| 1. |
- af Winklerfelt Hammarberg, Sandra
(författare)
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Aspects of common mental disorders in primary care
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)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.
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| 2. |
- af Winklerfelt Hammarberg, Sandra, et al.
(författare)
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Clinical effectiveness of care managers in collaborative primary health care for patients with depression : 12-and 24-month follow-up of a pragmatic cluster randomized controlled trial
- 2022
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Ingår i: BMC Primary Care. - : Springer Nature. - 2731-4553. ; 23:1
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Tidskriftsartikel (refereegranskat)abstract
- Background In previous studies, we investigated the effects of a care manager intervention for patients with depression treated in primary health care. At 6 months, care management improved depressive symptoms, remission, return to work, and adherence to anti-depressive medication more than care as usual. The aim of this study was to compare the long-term effectiveness of care management and usual care for primary care patients with depression on depressive symptoms, remission, quality of life, self-efficacy, confidence in care, and quality of care 12 and 24 months after the start of the intervention. Methods Cluster randomized controlled trial that included 23 primary care centers (11 intervention, 12 control) in the regions of Vastra Gotaland and Dalarna, Sweden. Patients >= 18 years with newly diagnosed mild to moderate depression (n = 376: 192 intervention, 184 control) were included. Patients at intervention centers co-developed a structured depression care plan with a care manager. Via 6 to 8 telephone contacts over 12 weeks, the care manager followed up symptoms and treatment, encouraged behavioral activation, provided education, and communicated with the patient's general practitioner as needed. Patients at control centers received usual care. Adjusted mixed model repeated measure analysis was conducted on data gathered at 12 and 24 months on depressive symptoms and remission (MADRS-S); quality of life (EQ5D); and self-efficacy, confidence in care, and quality of care (study-specific questionnaire). Results The intervention group had less severe depressive symptoms than the control group at 12 (P = 0.02) but not 24 months (P = 0.83). They reported higher quality of life at 12 (P = 0.01) but not 24 months (P = 0.88). Differences in remission and self-efficacy were not significant, but patients in the intervention group were more confident that they could get information (53% vs 38%; P = 0.02) and professional emotional support (51% vs 40%; P = 0.05) from the primary care center. Conclusions Patients with depression who had a care manager maintained their 6-month improvements in symptoms at the 12- and 24-month follow-ups. Without a care manager, recovery could take up to 24 months. Patients with care managers also had significantly more confidence in primary care and belief in future support than controls.
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| 3. |
- Af Winklerfelt Hammarberg, Sandra, et al.
(författare)
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Outcomes of psychiatric interviews and self-rated symptom scales in people on sick leave for common mental disorders: an observational study.
- 2022
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Ingår i: BMJ open. - : BMJ. - 2044-6055. ; 12:6
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Tidskriftsartikel (refereegranskat)abstract
- To investigate the correspondence between diagnoses on sick leave certificates and diagnoses made in structured psychiatric interviews. Secondary aims were to investigate length of sick leave by diagnoses on sick leave certificates, diagnoses made in structured interviews and symptom severity.Observational study consisting of a secondary analysis of data from a randomised controlled trial and an observational study.The regions of Stockholm and Västra Götaland, Sweden.480 people on sick leave for common mental disorders.Participants were examined with structured psychiatric interviews and self-rated symptom severity scales.(1) Sick leave certificate diagnoses, (2) diagnoses from the Mini International Neuropsychiatric Interview and the Self-rated Stress-Induced Exhaustion Disorder (SED) Instrument (s-ED), (3) symptom severity (Montgomery-Asberg Depression Rating Scale-self-rating version and the Karolinska Exhaustion Disorder Scale) and (4) number of sick leave days.There was little correspondence between diagnoses on sick leave certificates and diagnoses made in structured psychiatric interviews. Many participants on sick leave for SED, anxiety disorder or depression fulfilled criteria for other mental disorders. Most on sick leave for SED (76%) and anxiety disorder (67%) had depression (p=0.041). Length of sick leave did not differ by certificate diagnoses. Participants with SED (s-ED) had longer sick leave than participants without SED (144 vs 84 days; 1.72 (1.37-2.16); p<0.001). More severe symptoms were associated with longer sick leave.Diagnoses on sick leave certificates did not reflect the complex and overlapping nature of the diagnoses found in the structured psychiatric interviews. This finding is relevant to the interpretation of information from health data registers, including studies and guidelines based on these data. A result of clinical interest was that more severe symptoms predicted long-term sick leave better than actual diagnoses.
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| 4. |
- Hammarberg, Sandra af Winklerfelt, et al.
(författare)
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Care managers can be useful for patients with depression but their role must be clear : a qualitative study of GPs' experiences
- 2019
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Ingår i: Scandinavian Journal of Primary Health Care. - : TAYLOR & FRANCIS LTD. - 0281-3432 .- 1502-7724. ; 37:3, s. 273-282
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Vastra Gotaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear.
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| 5. |
- Hybelius, Jonna, 1993-, et al.
(författare)
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A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder : single-group prospective feasibility trial
- 2022
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Ingår i: Pilot and Feasibility Studies. - : Springer Science and Business Media LLC. - 2055-5784. ; 8
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Tidskriftsartikel (refereegranskat)abstract
- Background: Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events.Methods: Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment.Results: Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18–47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17–32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained.Conclusions: Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible.
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| 6. |
- Kolaas, Karoline, et al.
(författare)
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Feasibility of a video-delivered mental health course for primary care patients : a single-group prospective cohort study
- 2023
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Ingår i: BMC Primary Care. - : BioMed Central (BMC). - 2731-4553. ; 24:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: In many health care systems, primary care is tasked with offering psychological treatment for common mental disorders. Resources are often limited, which complicates widespread dissemination of traditional psychological treatments. Stepped care models where the less resource-intensive interventions are delivered first, can be employed, but often do not eliminate the need for a thorough diagnostic assessment, which can be time-consuming, has the potential to bottleneck patient intake, and can add to waiting times. Novel low-threshold formats are needed to improve access to mental health care in the primary care setting.METHODS: This was a single-group prospective cohort study (N = 91). We assessed the feasibility of a video-delivered course as a first-line intervention for patients seeking help for mental health problems at a primary care center. The course had a transdiagnostic approach, suitable for both depression and anxiety disorders, and was based on cognitive behavioral techniques. Patients in need of psychosocial assessment, which usually entailed a four- to six-week wait, were referred by physicians or triage nurses. Study participants could start within a week, without the need for conventional diagnostic assessment, and were informed that they would be offered assessment after the course if needed. Key feasibility outcomes included participant satisfaction, attendance rates, the proportion of participants in need of additional clinical intervention after the course, and the rate of clinically significant improvement in anxiety and depression symptoms.RESULTS: Participants scored a mean of 21.8 (SD = 4.0, 9-32, n = 86) on the Client Satisfaction Questionnaire-8; just below our target of 22. The mean attendance rate was 5.0/6 lectures (SD = 1.6, range: 0-6, n = 91). Forty-six percent (37/81) reported experiencing no need of further clinical intervention after the course. The rate of clinically significant improvement was 59% (27/46) for anxiety and 48% (22/46) for depression. No serious adverse event was reported.CONCLUSIONS: Delivering a low-threshold online video-delivered mental health course in primary care appears to be feasible. Adjustments to further improve patient satisfaction are warranted, such as offering the choice of participating online or face-to-face.TRIAL REGISTRATION: (ClinicalTrials.gov NCT04522713) August 21, 2020.
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