Research reportRisk factors for depression in primary care: Findings of the TADEP project
Introduction
Depression is the most common psychiatric disorder in patients consulting general practitioners (Katon, 1987). According to studies, one tenth of patients seen by GPs suffer from clinical depression and another tenth from milder symptoms of depression (Schulberg et al., 1985, Duncan-Jones and Henderson, 1978, Goldberg, 1979, Barrett et al., 1988, Block et al., 1988, Coyne et al., 1991, Paykel and Priest, 1992). In Finnish primary health care patients, the occurrence of depression proved to be very much the same; the prevalence of clinical depression was 10% and that of the additional depressive symptoms was a little less than 10% (Salokangas et al., 1996).
There are many problems in the recognition of depression in primary care, however, and a considerable proportion of cases remain unidentified by GPs (Andersen et al., 1989). It has been estimated that about one half of depressed patients are recognized by GPs at the first visit and another tenth at subsequent visits; some 60% of cases being identified during the six-month period following the first visit (Paykel and Priest, 1992). In our own project, the GPs detected only a quarter of clinical depressions and, surprisingly, they had more difficulty in detecting more severe than mild depressions (Poutanen, 1996a, Poutanen, 1996b).
According to recent studies, cases of depression identified and treated by GPs have a better outcome than cases of unrecognized depression (Johnstone and Goldberg, 1976, Freeling and Tylee, 1982, Ormel et al., 1990, Angst, 1996). This justifies finding methods that make detection of depression easier for GPs.
It is important that GPs are made aware of the high prevalence of depression among primary health care patients. Medical training should provide doctors with the skills they need for open communication with their patients, for using patient-orientated interview techniques and for using screening instruments. The patients should be encouraged more openly to raise and discuss their psychic problems during consultation, and the doctors must learn to spend enough time with their patients.
Psychiatric symptomatology is of central significance in detecting depression. In most cases, depression is a periodic, but frequently recurrent, disorder. Recent studies have also shown that partial remission, not full recovery, is often the rule, although depression has a better outcome than anxiety or mixed anxiety–depression (Ormel et al., 1993). Between the periods of illness, most patients suffer from depressive symptoms (Judd, 1996) which are the most important predictors of a relapse (Paykel et al., 1995). Persons with depressive symptoms, compared with those without such symptoms, are 4.4 times, and persons with dysthymia are 5.5 times, more likely to develop a first-onset major depression during a one-year period (Horwath et al., 1992).
Therefore, concentrating not only on clinical depression but also on depressive symptoms is a reasonable approach to find factors that are important for GPs in detecting depressive patients. On the other hand, there is a possibility of finding the risk factors that correlate with the patient's depression and are, at the same time, easy to detect in clinical practice.
The aim of this study was to elucidate the risk factors relating to depressiveness among individuals seen in primary care. The study belongs to the Tampere Depression Project (TADEP project), which began in 1990 and whose major aim was to facilitate the detection of depression and its treatment both in primary and psychiatric care. Papers dealing with screening for depression and the prevalence and recognition of depression in primary care have been published previously (Salokangas et al., 1995, Salokangas et al., 1996, Poutanen, 1996a, Poutanen, 1996b).
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Material and methods
The study group consisted of 2487 individuals, randomly selected from among individuals aged between 18 and 64 who had visited one of three community health centres in Central Finland (Tampere, Kangasala and Lempäälä) or health care facilities operating under them (including consultations in regular office hours, in the emergency unit, the occupational health service and visits to prenatal clinics) between September 1991 and May 1992. During the visit, the patient was given the DEPS screening
Results
Depressive symptoms were more common in older, non-married and less educated patients, but there was no difference between men and women (Table 1). The living situation and status of employment were also related to depressive symptoms. The subjects living in a marital relationship or with some other person (mainly young students) had the lowest DEPS scores, while those who lived with their children without having a spouse had high scores. On the other hand, the unemployed and those on sickness
Discussion
The aim of the study was to determine the risk factors that correlated with depressive symptoms among primary health care attenders. Therefore, in addition to the GP's regular office hours, the study sample also included emergency patients, patients who visited the occupational health service and patients of maternity clinics, all belonging to primary care in the Finnish health care system.
We did not find any difference in depressive symptoms between men and women; in fact, the DEPS score was a
Acknowledgements
The authors wish to thank the staff of the community health centers of Tampere, Kangasala and Lempäälä for their flexible cooperation in the data collection. The Academy of Finland has financially supported our research.
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