Efficacy and acceptability of pharmacological treatments for depressive disorders in primary care: systematic review and network meta-analysis.

PURPOSE: The purpose of this study was to investigate whether antidepressants are more effective than placebo in the primary care setting, and whether there are differences between substance classes regarding efficacy and acceptability. METHODS: We conducted literature searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO up to December 2013. Randomized trials in depressed adults treated by primary care physicians were included in the review. We performed both conventional pairwise meta-analysis and network meta-analysis combining direct and indirect evidence. Main outcome measures were response and study discontinuation due to adverse effects. RESULTS: A total of 66 studies with 15,161 patients met the inclusion criteria. In network meta-analysis, tricyclic and tetracyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), a serotonin-noradrenaline reuptake inhibitor (SNRI; venlafaxine), a low-dose serotonin antagonist and reuptake inhibitor (SARI; trazodone) and hypericum extracts were found to be significantly superior to placebo, with estimated odds ratios between 1.69 and 2.03. There were no statistically significant differences between these drug classes. Reversible inhibitors of monoaminoxidase A (rMAO-As) and hypericum extracts were associated with significantly fewer dropouts because of adverse effects compared with TCAs, SSRIs, the SNRI, a noradrenaline reuptake inhibitor (NRI), and noradrenergic and specific serotonergic antidepressant agents (NaSSAs). CONCLUSIONS: Compared with other drugs, TCAs and SSRIs have the most solid evidence base for being effective in the primary care setting, but the effect size compared with placebo is relatively small. Further agents (hypericum, rMAO-As, SNRI, NRI, NaSSAs, SARI) showed some positive results, but limitations of the currently available evidence makes a clear recommendation on their place in clinical practice difficult.

Physicians' attitudes, diagnostic process and barriers regarding depression diagnosis in primary care: a systematic review of qualitative studies.

BACKGROUND: Findings of diagnostic studies using standardized psychiatric interviews as a gold standard suggest that family physicians (FPs) both under- and over-diagnose depression. OBJECTIVE: We systematically reviewed qualitative studies investigating how FPs diagnose depression and what their concepts of depression and the perceived barriers are when diagnosing depression. METHODS: We searched Medline, Embase, PsychInfo, reference lists and family practice journals to identify qualitative studies on primary care providers addressing at least one of the following issues: concepts, process and barriers relevant to diagnosing depression. Thematic synthesis was used for collecting data by line-by-line coding of the findings of the primary studies and for the development of descriptive and analytical themes. RESULTS: Thirteen qualitative studies interviewing a total of 239 primary care providers met the inclusion criteria. Three distinct themes with nine subthemes that specify attitudes, diagnostic process and barriers while diagnosing depression were identified. The synthesis revealed that FPs use approaches to diagnose depression that are usually based on their knowledge of the patient's long-term history, an established patient-doctor relationship and a rule-out algorithm of other diagnoses. As such, these strategies markedly differ from the diagnostic criteria for depressive disorders that are used in psychiatrically oriented classification systems. CONCLUSIONS: FPs believe to have sensible strategies for diagnosing depression that are different from the concepts operationalized in psychiatrically oriented classifications. In diagnostic studies, considering standardized psychiatric interviews uncritically as a gold standard for diagnosis of depression in primary care might be misleading.

Unlimited access to health care--impact of psychosomatic co-morbidity on utilisation in German general practices.

BACKGROUND: The effect of psychosomatic co-morbidity on resource use for systems with unlimited access remains unclear. The aim of this study was to evaluate the impact on practice visits, referrals and periods of disability in German general practices and to identify predictors of health care utilisation. METHODS: Cross sectional observational study in 13 practices in Upper Bavaria. Patients were included consecutively and filled in the Patients Health Questionnaire (PHQ). Numbers of practice visits, referrals and periods of disability within the last twelve months and permanent mental and somatic diagnoses were extracted manually by review of the computerised charts. Physicians in Germany are obliged to document repetitive reasons of encounter as permanent diagnoses in terms of ICD-10-codes. These ICD-10-codes are used for legitimisation of reimbursement in German general practices. RESULTS: 1005 patients were included (58.6% female). On average, patients had 15.3 (sd 16.3) practice contacts, 3.8 (sd 4.2) referrals and 7.5 (sd 23.1) days of disability per year. The mean number of coded permanent diagnoses was 0.4 (sd 0.7) for mental and 4.0 (sd 4.0) for somatic diagnoses. Patients with mental diagnoses scored higher in depression, anxiety, panic and somatoform disorder scales of PHQ. Frequent practice visits were associated stronger with coded permanent mental diagnoses (OR 20.0; 95%CI 7.5-53.9) than with coded permanent somatic diagnoses (OR 14.4; 95%CI 5.9-35.4). Frequent referrals were associated stronger with somatic diagnoses (OR 4.9; 95%CI 2.0-11.9) than with mental diagnoses (OR 3.6; 95%CI 1.4-9.8). Periods of disability were predicted by mental diagnoses (OR 5.0; 95%CI 1.6-15.8) but not by somatic diagnoses (OR 2.5; 95%CI 0.7-8.1). CONCLUSIONS: Psychosomatic co-morbidity has a stronger impact on health care utilisation in German general practices with respect to practice visits and periods of disability whereas somatic disorders play a stronger role for referrals. Time constraints in the practices might lead to frequent contacts as too little time is left for patients with mental problems. Therefore, structural changes in the health care reimbursement systems might be necessary. Mental diagnoses might be helpful to identify patients at risk for high health care utilisation. However, the use of routinely coded diagnoses for reimbursement might lead to distorted estimation of resource use.

Treatment of depressive disorders in primary care--protocol of a multiple treatment systematic review of randomized controlled trials.

BACKGROUND: Several systematic reviews have summarized the evidence for specific treatments of primary care patients suffering from depression. However, it is not possible to answer the question how the available treatment options compare with each other as review methods differ. We aim to systematically review and compare the available evidence for the effectiveness of pharmacological, psychological, and combined treatments for patients with depressive disorders in primary care. METHODS/DESIGN: To be included, studies have to be randomized trials comparing antidepressant medication (tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), hypericum extracts, other agents) and/or psychological therapies (e.g. interpersonal psychotherapy, cognitive therapy, behavioural therapy, short dynamically-oriented psychotherapy) with another active therapy, placebo or sham intervention, routine care or no treatment in primary care patients in the acute phase of a depressive episode. Main outcome measure is response after completion of acute phase treatment. Eligible studies will be identified from available systematic reviews, from searches in electronic databases (Medline, Embase and Central), trial registers, and citation tracking. Two reviewers will independently extract study data and assess the risk of bias using the Cochrane Collaboration's corresponding tool. Meta-analyses (random effects model, inverse variance weighting) will be performed for direct comparisons of single interventions and for groups of similar interventions (e.g. SSRIs vs. tricyclics) and defined time-windows (up to 3 months and above). If possible, a global analysis of the relative effectiveness of treatments will be estimated from all available direct and indirect evidence that is present in a network of treatments and comparisons. DISCUSSION: Practitioners do not only want to know whether there is evidence that a specific treatment is more effective than placebo, but also how the treatment options compare to each other. Therefore, we believe that a multiple treatment systematic review of primary-care based randomized controlled trials on the most important therapies against depression is timely.

The impact of psychosomatic co-morbidity on discordance with respect to reasons for encounter in general practice.

OBJECTIVE: Concordance between general practitioners (GPs) and patients is an essential requirement for treatment success and patient satisfaction in general practice. The objectives of this were to estimate the total amount of discordance with respect to reason for encounter (RFE) during consultation in German general practices, and to explore the influence of psychosomatic co-morbidity of the patients in case of discordance. METHODS: 1101 consecutive patients completed a questionnaire, including questions about the RFE and the Patient Health Questionnaire (PHQ). RFEs, as stated by the patients and diagnosed by the GPs were matched according to a predefined index. Factors that may influence the level of discordance between patients' RFE and GPs' RFE were analysed. RESULTS: Amount of concordance was 74.9%, incomplete concordance 11.2%, discordance in different physical RFEs was 9.1%, and discordance when GPs diagnosed psychosomatic illness while patients presented physical complaints was found in 2.5%. The number of RFE (OR 3.03; 95%CI 2.48-3.69; P<.001), depression (OR 2.27; 95%CI 1.51-3.41), anxiety (OR 1.78; 95%CI 1.03-3.10) and somatisation syndrome (OR 2.20; 95%CI 1.50-3.22) significantly predicted incomplete concordance and discordance, respectively. The number of RFE was significantly associated with depression (OR 1.32; 95%CI 1.09-1.61) and somatoform syndrome (OR 1.45; 95%CI 1.21-1.74). CONCLUSION: The considerable amount of discordance and incomplete concordance can partly be explained by the psychosomatic co-morbidity of the patients. If it is seen as a fundamental right of patients to be adequately understood, more efforts are necessary to improve patient centredness. Further studies have to evaluate if improvement of identification of psychosomatic co-morbidity might reduce discordance.