Research report
Risk factors for depression in primary care: Findings of the TADEP project

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Abstract

Background: Depression is a common but poorly recognized disorder in primary care. Knowing risk factors related to depression can help doctors in diagnosing and treating depressive patients.

Methods: A random sample of 1643 individuals, aged 18 to 64, attending community health centres in Central Finland, took part in an inquiry with an instrument (the DEPS) measuring their depressiveness.

Results: Negative life events, poor physical health, poor marital or other interpersonal relationships, spouse's poor health, poor socio-economic and work situation and problems with alcohol were the major variables explaining the variance of depressive symptoms both in regression and discriminant analyses.

Conclusion: In the primary care patients, negative life events, poor physical health, poor marital or other interpersonal relationships, spouse's poor health, poor socio-economic and work situation and problems with alcohol indicate high risk for depression; they also often accumulate in the same patients. The connection between risk factors and depression is stronger in males than in females.

Limitation: The assessment of depression is based on the self-fulfilled scale and cannot, therefore, be directly generalized to clinical depression. Because of the cross-sectional study design, it is not possible to make any causal conclusion between risk factors and depression.

Clinical relevance: By paying attention to the most general risk factors of depression, general practitioners can become more sensitive in their recognition of depression.

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).

Section snippets

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.

References (42)

  • A Johnstone et al.

    Psychiatric screening in general practice

    Lancet

    (1976)
  • S.M Andersen et al.

    The recognition, diagnosis, and treatment of mental disorders by primary care physicians

    Med. Care

    (1989)
  • J Angst

    Outcome of treated vs. non-treated depressive episodes. A paper presented in the Xth World Congress of Psychiatry, 23–28 August 1996, Madrid.

    Abstracts

    (1996)
  • J.E Barrett et al.

    The prevalence of psychiatric disorders in a primary care practice

    Arch Gen Psychiatry

    (1988)
  • A.T Beck

    Thinking and depression: I. Idiosyncratic content and cognitive distortion

    Arch Gen Psychiatry

    (1963)
  • M Block et al.

    Diagnosing depression among new patients in ambulatory training settings

    J Am Board Fam Pract

    (1988)
  • Brown, G.W., Harris, T., 1978. Social origins of depression: A study of psychiatric disorder in women. Tavistock Press,...
  • T.S Brugha et al.

    Gender, social support and recovery from depressive disorders: a prospective clinical study

    Psychol Med

    (1990)
  • Cooley, W.W., Lohnes, P.R., 1971. Multivariate data analysis. John Wiley and Sons, New...
  • J.C Coyne et al.

    Recognizing depression: A comparison of family physician ratings, self-report, and interview measures

    J Am Board Fam Pract

    (1991)
  • P Duncan-Jones et al.

    The use of a two-phase design in a prevalence survey

    Soc Psychiatry

    (1978)
  • G Dunn et al.

    The natural history of depression in general practice: stochastic models

    Psychol Med

    (1981)
  • P Goering et al.

    Social support and post hospital outcome for depressed women

    Can J Psychiatry

    (1983)
  • Freeling, P., Tylee, A., 1982. Depression in general practice. In: Paykel, S. (Ed.), Handbook of Affective Disorders....
  • D Goldberg

    Detection and assessment of emotional disorders in a primary care setting

    Int J Ment Health

    (1979)
  • L Hansson et al.

    Screening for psychiatric illness in primary care

    Soc Psychiatry Psychiatr Epidemiol

    (1994)
  • S Henderson et al.

    Neurosis and social bonds in an urban population

    Aust NZ J Psychiatry

    (1979)
  • E Horwath et al.

    Depressive symptoms as relative and attributable risk factors for first-onset major depression

    Arch Gen Psychiatry

    (1992)
  • J Hurry et al.

    Sociodemographic association with social disablement in a community sample

    Soc Psychiatry

    (1983)
  • E.T Isometsä et al.

    Suicide in major depression

    Am J Psychiatry

    (1994)
  • L.L Judd

    New observations in the life course of unipolar major depression: risk factors and treatment goals. A paper presented in the XXth CINP Congress 23–27 June 1996, Melbourne.

    Eur Neuropsychopharmacol

    (1996)
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