Patients' representations of antidepressants: a clue to nonadherence?

OBJECTIVES: Antidepressants are prescribed frequently to chronic pain patients due to their pain relief effects. This medication raises major adherence issues. Despite the adverse effects, little is known about the factors that may jeopardize adherence in chronic pain patients. We carried out a qualitative study to investigate chronic pain patients' representations of antidepressants as compared with pain-free controls. METHODS: One hundred thirteen chronic pain patients recruited in a multidisciplinary pain clinic and 62 matched controls were questioned with standardized semistructured interviews. The interviews were submitted to content analysis. RESULTS: Ambivalence emerged as an important aspect of "patients" and controls' views about antidepressants. Antidepressants were described as potent chemicals acting in the brain, possibly causing effects on cognition, emotions, and personality, and inducing dependence and loss of control. Positive effects were mentioned, but when respondents related their own views and experiences, the statements became less favorable. Another key point was that neither the representations of the patients and nor those of the controls comprised the analgesic properties of antidepressants. DISCUSSION: Chronic pain patients' representations differed only little from those of controls. Antidepressants were not considered as addressing somatic problems. Thus, the prescription of antidepressants for chronic pain may be mistaken for a denial of the "reality" of pain. Although this study did not assess medication adherence, it is possible that patient representations have a bearing on adherence. Clinically, this suggests that these representations should be elicited and addressed, taking into account the patients' own models of pain.

Prevalence and treatment of depression in a hospital department of internal medicine.

BACKGROUND: Depressive disorders are overrepresented among patients admitted to nonpsychiatric units of general hospitals, but the majority of depressed patients are not identified in this setting. Effective and well-tolerated treatments and reliable diagnostic criteria, together with new assessment tools (self-administered or not), have been developed with encouraging results. Nevertheless, few studies have utilized standardized instruments and extensive clinical interviews by well-trained psychiatrists to assess depression. New research should test these tools in a French-speaking environment. METHODS: The investigation covered 292 patients aged 18-65 who were admitted over a period of 6 months to the internal medicine units of Geneva University Hospitals. Each patient filled in a self-administered questionnaire for depression [Patient Health Questionnaire (PHQ-9)]; 212 patients were also evaluated by a psychiatrist using DSM-IV diagnostic assessment and the Hamilton Depression Rating Scale during the first week of their hospital stay; both assessments were single-blinded. RESULTS: Psychiatric clinical interviews identified a high proportion (26.9%) of depressive disorders (37% among women) for all diagnoses; 11.3% (17.3% among women) of the patients met the DSM-IV criteria for major depression. The PHQ-9 identified depressive disorders among 34.9% of patients (42% among women) and identified a major depressive syndrome among 18.4% of patients (29.6% among women). Physicians in the internal medicine unit identified only about half the depressive patients; at the time of psychiatric examination, fewer than one in four patients was receiving antidepressant therapy. CONCLUSIONS: Our findings confirm the results of previous investigations, which showed that the failure to detect and treat depression is a major health problem among patients admitted to nonpsychiatric units of a general hospital.

Criterion validity of the French version of Patient Health Questionnaire (PHQ) in a hospital department of internal medicine.

OBJECTIVES: Depressive disorders are overrepresented among the patients admitted to non-psychiatric units in general hospitals. However, the majority of depressed patients fail to be identified within this care setting. Since a self-administered questionnaire (Patient Health Questionnaire, PHQ-9) has given encouraging results in English and Spanish, new research should test its criterion validity in a French-speaking environment. DESIGN: The study included 292 patients admitted to the internal medicine units of the University Hospitals of Geneva. Each patient filled the PHQ-9; 212 patients also underwent a blinded DSM-IV diagnostic assessment by a psychiatrist. METHODS: In order to assess the validity of PHQ-9 against the gold standard of the psychiatrist's DSM-IV diagnosis, we calculated overall accuracy, sensitivity, specificity, positive predictive value and Cohen kappa coefficients. We also studied the relationship between the PHQ-9 diagnostic and the severity of depression. Finally, analysis focused on the presence of a diagnosis of depression. RESULTS: Within the framework of the study, PHQ-9 showed an acceptable level of specificity. However, its sensitivity in detecting major depression was low (about 50% of false-negative results). As regards the overall presence of depressive disorders, this instrument performed hardly any better (35% of false negatives). Other characteristics of the population under investigation may have affected the data. CONCLUSIONS: The French version of PHQ-9 demonstrated low sensitivity as compared with psychiatrist-established diagnosis of DSM-IV A criterion and major depressive episode.

[New ways for treatment of depression in primary care]. / Nouvelles voies pour le traitement de la dépression en médecine de premier recours.

Depression is the most frequent psychiatric disorder and is associated with marked distress and work impairment. General practitioners are primarily involved in the treatment of these patients, but they lack specific training and the most important target to enhance access to suitable care. Systematic referral to a psychiatrist is not always recommended, not well accepted from the everyday patient and totally unfeasible due to the lack of therapists' vacancy. Well structured psychiatric counseling may be a valuable alternative in order to lower misdiagnosis and to improve the treatment. This paper reports the rationale of a pilot program aimed to disseminate the provision of such aid. This program extends the consultation-liaison to outpatient and may have a clinical and economic impact with relevance to depression treatment policies.

Contraceptive practice before and after termination of pregnancy: a prospective study.

This study is part of a larger prospective research program focusing on termination of pregnancy (TOP). One hundred and three women requesting TOP were interviewed before the intervention and 6 months later using open and closed questions and psychological tests. This paper focuses on contraceptive practices before and after abortion. The analysis took into account specific aspects of contraceptive practices and patients' behaviors. The aims were to assess: the level of women's knowledge and practice of contraception at the time of request for a TOP; the behavioral modifications following professional counseling 6 months after TOP; the influence of psychological and sexual factors, and those linked to the women's use of contraception. Most women (n = 101) had already used recommended contraception. During the cycle that had resulted in pregnancy, more than half (n = 58) had used recommended contraception and one third had not used any contraception. Six months later, 86 women used recommended contraception, and 17 did not. The majority of women reported changes in their contraceptive methods (n = 82). Most changes were within recommended methods. The women (n = 10) who continued to practice unprotected intercourse post-TOP were slightly older, satisfied with their sexual relations with their partner, often involved in a long-term and good relationship. During post-TOP period, it is essential to take into account the psychological dynamics involved in the choice of contraceptive methods. Counseling should emphasize not only protection against an unwanted pregnancy but also protection against sexually transmitted diseases, which is often perceived as a less important issue following TOP.

Guidelines and evaluation: improving the quality of consultation-liaison psychiatry.

Previous research has shown that residents in the consultation-liaison unit of Geneva University Hospital did not meet proposed guidelines on three counts: quickness of response to emergency situations, reporting cases to supervisors, and consulting with supervisors on major issues. The introduction of daily meetings between residents and supervisors improved the level of compliance with guidelines, from 69.2% to 82.6% for quickness of response, from 57.6% to 97.3% for reporting cases to supervisors, and from 25.0% to 98.0% for consulting with supervisors on major issues. Periodical evaluation would thus appear to enhance performance.