Improving the role of nursing in the treatment of depression in primary care in Spain

Effectiveness of therapeutic milieu intervention on inpatients with depressive disorder: A feasibility study from North India

PURPOSE

This study examined therapeutic milieu interventions on self-esteem, socio-occupational functioning, and depressive symptoms among inpatients with depressive disorders.

METHODS

A pretest-posttest nonequivalent control group quasi-experimental design was adopted. Sixty participants with depression who got admitted to the general hospital psychiatric ward were assigned to a control (Treatment as Usual) group and an experimental (therapeutic milieu intervention) group nonrandomly using a convenience sampling technique. We evaluated the following outcome measures: self-esteem, socio-occupational functioning, and depressive symptoms for both groups at baseline, 4th, 8th, and 12th weeks.

RESULTS

Therapeutic milieu interventions improved self-esteem, socio-occupational functioning, and reduced depressive symptoms. The findings provided initial evidence for practice.

IMPLICATIONS

Psychiatric nurses can implement simple, milieu therapy interventions in any setting, which will enhance the clinical outcomes and socio-occupational functioning of depressive patients.

A matrix for the qualitative evaluation of nursing tasks

AIMS

To formulate a model for patient-nurse interaction; to compile a comprehensive list of nursing tasks on hospital wards; and to construct a nursing tasks demand matrix.

BACKGROUND

The physical demands associated with nursing profession are of growing interest among researchers. Yet, it is the complexity of nursing tasks that defines the demands of ward nurses' role. This study explores nursing tasks, based on patient-nurse interaction on hospital wards.

METHODS

Extant literature was reviewed to formulate a patient-nurse interaction model. Twenty ward nurses were interviewed to compile a list of nursing tasks. These nursing tasks were mapped against the patient-nurse interaction model.

RESULTS

A patient-nurse interaction model was created, consisting of: (1) patient care, (2) patient surveillance and (3) patient support. Twenty-three nursing tasks were identified. The nursing tasks demand matrix was constructed.

CONCLUSIONS

Ward managers may use a nursing tasks demand matrix to determine the demands of nursing tasks on ward nurses.

IMPLICATIONS FOR NURSING MANAGEMENT

While many studies have explored either the physical or the psychosocial aspects of nursing tasks separately, this study suggests that the physicality of nursing tasks must be evaluated in tandem with their complexity. Ward managers may take a holistic approach to nursing tasks evaluation by using a nursing tasks demand matrix.

Collaborative care regarding major depressed patients: A review of guidelines and current practices

Major Depressive Disorder (MDD) is a severe and common mental disorder. A growing body of evidence suggests that stepped and/or collaborative care treatment models have several advantages for severely depressed patients and caretakers. However, despite the availability of these treatment strategies and guidance initiatives, many depressive patients are solely treated by the general practitioner (GP), and collaborative care is not common. In this paper, we review a selected set of international guidelines to inventory the best strategies for GPs and secondary mental health care providers to collaborate when treating depressed patients. Additionally, we systematically searched the literature, listing potential ways of cooperation, and potentially supporting tools. We conclude that the prevailing guidelines only include few and rather vague directions regarding the cooperation between GPs and specialised mental health practitioners. Inspiring recent studies, however, suggest that relatively little efforts may result in effective collaborative care and a broader implementation of the guidelines in general.

[Effect of an educational intervention on the attitudes of the nurses of primary care on depression]

OBJECTIVE

To describe nurse attitudes toward depression, using a standardized questionnaire and to evaluate how a training workshop can modify or influence these attitudes.

METHODS

A prospective study based on the application of the Depression Attitude Questionnaire, before and six months after, participating in a training day on the nursing role in the management of depression in Primary Care. The sample consisted of 40 Primary Care nurses from 10 health centers in the province of Tarragona.

RESULTS

Nurses are in a neutral position when considering the management of depressed patients as a difficult task, or to feel comfortable in this task, but there is a high degree of acceptance of the claim that the time spent caring for depressed patients is rewarding. In general, there was little significant difference in the mean scores for the different items of the Depression Attitude Questionnaire, before and six months, after the training intervention.

CONCLUSIONS

The attitude towards the management of depression in Primary Care and to the role that nurses can play in this task is generally favorable. Fruitful training and organizational initiatives can be established in order to define and structure the nursing role in the management of depression in Primary Care.

Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: a systematic review

BACKGROUND

For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care.

PURPOSE

To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care.

METHODS

A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP).

RESULTS

In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562.

CONCLUSION

Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Case Study: Community Nursing Care Plan for a Man With Functional and Psychosocial Problems Following a Stroke

PURPOSE

The study aims to use the standardized nursing process to assist a middle-aged man with functional and psychosocial problems following a stroke.

DATA SOURCES

Data were obtained from interviews with the patient during primary care nurse consultations, electronic health record reviews, and reports from other professionals. To build the care plan, we used available scientific evidence, and we also considered a nurse-patient agreement.

DATA SYNTHESIS

We used clinical reasoning with NANDA-I classification, the Nursing Outcomes Classification, and the Nursing Interventions Classification to select nursing diagnoses, patient outcomes, and nursing interventions.

CONCLUSIONS

Psychosocial problems complicate the management of a patient with functional consequences after a stroke. This fact has high impact on people who are going through this process.

Persistence in the long term of the effects of a collaborative care programme for depression in primary care

BACKGROUND

A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring.

METHODS

Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life.

TRIAL REGISTRATION

ISRCTN16384353.

RESULTS

A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance.

LIMITATIONS

The number of patients lost (31%) before follow-up may have introduced a bias.

CONCLUSIONS

Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables.

Cost-effectiveness analysis of a collaborative care programme for depression in primary care

BACKGROUND

Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care.

METHODS

A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007-2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs).

RESULTS

Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane.

LIMITATIONS

The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression.

CONCLUSIONS

The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.

Including nurses in care models for older people with mild to moderate depression: an integrative review

AIMS AND OBJECTIVES

The aim of this integrative literature review was twofold: (1) to investigate different collaborative programmes for older people with depression living at home with diverse access to care and (2) to describe conceptualisation of the nurses' role and interventions within these care models.

BACKGROUND

One in four older people who visits a General Practitioner suffers from depression. Depression is a concern for 15% of all older home-care service clients. Detecting and managing depression in older people is highlighted as a key role of nurses. A literature review has been conducted to investigate collaborative models of care, aimed at ensuring low-threshold access to care and exploring the scope of nurse practice within these models.

METHODS

Literature review comprising 14 studies and reviews.

RESULTS

Three different collaborative care programmes (Collaborative Care Model, Community Mental Health Team and Psychogeriatric Assessment and Treatment in City Housing programme) were identified. In all programmes, the essential aspects were complex and multifaceted interventions, provided by a variety of healthcare professionals, but the access to care differed. All studies described the role of nurses differently and with wide variations.

CONCLUSIONS

Despite a broad scope of practice, nurses play a pivotal role within the different models of care. Nurses have to have the educational background and expertise in mental health issues to recognise depression and eventually be able to provide more comprehensive interventions to alleviate depression in older people.

RELEVANCE TO PRACTICE

Collaboration is needed to meet the needs of older people with depression. New forms of work divisions are pivotal to achieve this objective.

Effectiveness of a multi-component programme for managing depression in primary care: a cluster randomized trial. The INDI project

BACKGROUND

There are significant shortcomings in the management and clinical outcomes of depressed patients. The objective is to assess the effectiveness of a multi-component programme to improve the management of depression in primary care.

METHODS

This is a cluster-randomized controlled trial, conducted between June 2007 and June 2010. Twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a multi-component programme with clinical, educational and organizational procedures including primary care nurses working as case-managers. Outcomes were monitored by a blinded interviewer at 0, 3, 6 and 12 months.

TRIAL REGISTRATION

ISRCTN16384353, at http://isrctn.org.

RESULTS

In total, 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 12 months, 302 patients were assessed, 172 in the intervention group and 130 in the control group. The severity of depression (mean Patient Health Questionnaire-9 score) was 1.76 points lower in the intervention group [7.15 vs. 8.78, 95% CI=-3.53 to 0.02, p=0.053]. The treatment response rate was 15.4% higher in the intervention group than in the controls [66.9% vs. 51.5%, odds ratio 1.9, 95% CI=1.2 to 3.1, p=0.011)], and the remission rate was 13.4% higher [48.8% vs. 35.4%, odds ratio 1.8, 95% CI=1.1 to 2.9, p=0.026)].

LIMITATIONS

Unblinded physicians diagnosed depression in their patients and decided whether to include them in the study, so we cannot discount a hidden selection bias.

CONCLUSIONS

The programme for managing depression leads to better clinical outcomes in patients with major depression in primary care settings.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

Overview of depression: epidemiology and implications for community nursing practice

Depressive disorders are among the most common psychological conditions currently affecting individuals living in the Westernized world. Yet, available data indicate that fewer than one third of adults with depression obtain appropriate professional treatment. This is attributed, among other reasons, to the under-recognition of the problem by health professionals, including district nurses. In order to improve recognition of the problem, it is imperative for nurses and especially those working in community settings, to appreciate the importance of prompt diagnosis which presumes both an understanding and knowledge of basic aspects of the problem and, an understanding of their role in dealing with depression. This overview presents epidemiological data and identifies the potential consequences of depression on daily functioning and other aspects of life among adults in Westernized countries, aiming to raise awareness and sensitize district nurses about the issue The article discusses how the role of district nurses can be enhanced to improve recognition rates.

[Attitudes and opinions of family doctors on depression: application of the Depression Attitudes Questionnaire (DAQ)]

AIM

To describe the attitudes of General Practitioners (GPs) towards depression in Primary Health Care Centres.

DESIGN

Cross-sectional study based on the application of a standard questionnaire.

SETTING AND PARTICIPANTS

A total of 112 GPs from all of the 20 Primary Health Care Centres in the Tarragona-Reus Primary Care Area (Catalan Health Institute).

MEASUREMENTS

A Spanish adaptation of Depression Attitudes Questionnaire was used.

RESULTS

A total of 88.4% of doctors agreed there was an increase in the number of depressive patients in recent years. Around half of the GPs thought that depression in Primary Health Care Centres are due to the adversities of life, but 72.3% considers that there is a biological root in severe depressions. A large majority (81.2%) of doctors believed that antidepressants used in Primary Care are efficient and the majority values psychotherapy as a useful therapeutic option. There is an agreement in the role of nursing staff when attending depressed patients. The role of psychiatric referral when a satisfactory result is not obtained in Primary Care is recognised. Although 64.3% of doctors consider that dealing with depressed patients is hard work, but 57.1% feel comfortable and only 19.7% think it is an unpleasant job.

CONCLUSIONS

In general, there is a favourable predisposition to deal with depression in Primary Care where training and organisational initiatives can be introduced to improve clinical outcomes of depression in Primary Care.