self perceived competence was relatively high. Forty-three percent had participated in courses about suicide assessment and treatment.
Conclusions
The physicians reported positive attitudes and relatively high competence. They were least committed to treat patients with substance misuse. None of the professional groups thought that patients with incurable illness should be given help to commit suicide.
Further customized education with focus on substance misuse might be useful.
doi:10.1186/1472-6963-14-208
PMCID: PMC4048050  PMID: 24886154
Attitudes; Incurable illness; Substance misuse; Suicide attempt; Physicians
9.  Roles and practices of general practitioners and psychiatrists in management of depression in the community 
Background
Little is known about depressed patients' profiles and how they are managed. The aim of the study is to compare GPs and psychiatrists for 1°) sociodemographic and clinical profile of their patients considered as depressed 2°) patterns of care provision.
Methods
The study design is an observational cross-sectional study on a random sample of GPs and psychiatrists working in France. Consecutive inclusion of patients seen in consultation considered as depressed by the physician. GPs enrolled 6,104 and psychiatrists 1,433 patients. Data collected: sociodemographics, psychiatric profile, environmental risk factors of depression and treatment. All clinical data were collected by participating physicians; there was no direct independent clinical assessment of patients to check the diagnosis of depressive disorder.
Results
Compared to patients identified as depressed by GPs, those identified by psychiatrists were younger, more often urban (10.5% v 5.4% – OR = 2.4), educated (42.4% v 25.4% – OR = 3.9), met DSM-IV criteria for depression (94.6% v 85.6% – OR = 2.9), had been hospitalized for depression (26.1% v 15.6% – OR = 2.0) and were younger at onset of depressive problems (all adjusted p < .001). No difference was found for psychiatric and somatic comorbidity, suicide attempt and severity of current depression.
Compared to GPs, psychiatrists more often prescribed tricyclics and very novel antidepressants (7.8% v 2.3% OR = 5.0 and 6.8% v 3.0% OR = 3.8) with longer duration of antidepressant treatment. GPs' patients received more "non-conventional" treatment (8.8% v 2.4% OR = 0.3) and less psychotherapy (72.2% v 89.1% OR = 3.1) (all adjusted p < .001).
Conclusion
Differences between patients mainly concerned educational level and area of residence with few differences regarding clinical profile. Differences between practices of GPs and psychiatrists appear to reflect more the organization of the French care system than the competence of providers.
doi:10.1186/1471-2296-7-5
PMCID: PMC1388221  PMID: 16445855
10.  Muslim women having abortions in Canada 
Canadian Family Physician  2011;57(4):e134-e138.
Abstract
Objective
To improve understanding of the attitudes, beliefs, and experiences of Muslim patients presenting for abortion.
Design
Exploratory study in which participants completed questionnaires about their attitudes, beliefs, and experiences.
Setting
Two urban, free-standing abortion clinics.
Participants
Fifty-three self-identified Muslim patients presenting for abortion.
Main outcome measures
Women’s background, beliefs, and attitudes toward their religion and toward abortion; levels of anxiety, depression, and guilt, scored on a scale of 0 to 10; and degree of pro-choice or anti-choice attitude toward abortion, assessed by having respondents identify under which circumstances a woman should be able to have an abortion.
Results
The 53 women in this study were a diverse group, aged 17 to 47 years, born in 17 different countries, with a range of beliefs and attitudes toward abortion. As found in previous studies, women who were less pro-choice (identified fewer acceptable reasons to have an abortion) had higher anxiety and guilt scores than more pro-choice women did: 6.9 versus 4.9 (P = .01) and 6.9 versus 3.6 (P = .004), respectively. Women who said they strongly agreed that abortion was against Islamic principles also had higher anxiety and guilt scores: 9.3 versus 5.9 (P = .03) and 9.5 versus 5.3 (P = .03), respectively.
Conclusion
Canadian Muslim women presenting for abortion come from many countries and schools of Islam. The group of Muslim women that we surveyed was so diverse that no generalizations can be made about them. Their attitudes toward abortion ranged from being completely pro-choice to believing abortion is wrong unless it is done to save a woman’s life. Many said they found their religion to be a source of comfort as well as a source of guilt, turning to prayer and meditation to cope with their feelings about the abortion. It is important that physicians caring for Muslim women understand that their patients come from a variety of backgrounds and can have widely differing beliefs. It might be helpful to be aware that patients who hold more anti-choice beliefs are likely to experience more anxiety and guilt related to their abortion than pro-choice patients do.
PMCID: PMC3076497  PMID: 21626898
11.  The Characteristics of Psychiatrists Disciplined by Professional Colleges in Canada 
PLoS ONE  2012;7(11):e50558.
Background
The identification of health care professionals who are incompetent, impaired, exploitative or have criminal intent is important for public safety. It is unclear whether psychiatrists are more likely to commit medical misconduct offences than non-psychiatrists, and if the nature of these offences is different.
Aim
The aim of this study was to compare the characteristics of psychiatrists disciplined in Canada and the nature of their offences and disciplinary sentences for the ten years from 2000 through 2009 to other physicians disciplined during that timeframe.
Methods
Utilizing a retrospective cohort design, we constructed a database of all physicians disciplined by provincial licensing authorities in Canada for the ten years from 2000 through 2009. Demographic variables and information on type of misconduct violation and penalty imposed were also collected for each physician disciplined. We compared psychiatrists to non-psychiatrists for the various outcomes.
Results
There were 82 (14%) psychiatrists of 606 physicians disciplined in Canada in the ten years from 2000 through 2009, double the national proportion of psychiatrists. Of those disciplined psychiatrists, 8 (9.6%) were women compared to 29% in the national cohort. A total of 5 (6%) psychiatrists committed at least two separate offenses, accounting for approximately 11% of the total violations. A higher proportion of psychiatrists were disciplined for sexual misconduct (OR 3.62 [95% Confidence Interval [CI] 2.45–5.34]), fraudulent behavior (OR 2.32 [95% CI 1.20–4.40]) and unprofessional conduct (OR 3.1 [95% CI 1.95–4.95]). As a result, psychiatrists had between 1.85–4.35 greater risk of having disciplinary penalties in almost all categories in comparison to other physicians.
Conclusion
Psychiatrists differ from non-psychiatrist physicians in the prevalence and nature of medical misconduct. Efforts to decrease medical misconduct by psychiatrists need to be conducted and systematically evaluated.
doi:10.1371/journal.pone.0050558
PMCID: PMC3509088  PMID: 23209779
12.  Self-reported competence, attitude and approach of physicians towards patients with dementia in ambulatory care: Results of a postal survey 
Background
Caring for patients with dementia is a demanding task. Little is known as to whether physicians feel competent enough to perform this task or whether a lack of self-perceived competence influences attitudes and professional approach. Even less is known with respect to potential differences between general practitioners (GPs) and specialists. The purpose of this study was to investigate the interrelationship between the self-perceived competence, attitude and professional approach of physicians in ambulatory care in Germany. A further aim was to compare GPs and specialists with regard to differences in these areas.
Methods
A standardised postal survey was sent to 389 GPs and 239 neurologists and psychiatrists in six metropolitan areas in Germany. The 49-item questionnaire consisted of attitudinal statements to be rated on a Likert-type scale. Return rates were 54 percent for GPs and 40 percent for specialists. Statistical methods used to analyze data included correlation analysis, cluster analysis and ordinal regression analysis.
Results
No differences were found between GPs and specialists with regard to their general attitude towards caring for patients with dementia. Approximately 15 percent of both disciplines showed a clearly negative attitude. Self-reported competence was strongly associated with general attitude. In particular among GPs, and less so among specialists, a strong positive association was found between self-reported competence, general attitude and professional approach (e.g. early detection, active case finding and cooperation with caregivers). Differences between GPs and specialists were smaller than expected and appear to predominantly reflect task differences within the German health care system.
Conclusion
Training opportunities which enable in particular GPs to enhance not only their competence but also their general attitude towards dementia care would appear to be beneficial and might carry positive consequences for patients and their caregivers.
doi:10.1186/1472-6963-8-54
PMCID: PMC2289812  PMID: 18321394
13.  Differing mental health practice among general practitioners, private psychiatrists and public psychiatrists 
BMC Public Health  2005;5:104.
Background
Providing care for mental health problems concerns General Practitioners (GPs), Private Psychiatrists (PrPs) and Public Psychiatrists (PuPs). As patient distribution and patterns of practice among these professionals are not well known, a survey was planned prior to a re-organisation of mental health services in an area close to Paris
Methods
All GPs (n = 492), PrPs (n = 82) and PuPs (n = 78) in the South-Yvelines area in France were informed of the implementation of a local mental health program. Practitioners interested in taking part were invited to include prospectively all patients with mental health problem they saw over an 8-day period and to complete a 6-month retrospective questionnaire on their mental health practice. 180 GPs (36.6%), 45 PrPs (54.9%) and 63 PuPs (84.0%) responded.
Results
GPs and PrPs were very similar but very different from PuPs for the proportion of patients with anxious or depressive disorders (70% v. 65% v. 38%, p < .001), psychotic disorders (5% v. 7% v. 30%, p < .001), previous psychiatric hospitalization (22% v. 26 v. 61%, p < .001) and receiving disability allowance (16% v. 18% v. 52%, p < .001). GPs had fewer patients with long-standing psychiatric disorders than PrPs and PuPs (52%, 64% v. 63%, p < .001). Time-lapse between consultations was longest for GPs, intermediate for PuPs and shortest for PrPs (36 days v. 26 v. 18, p < .001). Access to care had been delayed longer for Psychiatrists (PrPs, PuPs) than for GPs (61% v. 53% v. 25%, p < .001). GPs and PuPs frequently felt a need for collaboration for their patients, PrPs rarely (42% v. 61%. v. 10%, p < .001).
Satisfaction with mental health practice was low for all categories of physicians (42.6% encountered difficulties hospitalizing patients and 61.4% had patients they would prefer not to cater for). GPs more often reported unsatisfactory relationships with mental health professionals than did PrPs and PuPs (54% v. 15% v. 8%, p < .001).
Conclusion
GP patients with mental health problems are very similar to patients of private psychiatrists; there is a lack of the collaboration felt to be necessary, because of psychiatrists' workload, and because GPs have specific needs in this respect. The "Yvelines-Sud Mental Health Network" has been created to enhance collaboration.
doi:10.1186/1471-2458-5-104
PMCID: PMC1266376  PMID: 16212666
14.  Predictors of Treatments Acceptable to Patients for Late-Life Depression 
The Scientific World Journal  2013;2013:207493.
Objectives. Describe older patients' perceptions about depression and characteristics associated with acceptance of treatments. Design. Cross-sectional study. Setting. Three primary care clinics in Iowa. Participants. Consecutive sample of 529 primary care patients. Measurements. Depression screening tool (a 9-item patient health questionnaire [PHQ-9]) and questionnaire including sociodemographic data, patient attitudes about depression, and acceptability of different treatments. Results. Mean age was 71.9 years (range 60–93 years), 314 (59%) female. Among the 529 participants, 93 (17.5%) had history of depression and 60 (11.3%) had PHQ-9 scores of 10 or greater. Participants believed depression is a disease for which they would use medication and counseling. Accepting medications from primary physicians was strongly associated with a past history of depression (P < 0.01) and with agreeing that depression needs treatment (P < 0.01). Counseling was not acceptable for those believing that they can control depression on their own (P < 0.01). Older patients (P < 0.001) and those with higher education levels (P < 0.01) were less likely to accept herbs or supplements as treatment options. Willingness to discuss treatments with family was associated with not using alcohol as a treatment and acceptance of all other treatment options (P < 0.001). Conclusions. Attitude that depression is a disease and the willingness to discuss depression with family may enhance treatment acceptance.
doi:10.1155/2013/207493
PMCID: PMC3821957  PMID: 24250257
15.  Cross-sectional and Longitudinal Relationships Between Insight and Attitudes Toward Medication and Clinical Outcomes in Chronic Schizophrenia 
Schizophrenia Bulletin  2008;35(2):336-346.
Background: We evaluated the cross-sectional and longitudinal association of measures of both insight and attitudes toward medication to outcomes that included psychopathology and community functioning. Methods: Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) was a large 18-month follow-up study pharmacotherapy of people with schizophrenia. Insight was measured using the Insight and Treatment Attitudes Questionnaire and attitudes toward medication by the Drug Attitude Inventory. Widely known scales were used to assess symptoms of schizophrenia and depression and community functioning. Medication adherence was globally assessed by the treating psychiatrist using several sources of information. Bivariate correlations and mixed model regression analyses were used to test the relationship of insight and medication attitudes to outcomes at baseline and during the follow-up period. Regression models were used to evaluate the relationship between change in insight and medication attitudes and changes outcomes. Results: There was a significant relationship at baseline between insight and drug attitudes and symptoms of schizophrenia and depression, as well as with community functioning. Higher levels of insight at baseline were significantly associated with lower levels of schizophrenia symptoms at follow-up while more positive medication attitudes were significantly associated with both lower symptom levels and better community functioning. Change in insight scores over time was associated with declining schizophrenia symptoms but increasing levels of depression. Change toward more positive medication attitudes was associated, independently of changes in insight, with significant decreases in psychopathology, improvement in community functioning, and greater medication compliance. Conclusion: Greater patient understanding of their illness and more positive attitudes toward medication may improve outcomes. Educational interventions that affect these attitudes may be an important part of psychosocial rehabilitation and/or recovery-oriented services.
doi:10.1093/schbul/sbn067
PMCID: PMC2659303  PMID: 18586692
schizophrenia; insight; medication attitude; social functioning; quality of life
16.  An Academic-Marketing Collaborative to Promote Depression Care: A Tale of Two Cultures 
Patient education and counseling  2011;90(3):411-419.
Objectives
Commercial advertising and patient education have separate theoretical underpinnings, approaches, and practitioners. This paper aims to describe a collaboration between academic researchers and a marketing firm working to produce demographically targeted public service anouncements (PSAs) designed to enhance depression care-seeking in primary care.
Methods
An interdisciplinary group of academic researcherss contracted with a marketing firm in Rochester, NY to produce PSAs that would help patients with depressive symptoms engage more effectively with their primary care physicians (PCPs). The researchers brought perspectives derived from clinical experience and the social sciences and conducted empirical research using focus groups, conjoint analysis, and a population-based survey. Results were shared with the marketing firm, which produced four PSA variants targeted to gender and socioeconomic position.
Results
There was no simple, one-to-one relationship between research results and the form, content, or style of the PSAs. Instead, empirical findings served as a springboard for discussion and kept the creative process tethered to the experiences, attitudes, and opinions of actual patients. Reflecting research findings highlighting patients’ struggles to recognize, label, and disclose depressive symptoms, the marketing firm generated communication objectives that emphasized: a) educating the patient to consider and investigate the possibility of depression; b) creating the belief that the PCP is interested in discussing depression and capable of offering helpful treatment; and c) modelling different ways of communicating with physicians about depression. Before production, PSA prototypes were vetted with additional focus groups.
The winning prototype, “Faces,” involved a multi-ethnic montage of formerly depressed persons talking about how depression affected them and how they improved with treatment, punctuated by a physician who provided clinical information. A member of the academic team was present and consulted closely during production. Challenges included reconciling the marketing tradition of audience segmentation with the overall project goal of reaching as broad an audience as possible; integrating research findings across dimensions of words, images, music, and tone; and dealing with misunderstandings related to project scope and budget.
Conclusion
Mixed methods research can usefully inform PSAs that incorporate patient perspectives and are produced to professional standards. However, tensions between the academic and commercial worlds exist and must be addressed.
Practice implications
With certain caveats, implementation and dissemination researchers should consider opporutnities to join forces with marketing specialists. The results of such collaborations should be rigorously evaluated.
doi:10.1016/j.pec.2011.07.003
PMCID: PMC3235260  PMID: 21862274
17.  Indian Psychiatric Society-World Psychiatric Association - World Health Organization survey on usefulness of International Classification of Diseases-10 
Indian Journal of Psychiatry  2014;56(4):350-358.
Background:
World Health Organization (WHO) is in the process of revising the International Classification of Diseases 10 (ICD-10). For increasing the acceptability of the ICD-11, WHO along with World Psychiatric Association (WPA), conducted a survey of psychiatrists around the world, in which 386 psychiatrists from India participated.
Aim:
To present the findings of “WPA-WHO Global Survey of Psychiatrists’ Attitudes toward Mental Disorders Classification” for Indian psychiatrists who participated in the survey as members of Indian Psychiatric Society.
Methodology:
The online survey was sent to qualified psychiatrists who are members of Indian Psychiatric Society and are residing in India.
Results:
Of the 1702 members who were urged to participate in the survey, 386 (22.7%) participated. Most(79%) of the psychiatrists opined that they use formal classificatory systems in their day-to-day clinical practice. ICD-10 was the most commonly (71%) followed classificatory system. Nearly half (48%) felt the need for only 10–30 categories for use in clinical settings and another 44% opined that 31-100 categories are required for use. Most of the participants (85%) suggested that a modified/simpler classificatory system should be designed for primary care practitioners. Similarly, the same number of participants (89%) argued that for maximum utility of a nosological system diagnostic criteria should provide flexible guidance that allows cultural variation and clinical judgement. About 75% opined that the diagnostic system they were using was difficult to apply across cultures.
Conclusion:
Findings of the survey suggest that classificatory systems are routinely used in day-to-day practice by most of the participating psychiatrists in India and most expect that future classificatory system should provide flexible guidance that allows cultural variation and clinical judgement.
doi:10.4103/0019-5545.146522
PMCID: PMC4279292  PMID: 25568475
India; nosology; ICD-11
18.  Geriatric depression assessment by rural primary care physicians 
Rural and remote health  2009;9(4):1180.
Introduction
Depression is the fourth leading cause of the global disease burden, and approximately one in four elderly people may suffer from depression or depressive symptoms. Depression in later life is generally regarded as highly treatable, but under-treatment is still common in this population, especially among those in rural areas where access to healthcare is often an issue. In this study rural primary care physicians’ practices, attitudes, barriers and perceived needs in the diagnosis and treatment of geriatric depression were described, and trends in care delivery examined.
Methods
A survey was sent to 162 rural Illinois family physicians and general internists. The survey focused on current practices, attitudes and perceptions regarding geriatric depression, barriers to and needs for improvement in depression care and physician and practice characteristics.
Results
Seventy-six physicians (47%) responded. The rural physicians indicated that over one-third of their patients aged 60 years and older were depressed. All reported routine screening for depression, with 24% using the Beck Depression Inventory. Overall, physicians expressed positive attitudes about their involvement in treating older depressed patients. However, 45% indicated a ‘gap’ between ideal and available care in their rural practices. Physicians with higher proportions of elderly patients in their panels were more likely to feel that more training in residency in geriatric care would be helpful in improving care, and that better availability of psychologists and counselors would be important for improvement of care for older, depressed patients.
Conclusions
This study responds to recent calls to better understand how primary care physicians diagnose and treat depression in older adults. Generally, primary care physicians appear comfortable and prepared in depression diagnosis and management, but factors such as availability of appropriate care remain a challenge.
PMCID: PMC3740521  PMID: 19929129
depression; geriatric; primary care; USA
19.  Training Latin American primary care physicians in the WPA module on depression: results of a multicenter trial 
Psychological medicine  2005;35(1):35-45.
Background
In order to improve care for people with depressive disorders and to reduce the increasing burden of depression, the American Regional Office of the World Health Organization has launched a major region-wide initiative. A central part of this effort was directed to the primary care system where the diagnosis and treatment of depression are deficient in many countries. This study evaluated the materials developed by the World Psychiatric Association in a training program on depression among primary care physicians by measuring changes in their knowledge, attitudes, and practice (KAP).
Method
One hundred and seven physicians and 6174 patients from five Latin American countries participated in the trial. KAP were assessed 1 month before and 1 month following the training program. In addition, the presence of depressive symptoms was measured in patients who visited the clinic during a typical week at both times using the Zung Depression Scale and a DSM-IV/ICD-10 major depression checklist.
Results
The program slightly improved knowledge about depression and modified some attitudes, but had limited impact on actual practice. There was no evidence that the diagnosis of depression was made more frequently, nor was there an improvement in psychopharmacological management. The post-training agreement between physician diagnosis and that based on patient self-report remained low. The physicians, however, seemed more confident in treating depressed patients after training, and referred fewer patients to psychiatrists.
Conclusions
Traditional means of training primary care physicians in depression have little impact on clinical practice regardless of the quality of the teaching materials.
doi:10.1017/S0033291704002764
PMCID: PMC2723767  PMID: 15842027
20.  Stigma toward schizophrenia: do all psychiatrists behave the same? Latent profile analysis of a national sample of psychiatrists in Brazil 
BMC Psychiatry  2013;13:92.
Background
An important issue concerning the worldwide fight against stigma is the evaluation of psychiatrists’ beliefs and attitudes toward schizophrenia and mental illness in general. However, there is as yet no consensus on this matter in the literature, and results vary according to the stigma dimension assessed and to the cultural background of the sample. The aim of this investigation was to search for profiles of stigmatizing beliefs related to schizophrenia in a national sample of psychiatrists in Brazil.
Methods
A sample of 1414 psychiatrists were recruited from among those attending the 2009 Brazilian Congress of Psychiatry. A questionnaire was applied in face-to-face interviews. The questionnaire addressed four stigma dimensions, all in reference to individuals with schizophrenia: stereotypes, restrictions, perceived prejudice and social distance. Stigma item scores were included in latent profile analyses; the resulting profiles were entered into multinomial logistic regression models with sociodemographics, in order to identify significant correlates.
Results
Three profiles were identified. The “no stigma” subjects (n = 337) characterized individuals with schizophrenia in a positive light, disagreed with restrictions, and displayed a low level of social distance. The “unobtrusive stigma” subjects (n = 471) were significantly younger and displayed the lowest level of social distance, although most of them agreed with involuntary admission and demonstrated a high level of perceived prejudice. The “great stigma” subjects (n = 606) negatively stereotyped individuals with schizophrenia, agreed with restrictions and scored the highest on the perceived prejudice and social distance dimensions. In comparison with the first two profiles, this last profile comprised a significantly larger number of individuals who were in frequent contact with a family member suffering from a psychiatric disorder, as well as comprising more individuals who had no such family member.
Conclusions
Our study not only provides additional data related to an under-researched area but also reveals that psychiatrists are a heterogeneous group regarding stigma toward schizophrenia. The presence of different stigma profiles should be evaluated in further studies; this could enable anti-stigma initiatives to be specifically designed to effectively target the stigmatizing group.
doi:10.1186/1471-244X-13-92
PMCID: PMC3608131  PMID: 23517184
Social distance; Stereotype; Prejudice; Psychosis; Mental health professionals
21.  Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. 
BMJ : British Medical Journal  1996;313(7061):858-859.
OBJECTIVE: To investigate the attitudes of the general public towards depression before the Defeat Depression Campaign of the Royal Colleges of Psychiatrists and General Practitioners; these results form the baseline to assess the change in attitudes brought about by the campaign. DESIGN: Group discussions generated data for initial qualitative research. The quantitative survey comprised a doorstep survey of 2003 people in 143 places around the United Kingdom. RESULTS: The lay public in general seemed to be sympathetic to those with depression but reluctant to consult. Most (1704 (85%)) believed counselling to be effective but were against antidepressants. Many subjects (1563 (78%)) regarded antidepressants as addictive. CONCLUSIONS: Although people are sympathetic towards those with depression, they may project their prejudices about depression on to the medical profession. Doctors have an important role in educating the public about depression and the rationale for antidepressant treatment. In particular, patients should know that dependence is not a problem with antidepressants.
PMCID: PMC2359082  PMID: 8870574
22.  Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies 
PLoS Medicine  2013;10(5):e1001439.
Karen Devries and colleagues conduct a systematic review of longitudinal studies to evaluate the direction of association between symptoms of depression and intimate partner violence.
Please see later in the article for the Editors' Summary
Background
Depression and suicide are responsible for a substantial burden of disease globally. Evidence suggests that intimate partner violence (IPV) experience is associated with increased risk of depression, but also that people with mental disorders are at increased risk of violence. We aimed to investigate the extent to which IPV experience is associated with incident depression and suicide attempts, and vice versa, in both women and men.
Methods and Findings
We conducted a systematic review and meta-analysis of longitudinal studies published before February 1, 2013. More than 22,000 records from 20 databases were searched for studies examining physical and/or sexual intimate partner or dating violence and symptoms of depression, diagnosed major depressive disorder, dysthymia, mild depression, or suicide attempts. Random effects meta-analyses were used to generate pooled odds ratios (ORs). Sixteen studies with 36,163 participants met our inclusion criteria. All studies included female participants; four studies also included male participants. Few controlled for key potential confounders other than demographics. All but one depression study measured only depressive symptoms. For women, there was clear evidence of an association between IPV and incident depressive symptoms, with 12 of 13 studies showing a positive direction of association and 11 reaching statistical significance; pooled OR from six studies = 1.97 (95% CI 1.56–2.48, I2 = 50.4%, pheterogeneity = 0.073). There was also evidence of an association in the reverse direction between depressive symptoms and incident IPV (pooled OR from four studies = 1.93, 95% CI 1.51–2.48, I2 = 0%, p = 0.481). IPV was also associated with incident suicide attempts. For men, evidence suggested that IPV was associated with incident depressive symptoms, but there was no clear evidence of an association between IPV and suicide attempts or depression and incident IPV.
Conclusions
In women, IPV was associated with incident depressive symptoms, and depressive symptoms with incident IPV. IPV was associated with incident suicide attempts. In men, few studies were conducted, but evidence suggested IPV was associated with incident depressive symptoms. There was no clear evidence of association with suicide attempts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depression and suicide are responsible for a substantial proportion of the global disease burden. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—affects more than 350 million people worldwide. It is the eleventh leading cause of global disability-adjusted life-years (a measure of overall disease burden), and it affects one in six people at some time during their lives. Globally, about a million people commit suicide every year, usually because they have depression or some other mental illness. Notably, in cross-sectional studies (investigations that look at a population at a single time point), experience of intimate partner violence (IPV, also called domestic violence) is strongly and consistently associated with both depressive disorders and suicide. IPV, like depression and suicide, is extremely common—in multi-country studies, 15%–71% of women report being physically assaulted at some time during their lifetime. IPV is defined as physical, sexual, or psychological harm by a current or former partner or spouse; men as well as women can be the victims of IPV.
Why Was This Study Done?
It may seem obvious to assume that IPV is causally related to subsequent depression and suicidal behavior. However, cross-sectional studies provide no information about causality, and it is possible that depression and/or suicide attempts cause subsequent IPV or that there are common risk factors for IPV, depression, and suicide. For example, individuals with depressive symptoms may be more accepting of partners with characteristics that predispose them to use violence, or early life exposure to violence may predispose individuals to both depression and choosing violent partners. Here, as part of the Global Burden of Disease Study 2010, the researchers investigate the extent to which experience of IPV is associated with subsequent depression and suicide attempts and vice versa in both men and women by undertaking a systematic review and meta-analysis of longitudinal studies that have examined IPV, depression, and suicide attempts. A systematic review uses predefined criteria to identify all the research on a given topic, meta-analysis combines the results of several studies, and longitudinal studies track people over time to investigate associations between specific characteristics and outcomes.
What Did the Researchers Do and Find?
The researchers identified 16 longitudinal studies involving a total of 36,163 participants that met their inclusion criteria. All the studies included women, but only four also included men. All the studies were undertaken in high- and middle-income countries. For women, 11 studies showed a statistically significant association (an association unlikely to have occurred by chance) between IPV and subsequent depressive symptoms. In a meta-analysis of six studies, experience of IPV nearly doubled the risk of women subsequently reporting depressive symptoms. In addition, there was evidence of an association in the reverse direction. In a meta-analysis of four studies, depressive symptoms nearly doubled the risk of women subsequently experiencing IPV. IPV was also associated with subsequent suicide attempts among women. For men, there was some evidence from two studies that IPV was associated with depressive symptoms but no evidence for an association between IPV and subsequent suicide attempt or between depressive symptoms and subsequent IPV.
What Do These Findings Mean?
These findings suggest that women who are exposed to IPV are at increased risk of subsequent depression and that women who are depressed are more likely to be at risk of IPV. They also provide evidence of an association between IPV and subsequent suicide attempt for women. The study provides little evidence for similar relationships among men, but additional studies are needed to confirm this finding. Moreover, the accuracy of these findings is likely to be affected by several limitations of the study. For example, few of the included studies controlled for other factors that might have affected both exposure to IPV and depressive symptoms, and none of the studies considered the effect of emotional violence on depressive symptoms and suicide attempts. Nevertheless, these findings have two important implications. First, they suggest that preventing violence against women has the potential to reduce the global burden of disease related to depression and suicide. Second, they suggest that clinicians should pay attention to past experiences of violence and the risk of future violence when treating women who present with symptoms of depression.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001439.
This study is further discussed in a PLOS Medicine Perspective by Alexander Tsai
The US National Institute of Mental Health provides information on all aspects of depression and of suicide and suicide prevention (in English and Spanish)
The UK National Health Service Choices website provides detailed information about depression, including personal stories about depression, and information on suicide and its prevention; it has a webpage about domestic violence, which includes descriptions of personal experiences
The World Health Organization provides information on depression, on the global burden of suicide and on suicide prevention, and on intimate partner violence (some information in several languages)
MedlinePlus provides links to other resources about depression, suicide, and domestic violence (in English and Spanish)
The charity Healthtalkonline has personal stories about depression and about dealing with suicide
doi:10.1371/journal.pmed.1001439
PMCID: PMC3646718  PMID: 23671407
23.  Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians. 
OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. Survey: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.
PMCID: PMC1338055  PMID: 7600468
24.  TELEPHONE-DELIVERED COLLABORATIVE-CARE FOR TREATING POST-CABG DEPRESSION: A RANDOMIZED CONTROLLED TRIAL 
Context
Depressive symptoms commonly follow coronary artery bypass (CABG) surgery and are associated with worse clinical outcomes.
Objective
To test the effectiveness of telephone-delivered collaborative care for post-CABG depression versus doctors’ usual care.
Design
Single-blind effectiveness trial.
Setting
Seven Pittsburgh-area university-based and community hospitals.
Participants
302 depressed post-CABG patients and a non-depressed comparison group of 151 randomly sampled post-CABG patients recruited between 3/2004 and 9/2007 and followed as outpatients.
Intervention
8-Months of telephone-delivered collaborative care provided by nurses working with patients’ primary care physicians and supervised by a study psychiatrist and study primary care physician.
Main Outcome Measures
Mental health-related quality of life (HRQoL) as measured by the SF-36 MCS at 8-months follow-up; secondary outcome measures included mood symptoms (Hamilton Rating Scale for Depression (HRS-D)), physical HRQoL (SF-36 PCS) and functioning (Duke Activity Status Index (DASI)); and hospital readmissions.
Results
Depressed intervention patients (N=150) reported greater improvements (all P ≤ 0.02) in mental HRQoL (SF-36 MCS: Δ 3.2 points; 95% CI: 0.5–6.0), physical functioning (DASI: Δ 4.6 points; 1.9–7.3), and mood symptoms (HRS-D: Δ3.1 points (1.3–4.9); and were more likely to report a ≥ 50% decline in HRS-D score from baseline (50.0% vs. 29.6%; NNT 4.9 (3.2–10.4)) than depressed patients randomized to their physicians’ usual care (N=152) (P<0.001). Depressed men were particularly likely to benefit from the intervention (SF-36 MCS: Δ 5.7 points (2.2–9.2); P=0.001) and tended to have a lower incidence of rehospitalization for cardiovascular causes than depressed men receiving usual care (13% vs. 23%; P=0.07) or depressed women (19% vs. 11%; P=0.22). However, the mean HRQoL and physical functioning of depressed intervention patients did not reach that of our non-depressed comparison group.
Conclusions
Compared to usual care, telephone-delivered collaborative care for post-CABG depression resulted in improved HRQoL, physical functioning, and mood symptoms at 8-months follow-up.
doi:10.1001/jama.2009.1670
PMCID: PMC3010227  PMID: 19918088
Depression; coronary artery bypass surgery; randomized clinical trial; collaborative care; coronary artery disease
25.  Acupuncture and Counselling for Depression in Primary Care: A Randomised Controlled Trial 
PLoS Medicine  2013;10(9):e1001518.
In a randomized controlled trial, Hugh MacPherson and colleagues investigate the effectiveness of acupuncture and counseling compared with usual care alone for the treatment of depression symptoms in primary care settings.
Please see later in the article for the Editors' Summary
Background
Depression is a significant cause of morbidity. Many patients have communicated an interest in non-pharmacological therapies to their general practitioners. Systematic reviews of acupuncture and counselling for depression in primary care have identified limited evidence. The aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care.
Methods and Findings
In a randomised controlled trial, 755 patients with depression (Beck Depression Inventory BDI-II score ≥20) were recruited from 27 primary care practices in the North of England. Patients were randomised to one of three arms using a ratio of 2∶2∶1 to acupuncture (302), counselling (302), and usual care alone (151). The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat.
PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of ten sessions for acupuncture and nine sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 months for acupuncture (−2.46, 95% CI −3.72 to −1.21) and counselling (−1.73, 95% CI −3.00 to −0.45), and over 12 months for acupuncture (−1.55, 95% CI −2.41 to −0.70) and counselling (−1.50, 95% CI −2.43 to −0.58). Differences between acupuncture and counselling were not significant. In terms of limitations, the trial was not designed to separate out specific from non-specific effects. No serious treatment-related adverse events were reported.
Conclusions
In this randomised controlled trial of acupuncture and counselling for patients presenting with depression, after having consulted their general practitioner in primary care, both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone.
Trial Registration
Controlled-Trials.com ISRCTN63787732
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depression–overwhelming sadness and hopelessness–is responsible for a substantial proportion of the global disease burden and is a major cause of suicide. It affects more than 350 million people worldwide and about one in six people will have an episode of depression during their lifetime. Depression is different from everyday mood fluctuations. For people who are clinically depressed, feelings of severe sadness, anxiety, hopelessness, and worthlessness can last for months and years. Affected individuals lose interest in activities they used to enjoy and sometimes have physical symptoms such as disturbed sleep. Clinicians can diagnose depression and determine its severity by asking patients to complete a questionnaire (for example, the Beck Depression Inventory [BDI-II] or the Patient Health Questionnaire 9 [PHQ-9]) about their feelings and symptoms. The answer to each question is given a score and the total score from the questionnaire (“depression rating scale”) indicates the severity of depression. Antidepressant drugs are usually the front-line treatment for depression in primary care.
Why Was This Study Done?
Unfortunately, antidepressants don't work for more than half of patients. Moreover, many patients would like to be offered non-pharmacological treatment options for depression such as acupuncture–a therapy originating from China in which fine needles are inserted into the skin at specific points of the body–and counseling–a “talking therapy” that provides patients with a safe, non-judgmental place to express feelings and emotions and that helps them recognize their capacity for growth and fulfillment. However, it is unclear whether either of these treatments is effective in depression. In this pragmatic randomized controlled trial, the researchers investigate the clinical effectiveness of acupuncture or counseling in patients with depression compared to usual care in primary care in northern England. A randomized controlled trial compares outcomes in groups of patients who are assigned to different interventions through the play of chance. A pragmatic trial asks whether the intervention works under real-life conditions. Patient selection reflects routine practice and some aspects of the intervention are left to the discretion of clinician, By contrast, an explanatory trial asks whether an intervention works under ideal conditions and involves a strict protocol for patient selection and treatment.
What Did the Researchers Do and Find?
The researchers recruited 755 patients who had consulted their primary health care provider about depression within the past 5 years and who had a score of more than 20 on the BDI-II–a score that is defined as moderate-to-severe depression on this depression rating scale–at the start of the study. Patients were randomized to receive up to 12 weekly sessions of acupuncture plus usual care (302 patients), up to 12 weekly sessions of counseling plus usual care (302 patients), or usual care alone (151 patients). Both the acupuncture protocol and the counseling protocols allowed for some individualization of treatment. Usual care, including antidepressants, was available according to need and monitored in all three groups. Compared to usual care alone, there was a significant reduction (a reduction unlikely to have occurred by chance) in the average PHQ-9 scores at both 3 and 6 months for both the acupuncture and counseling interventions. The difference between the mean PHQ-9 score for acupuncture and counseling was not significant. At 9 months and 12 months, because of improvements in the PHQ-9 scores in the usual care group, acupuncture and counseling were no longer significantly better than usual care.
What Do These Findings Mean?
These findings suggest that, compared to usual care alone, both acupuncture and counseling when provided alongside usual care provided significant benefits at 3 months in primary care to patients with recurring depression. Because this trial was a pragmatic trial, these findings cannot indicate which aspects of acupuncture and counseling are likely to be most or least beneficial. Nevertheless they do provide an estimate of the overall effects of these complex interventions, an estimate that is of most interest to patients, practitioners, and health care providers. Moreover, because this trial only considers the effect of these interventions on patients with moderate-to-severe depression as classified by the BDI-II; it provides no information about the effectiveness of acupuncture or counseling compared to usual care for patients with mild depression. Importantly, however, these findings suggest that further research into optimal treatment regimens for the treatment of depression with acupuncture and counseling is merited.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001518.
The US National Institute of Mental Health provides information on all aspects of depression (in English and Spanish)
The UK National Health Service Choices website provides detailed information about depression, including personal stories about depression, and information on counseling and acupuncture
The UK charity Mind provides information on depression, on talking treatments, and on complementary and alternative therapies including acupuncture; Mind also includes personal stories about depression on its website
More personal stories about depression are available from Healthtalkonline
MedlinePlus provides links to other resources about depression and about acupuncture (in English and Spanish)
doi:10.1371/journal.pmed.1001518
PMCID: PMC3782410  PMID: 24086114

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