Adequate follow-up can’t be optional : Improving the management of major depression in primary care

Abstract

Depressive illness is a public health issue of major significance. Despite proven efficacy of antidepressant medication, few patients with major depression receive levels of treatment consistent with guidelines. Moreover, effectiveness of antidepressant medication is reduced by patients’ non-adherence. This may result in treatment failure, high medical care utilization, and functional impairment.

In this thesis, we aimed to gain more insight into the possibilities to improve adherence, pa-tients’ attitudes towards antidepressant medication, and depression outcome. In addition, the possibility to predict outcome was studied.A review of the literature demonstrated that interventions using enhanced patient education, counseling, improved quality of care, and collaboration with practice nurses and mental health workers resulted in significant improve-ments in rates of adherence, and better depression outcomes, compared with usual care. Most of the effective interventions consisted of multiple ingredients and required intensive support from research teams, which likely precludes implementation in daily practice. Inter-ventions which are compatible with usual systems of care are needed.We therefore de-veloped a depression care program (DCP) that was feasible in the Netherlands. DCP con-sisted of enhanced patient education, enhanced general practitioner education, stimulation of particaption of general practioner and patient in the treatment, patient’s self-management support, and discussing the costs and benefits of antidepressants. In a cluster randomized trial, this program was compared with a less complex systematic follow-up program (SFP) in patients suffering from major depression, who were prescribed selective serotonin reuptake inhibitors. The results demonstrated that adherence was high and depression outcomes were favorable in both conditions. So, it was concluded that SFP is an effective intervention per se. Management of depression might also improve when clinicians could estimate beforehand which patients presumably will not profit from certain interventions. Therefore, we developed a prediction rule from collected baseline characteristics, which provides the gen-eral practitioner with a useful instrument to predict remission of individual patients. Prediction of unfavorable outcome might also be obtained from rating symptoms change after antidepressant treatment is actually started. Most guidelines on the treatment of de-pression recommend to evaluate treatment results after four to six weeks, and, if necessary, to change treatment. However, the evidence on which such recommendations are based is rather weak. We investigated the relation between initial symptoms change and remission. The data show that treatment with antidepressant medication should be reconsidered if pa-tients still fail to improve or are only partly improved after six weeks. Many depressed patients have negative attitudes towards antidepressants, possibly leading to poor adher-ence. In a study comparing DCP with SFP, it was demonstrated that these attitudes can be ameliorated using DCP.In conclusion, the management of major depression in primary care can be substantially improved. This may result in higher adherence rates, more positive patient attitudes towards antidepressant medication, and better outcome of depression treatment. Since systematic follow-up seems as effective as more complex interventions in most patients, one might rightly state that systematic follow-up can’t be optional any-more.