Where are the gaps in ‘usual care’ for patients at high risk of persistent depression?

Problem

Depression trajectories in primary care are heterogeneous. While many patients will have a mild and self-limiting course of symptoms, others experience severe and prolonged disorder. Improving outcomes for these patients requires an understanding of the care they usually receive, in order to design interventions that address gaps in current practice.

Approach

We conducted a secondary analysis of cross-sectional data provided by Australian general practice attendees with depressive symptoms (the diamond cohort). Our group has previously developed a clinical prediction algorithm that identifies low, medium and high risk of persistent depressive symptoms. In this study we map the current usual care of primary care patients at according to their likelihood of persistent depression. Two hundred and thirteen patients aged 18- 65 completed self-report questionnaires about the mental health care they received from their GP and engagement in self-help strategies to manage mental health.

Findings

Patients in at high risk of persistent depression were slightly more likely to report a mental health related visit to their GP in the past three months (81% vs 76% in the low risk group), but substantially more likely to have seen a mental health specialist (30% saw a psychologist vs 16% of those in the low risk group). Just over half of the high risk patients were taking antidepressant medication, compared to one third of the low and medium risk groups. High risk patients were also more likely to receive written information about depression from their GP (20% vs 11% in low group) and received more behavioural advice, about issues such as getting a good night’s sleep (32% vs 15%), exercise (40% vs 28%), diet (32% vs 18%), and cutting down alcohol or drug use (15% vs 5%). Despite this advice, patients at high risk of depression were actually less likely to enact lifestyle changes to try and improve their mental health; for example, 61% reported exercising compared to 70% of low risk patients, and 20% reduced their alcohol or drug intake while 29% of the low risk patients did so. Seeking support from others was also less common; 58% of high risk patients talked to their family or friends to help manage their mental health, compared to 71% of low risk patients.

Consequences

Primary care patients at high risk of persistent depression have greater health service usage compared to others, but are less likely to try methods of managing their mental health outside of the health system. In order to improve outcomes for this group and reduce the burden they place on services, interventions should be tailored to address these differences.