Reading of the Week: Depression and Primary Care (Depression: Week 2 of 3)

Depression is a common psychiatric disorder and a major contributor to mortality and morbidity worldwide. Over the past decade in Sweden, work absence because of mental ill health has risen markedly and depression is a major factor. Substantial societal costs are associated with the disorder, which affects up to 15% of the population at any one time and tends to be recurrent. There are compelling reasons to investigate alternative treatments for depression. Although effective treatments exist, most people with the disorder never seek professional help. Among those that do, only half appear to benefit. Adherence with medication is often poor and waiting times for cognitive–behavioural therapy (CBT) can be lengthy, resulting in more entrenched symptoms and a worse long-term prognosis. As general medical practitioners are frequently the main care providers for depression, treatment options that are non-stigmatising, have few side-effects and can readily be prescribed in community healthcare settings are needed.

So begins a new paper that considers depression treatment in Sweden. These issues sound very familiar. Reading over this list of problems – the burden of illness, the inaccessibility of care, etc. – we could replace Sweden with Canada. And that’s why this paper is so relevant to us.

This week’s Reading: “Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: randomised controlled trial” by Mats Hallgren et al., which was just published in the British Journal of Psychiatry.

Mats Hallgren

A quick summary: this is a smart paper seeking ways to improve the treatment of depression in the primary care setting. How to achieve better results? Hallgren et al. consider exercise and Internet-based CBT, and compare such interventions to the usual care.

The paper can be found here:

http://bjp.rcpsych.org/content/207/3/227

This is the second part in a three-part series on depression.

Last week: a look at better psychopharmacological management.

This week: consideration of better treatment in the primary care setting.

Next week: a look at the burden of illness on the patient and the psychiatrist.

(And this isn’t Mad Men Season 4. Miss a week and you aren’t lost.)

This study doesn’t require a big preamble. They do a randomized controlled trial comparing treatment as usual with two other interventions. The results aren’t exactly surprising, but they raise larger questions about our basic approach to treatment.

Here’s what they did:

· Essentially, the study authors conducted a randomized controlled trial considering the effectiveness of three treatments for depression over a 12 week period.

· Patients were recruited from 6 county councils in Sweden.

· Patients were over the age of 18 and scored over 9 on a PHQ-9. Exclusion criteria included: primary alcohol or drug use, severe somatic illness, a diagnosis that required specialist treatment (e.g., psychosis).

· Different scales were used. The primary outcome was the severity of depression, assessed using the MADRS. A secondary outcome was self-rated work capacity, using a 10-item Likert scale.

· Patients were randomized to one of three interventions. Physical exercise. Patients were further randomized to light exercise (yoga), moderate exercise (aerobics), or vigorous exercise (aerobics and balance). Exercise classes ran for 60 minutes, 3 times a week for 12 weeks. ICBT. Patients were offered CBT through the internet meaning that they could log into a website and work through modules representing basic CBT concepts, guided by a therapist who was accessible by email. Treatment as usual. Patients were treated by their primary care physician who had flexibility to choose the treatment he or she felt was appropriate, including CBT sessions.

Here’s what they found:

· 946 people were recruited for the study. The 3 month reassessment was completed by 740 (78%).

· Most of the participants were women (73%) with a mean age of 43 years and 78% of the sample was employed or studying at baseline.

· “Level of depression reduced significantly from baseline to post-treatment in all three treatment groups.” That said, improvements in depression at 3 months were significantly larger in both the physical exercise group (mean difference 2.99) and the ICBT group (mean difference 2.83), respectively. The treatment effect of exercise and ICBT were about the same.

· In terms of the self-reported work capacity, patients reported improvements with all three treatments and there were no differences among the groups.

Change over time. Men (a), women (b)

In this study, all three interventions were associated with improvements in depressive symptoms at follow-up. However, the mean reduction in depression scores were significantly larger in the physical exercise and ICBT groups compared with TAU; an effect seen among both men and women.

A few thoughts:

1. This is a good study; it’s well designed.

2. So much evidence suggests that exercise is effective for the treatment of depression. The paper opens by noting that “a recent Cochrane review of 32 randomised controlled trials (RCTs) concluded that exercise is moderately more effective than a control intervention for reducing the symptoms of depression,” yet only 1 in 1000 visits to a primary care physician in Sweden resulted in a prescription of exercise. (!) Would it be any better here? I doubt that – and yet look at the results of this study in a head-to-head comparison with the usual care.

3. And this study – like several before it – shows the usefulness of ICBT, something increasingly available in Sweden and Australia but not particularly available in Canada. (I’m going to digress for a moment and note that ICBT is offered at The Scarborough Hospital.) If we are serious about treating depression more aggressively, why aren’t we making ICBT more available? This intervention is inexpensive compared to traditional CBT and offers care to patients on their terms and their schedule.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.