Depression stigma and management of suicidal callers: a cross-sectional survey of crisis hotline counselors.

BACKGROUND: Crisis hotlines play a key role in suicide prevention worldwide following different approaches regarding risk assessment and management of suicidality. This is to our knowledge the first study investigating depression stigma in crisis hotline counselors. The association between stigma and self-rated knowledge and their exploration of suicide risk and consecutive management of suicidal callers is being investigated. METHODS: Data on depression stigma, self-rated knowledge, self-reported exploration and management of suicidality was collected from 893 counselors working for the German crisis hotline. Stigma in counselors had been compared to matched population sample (1002). RESULTS: Crisis hotline counselors reported significantly lower depression stigma compared to the general population. Depression stigma and age associations differed in both samples. The reported exploration of suicide risk in callers differed depending on the self-rated knowledge about suicidality and depending on the personal depression stigma, but not the reported consecutive management. CONCLUSION: Compared to the general population, crisis hotline counselors seem to have fewer stigmatizing attitudes toward depression. Attitudes and self-rated knowledge seem to influence the confidence in counselors regarding the exploration of suicidal callers, but not the consecutive management. The results indicate that a profound training and hands-on information about depression and suicide risk seem to be essential.

[Simple guideline-oriented supportive tools in primary care: Effects on adherence to the S3/NV guideline unipolar depression]. / Niederschwellige leitlinienorientierte supportive Materialien (NILS) in der primärärztlichen Versorgung: Effekte auf die Orientierung an der S3/NV-Leitlinie Unipolare Depression.

Simple guideline-oriented supportive tools in primary care: Effects on adherence to the S3/NV guideline unipolar depression Objectives: Does the provision of supportive tools improve guideline-oriented recognition and treatment of patients with depression in primary care? METHODS: In a nested intervention study, as part of a larger epidemiological study program in German primary care, 46 randomly drawn practices received tools to facilitate identification and treatment decisions.Pre-post effects were compared to 42 matched control practices without intervention. RESULTS: The proportion of correctly identified depression cases was similar in the intervention (47.2%) and the control group (42.3%, p = 0.537). Compared to controls, practitioners in the intervention group rated their competence in case identification and treatment at post-intervention more positively (p = 0.016). No effects were observed regarding the usage of the tools, practitioners' attitudes towards national depression guidelines, and depression treatment procedures. CONCLUSIONS: Since provision of guideline-oriented tools did not improve recognition and quality of treatment, delineation of alternative strategies for enhanced guideline adherence in primary care for depression is warranted.

[How frequently are depressive disorders recognized in primary care patients? : A cross-sectional epidemiological study in Germany]. / Wie häufig werden Patienten mit depressiven Störungen in der hausärztlichen Praxis erkannt? : Eine epidemiologische Querschnittsstudie.

BACKGROUND: Primary care physicians (PCPs) play a crucial role for guideline-oriented intervention in patients with depression. OBJECTIVES: Based on a diagnostic screening questionnaire, this study investigates the sensitivity of PCPs to recognize patients with depression as well as the factors facilitating recognition and concordant diagnostic decisions. METHOD: In a cross-sectional epidemiological study in six regions of Germany, 3563 unselected patients filled in questionnaires on mental and physical complaints and were diagnostically evaluated by their PCP (N = 253). The patient reports on an established Depression-Screening-Questionnaire (DSQ), which allows the approximate derivation of an ICD-10 depression diagnosis, were compared with the physician diagnosis (N = 3211). In a subsample of discordant cases a comprehensive standardized clinical-diagnostic interview (DIA-X/CIDI) was applied. RESULTS: On the study day, the prevalence of ICD-10 depression was 14.3% according to the DSQ and 10.7% according to the physician diagnosis. Half of the patients identified by DSQ were diagnosed with depression by their physician and two thirds were recognized as mental disorder cases. More severe depression symptomatology and the persistent presence of main depression symptoms were related to better recognition and concordant diagnostic decisions. Diagnostic validation interviews confirmed the DSQ diagnosis in the majority of the false-negative cases. Indications for at least a previous history of depression were found in up to 70% of false-positive cases. CONCLUSION: Given the high prevalence of depression in primary care patients, there is continued need to improve the recognition and diagnosis of these patients to assure guideline-oriented treatment.

[From the Competence Network on Depression and Suicidality to the German Depression Foundation. National and international prevention of suicidal behaviour and optimizing health care through using of E­Mental-Health]. / Vom Kompetenznetz Depression, Suizidalität zur Stiftung Deutsche Depressionshilfe. Nationale und internationale Suizidprävention und Versorgungsoptimierung unter Nutzung neuer Medien.

Depression is a very common, severe, socio-economically highly relevant disorder and the main cause for approximately 10,000 suicides in Germany annually. There is capital room for improvement and optimization of the care for depressed patients, as effective and evidence-based treatment options are available. However, they are only used optimally by a minority of the people affected due to huge diagnostic and therapeutic deficits. The "Compentence Network on Depression and Suicidality" provided several evidence-based concepts to improve care for patients affected by depression and to prevent suicidal behaviour. Especially the four-level intervention approach of the Alliances Against Depression has been successfully adapted and implemented by more than 100 regions within Europe and globally as well. The infrastructure of the Competence Network could be efficiently sustained throughout the establishment of the German Depression Foundation and the European Alliance against Depression. Since 2014, all research activities have been extended nationally and internationally by the establishment of a Depression Research Centre with a special focus on various E­Mental-Health-projects.

Munich Alliance Against Depression.

Background: A four-level community-based intervention aiming simultaneously to improve the care for depression and to prevent suicidal behavior has been implemented in the German city Munich. Aims: Changes in suicide rates in Munich during 2009-2014 were analyzed with respect to a 10-year baseline. The same was true for a control region (Cologne) and Germany minus Munich. Method: The interventions included training of primary care providers, a public awareness campaign, training of community facilitators, and support for patients and relatives. Analyses included repeated-measures, generalized linear models. Results: In Munich, the suicide rate significantly decreased during the intervention period compared to baseline (percentage change = -15.0%; p < .001, 198 compared to 222 suicides per year). Differences in the change for Munich and the change for the control locations (Cologne; -1.7%; p = .71) and Germany minus Munich (-6.2%; p = .09) were not significant. Limitations: Data on suicide attempts were unavailable. Conclusion: In Munich, a clinically and statistically significant decrease in suicide rate was found. This change was numerically but not significantly larger than in the control regions. The results are promising, however. Because of low suicide base rates and limited power, no strong conclusions can be drawn concerning suicide preventive effects of the intervention.

The German Alliance Against Depression and suicide rates: A retrospective analysis.

Supported by the German Alliance Against Depression, 82 regions in Germany launched their own community-based multi-level intervention programs targeting both depression and suicidal behavior prior to January 2016. Sixteen of these regions have implemented the full 4-level intervention program comprising 1) training of General Practitioners, 2) a public awareness campaign, 3) training of community facilitators and 4) support for depressed patients and their relatives for at least three years. The aim of the study was to examine possible suicide prevention effects in these sixteen 4-level intervention regions (comprising a population of 6,976,309) by 1) comparing the annual suicide rates during the 3-year intervention period to a 10-year baseline and 2) comparing these differences to corresponding trends in Germany after excluding all intervention regions (Germany-IR). Primary outcome was the annual rate of suicides. Analyses included negative binomial regression models. When examining differences between suicide rates during the intervention period compared to the baseline period, only a trend towards a significant reduction was found. This reduction of suicides in the sixteen 4-level intervention regions did not differ from that in Germany-IR as control. The interpretation of these findings has to take into account that the training of General Practitioners, police and other community facilitators might have improved the recognition of suicides, thus increasing detection rates. Furthermore, destigmatizing effects of the public awareness campaigns might have increased the number of suicides by lowering suicide threshold ("normalization") for those at risk and by decreasing the rate of suicides deliberately hidden by suicide victims or their relatives.

The 4-Level Approach: Prevention of Suicidal Behaviour Through Community-Based Intervention.

Due to the many different factors contributing to diagnostic and therapeutic deficits concerning depression and the risk of suicidal behaviour, community-based interventions combining different measures are considered the most efficient way to address these important areas of public health. The network of the European Alliance Against Depression has implemented in more than 120 regions within and outside of Europe community-based 4-level-interventions that combine activities at four levels: (i) primary care, (ii) general public, (iii) community facilitators and gatekeepers (e.g., police, journalists, caregivers, pharmacists, and teachers), and (iv) patients, individuals at high risk and their relatives. This review will discuss lessons learned from these broad implementation activities. These include targeting depression and suicidal behaviour within one approach; being simultaneously active on the four different levels; promoting bottom-up initiatives; and avoiding any cooperation with the pharmaceutical industry for reasons of credibility.

"Doctor, my back hurts and I cannot sleep." Depression in primary care patients: Reasons for consultation and perceived depression stigma.

BACKGROUND: General practitioners (GPs) play a significant role in depression care. Recognition of depression is crucial for adequate treatment but is impeded by a high portion of depressed patients only reporting physical symptoms to their GP. Among the many reasons for this phenomenon is mental health stigma. We investigated how patients with depression differed from patients without depression regarding the types and number of complaints presented to their GP, as well as their depression stigma. For the subgroup of patients with depression, potential associations between perceived depression stigma and number and types of presented complaints were investigated to see if these might reflect the patient's intention to conceal mental health symptoms due to fear of being stigmatized by others. Further, we investigated if perceived depression stigma is related to depression treatment. METHODS: Data on depressive symptoms (assessed by the Depression Screening Questionnaire; DSQ), depression stigma (assessed by the Depressions Stigma Scale; DSS), type of complaints reported to the GP and treatment-related factors were collected from 3,563 unselected primary care patients of 253 GPs in a cross-sectional epidemiological study ("VERA study") in six different German regions. Data of a total of 3,069 patients was used for analysis on complaints reported to the GP (subsample of the VERA study), and for 2,682 out of 3,069 patients data on a stigma questionnaire was available. RESULTS: Nearly half of the primary care patients with depression (42.2%) reported only physical complaints to their GP. Compared to patients without a depression diagnosis, patients with depression reported twice as many complaints to their GP with a mean of 2.02 (1.33) vs. 1.2 (0.69), including a more frequent combination of physical and mental symptoms (28.8% vs. 3.5%). Patients with depression showed higher total stigma compared to patients without depression, Mdn = 48 (IQR 40-54) vs. Mdn = 46.3 (IQR 29-53), due to higher perceived stigma, Mdn = 27 (IQR 21-32) vs. Mdn = 25.9 (IQR 20-29). Perceived stigma was associated with male gender (beta -.14, p = .005) and a lack of pharmacological treatment (beta -.14, p = .021) in patients with a depression diagnosis. CONCLUSION: The number of complaints presented to the GP might function as a marker to actively explore depression in primary care patients, in particular when both physical and mental symptoms are reported. Perceived depression stigma should also be addressed especially in male patients. Further research should clarify the role of perceived stigma as a potential inhibitor of pharmacological treatment of depression in primary care.