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      A qualitative study of perceived needs and factors associated with the quality of care for common mental disorders in patients with chronic diseases: the perspective of primary care clinicians and patients

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          Abstract

          Background

          The prevalence of comorbid anxiety and depressive disorders is high among patients with chronic diseases in primary care, and is associated with increased morbidity and mortality rates. The detection and treatment of common mental disorders in patients with chronic diseases can be challenging in the primary care setting. This study aims to explore the perceived needs, barriers and facilitators for the delivery of mental health care for patients with coexisting common mental disorders and chronic diseases in primary care from the clinician and patient perspectives.

          Methods

          In this qualitative descriptive study, we conducted semi-structured interviews with clinicians (family physician, nurse, psychologist, social worker; n = 18) and patients ( n = 10) from three primary care clinics in Quebec, Canada. The themes explored included clinician factors (e.g., attitudes, perception of roles, collaboration, management of clinical priorities) and patient factors (e.g., needs, preferences, access to care, communication with health professionals) associated with the delivery of care. Qualitative data analysis was conducted based on an interactive cyclical process of data reduction, data display and conclusion drawing and verification.

          Results

          Clinician interviews highlighted a number of needs, barriers and enablers in the provision of patient services, which related to inter-professional collaboration, access to psychotherapy, polypharmacy as well as communication and coordination of services within the primary care clinic and the local network. Two specific facilitators associated with optimal mental health care were the broadening of nurses’ functions in mental health care and the active integration of consulting psychiatrists. Patients corroborated the issues raised by the clinicians, particularly in the domains of whole-person care, service accessibility and care management.

          Conclusions

          The results of this project will contribute to the development of quality improvement interventions to increase the uptake of organizational and clinical evidence-based practices for patients with chronic diseases and concurrent common mental disorders, in priority areas including collaborative care, access to psychotherapy and linkages with specialized mental health care.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12875-016-0531-y) contains supplementary material, which is available to authorized users.

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          Most cited references 61

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          The PHQ-9: validity of a brief depression severity measure.

          While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
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            A brief measure for assessing generalized anxiety disorder: the GAD-7.

            Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.
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              Depression, chronic diseases, and decrements in health: results from the World Health Surveys.

              Depression is an important public-health problem, and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as a comorbidity, on overall health status. The WHO World Health Survey (WHS) studied adults aged 18 years and older to obtain data for health, health-related outcomes, and their determinants. Prevalence of depression in respondents based on ICD-10 criteria was estimated. Prevalence values for four chronic physical diseases--angina, arthritis, asthma, and diabetes--were also estimated using algorithms derived via a Diagnostic Item Probability Study. Mean health scores were constructed using factor analysis and compared across different disease states and demographic variables. The relation of these disease states to mean health scores was determined through regression modelling. Observations were available for 245 404 participants from 60 countries in all regions of the world. Overall, 1-year prevalence for ICD-10 depressive episode alone was 3.2% (95% CI 3.0-3.5); for angina 4.5% (4.3-4.8); for arthritis 4.1% (3.8-4.3); for asthma 3.3% (2.9-3.6); and for diabetes 2.0% (1.8-2.2). An average of between 9.3% and 23.0% of participants with one or more chronic physical disease had comorbid depression. This result was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0.0001). After adjustment for socioeconomic factors and health conditions, depression had the largest effect on worsening mean health scores compared with the other chronic conditions. Consistently across countries and different demographic characteristics, respondents with depression comorbid with one or more chronic diseases had the worst health scores of all the disease states. Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes. The comorbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression. These results indicate the urgency of addressing depression as a public-health priority to reduce disease burden and disability, and to improve the overall health of populations.
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                Author and article information

                Contributors
                819 821-8000 , Pasquale.Roberge@USherbrooke.ca
                Catherine.Hudon@USherbrooke.ca
                alan.pavilanis@ssss.gouv.qc.ca
                Marie-Claude.Beaulieu@USherbrooke.ca
                Annie.C.Benoit@USherbrooke.ca
                helene.brouillet.cssspb16@ssss.gouv.qc.ca
                Isabelle.Boulianne@USherbrooke.ca
                anna.isbister-depauw.chsm@ssss.gouv.qc.ca
                Serge.Frigon@USherbrooke.ca
                Isabelle.Gaboury@USherbrooke.ca
                Martine.Gaudreault@USherbrooke.ca
                ariane.girard1@uqac.ca
                Marie.Giroux@USherbrooke.ca
                Elyse.Gregoire@USherbrooke.ca
                Line.Langlois@USherbrooke.ca
                Martin.Lemieux@USherbrooke.ca
                Christine.Loignon@USherbrooke.ca
                Alain.Vanasse@usherbrooke.ca
                Journal
                BMC Fam Pract
                BMC Fam Pract
                BMC Family Practice
                BioMed Central (London )
                1471-2296
                13 September 2016
                13 September 2016
                2016
                : 17
                : 1
                Affiliations
                [1 ]Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
                [2 ]St. Mary’s Hospital Center, 3830 Lacombe Avenue, Montreal, QC Canada
                [3 ]CISSS de la Montérégie-Est, 90 Sainte-Foy Boulevard, Longueuil, QC Canada
                [4 ]Université de Sherbrooke, UMF Chicoutimi, 305, St-Vallier, Chicoutimi, QC Canada
                [5 ]Université du Québec à Chicoutimi, 555, Boulevard de l’Université, Chicoutimi, QC Canada
                [6 ]Université de Sherbrooke - Campus de la santé, Groupe de recherche PRIMUS, 3001, 12e avenue nord, Sherbrooke, QC J1H 5N4 Canada
                Article
                531
                10.1186/s12875-016-0531-y
                5020556
                27620166
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: Réseau-1 Québec (through its funding from the Fonds de recherche du Québec Santé, Pfizer, the Quebec Department of Health and Social Services, the Canadian Institutes of Health Research and McGill University)
                Award ID: n/a
                Award Recipient :
                Funded by: Université de Sherbrookes Practice Based Research Network
                Award ID: n/a
                Award Recipient :
                Funded by: Fonds de recherche, dinnovation et de promotion du savoir of the Université de Sherbookes Department of Family and Emergency Medicine
                Award ID: n/a
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2016

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