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- 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. |
- 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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