Family Practice Vol. 19, No. 4, 397-400
© Oxford University Press 2002
Depression in primary care. A nationwide epidemiological survey
Institute of Psychiatry, Bologna University,
a Italian Society of General Practitioners,
b Villa Baruzziana Clinic,
e Mental Health Department, Local Health Unit, Bologna,
d Mental Health Department, Local Health Unit, Bologna Sud,
f Niguarda Hospital, Milano, Italy and
c Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA, USA.
Professor Domenico Berardi, Istituto di Psichiatria, Viale Pepoli, 5, 40123 Bologna, Italy; E-mail: dberardi{at}alma.unibo.it
Berardi D, Leggieri G, Berti Ceroni G, Rucci P, Pezzoli A, Paltrinieri E, Grazian N and Ferrari G. Depression in primary care. A nationwide epidemiological survey. Family Practice 2002; 19: 397–400.
Received 30 March 2001; Revised 15 October 2001; Accepted 11 March 2002.
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Abstract |
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Background. Most epidemiological studies on depression in primary care are conducted at single sites, and variations in reported prevalence may depend on characteristics of health care services and other local factors.
Objectives. Our aim was to investigate the prevalence of depression in primary care in Italy and its association with physical illness, disability and health care utilization.
Methods. This nationwide epidemiological study involved 191 primary care physicians (PCPs) who assessed during one index week 1896 patients aged 14 and over attending their clinics. Screening was conducted by using the General Health Questionnaire-12. Probable cases were assessed by PCPs with the WHO ICD-10 Checklist for Depression and rated for severity of physical illness.
Results. The prevalence of current depression ranged between 7.8 and 9.0% in the three main Italian areas, with no significant variations. A linear increase from North to South was observed for psychological distress, disability and frequency of medical consultation. Depression was associated with severe, but not with mild or moderate physical illness. Depression was also associated with disability and accounted for an increased rate of consultation.
Conclusion. Because of the disability associated with depression and of its impact on health care utilization, guidelines and intervention strategies are needed.
Keywords. Depression, disability, health service utilization, primary health care, physical co-morbidity.
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Introduction |
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Depression represents an important public health problem in which primary care physicians (PCPs) play a pivotal role. Most of the epidemiological studies on depression in primary care were conducted at single sites.1–4 The impact of local factors and methodological differences may limit the comparability among studies and may partly account for variations in reported prevalence figures, ranging between 3.3 and 15.3%. The present nationwide epidemiological survey has been undertaken by the Italian Society of General Practitioners, in co-operation with the Institute of Psychiatry of Bologna University, to provide the 1-week prevalence of depression in primary care in Italy and to analyse the association of depression with physical illness, disability and health care utilization.
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Methods |
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In each administrative region of Italy, a PCP co-ordinated 10 colleagues working both in urban and rural areas and trained them in the use of the instruments. During an index week, each PCP randomly selected 10 adult patients among those attending the out-patients department. Patients with cognitive impairment, inability to read or write or medical illness that would prevent completion of the interview were excluded (n = 35). Seventy-nine subjects refused to participate. In case of exclusion or refusal, the next patient was enrolled until each PCP obtained a total of 10 cases.
Patients gave written informed consent and completed the General Health Questionnaire-12 (GHQ)5 and the Brief Disability Questionnaire (BDQ)1. The PCPs assessed severity of physical illness on a 5-point Likert scale, and recorded psychiatric diagnosis, frequency and reason for consultation using forms adopted in the WHO PPGHC study.1 Patients scoring 
5 on the GHQ were assessed by the PCPs using the WHO ICD-10 checklist for depression.6 This consists of 21 symptoms and was used to diagnose a current episode of depression, according to ICD-10 classification.7
t-test and one-way analysis of variance were used to compare means of continuous variables among two or more groups, respectively. Chi-square was used to compare the frequency of categorical variables among groups. We adopted a conservative significance level of alpha = 0.01. Logistic regression was used to analyse the association between depression and physical illness. Continuous variables are reported throughout as mean ± SD. Data were analysed using SPSS for Windows, version 6.0.
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Results |
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The study was conducted in 18 of the 20 Italian regions. The two smallest regions, Valle d'Aosta and Molise, did not participate because of difficulties in recruiting a sufficient number of PCPs. Out of the 198 PCPs who were asked to participate, 191 completed the study (72 from the North, 41 from the central region and 77 from the South). Most PCPs (130) came from urban areas with >15 000 inhabitants, and 61 practised in rural areas. Most physicians were male (n = 161), and their mean age was 42.9 years. All were established physicians with an average of 14 years of practice and ~1500 patients on their list.
Demographic and clinical characteristics of the sample are shown in Table 1
. The overall prevalence of current depression was 8.4% [95% confidence interval (CI) 7.2–9.6] and the severity of the index episode was mild in 57.5% of cases, moderate in 36.3% and severe in 6.2%. There was no difference in prevalence of depression between the North (9.0%, 6.9–11.1), the central region (7.8%, 5.2–10.4) and the South (8.3%, 6.3–10.3). Severity of physical illness, as rated by the PCPs, was not associated with depression in bivariate analyses. Then, we analysed the relationship between physical illness and depression adjusted for gender and age (14–59 versus 60 years), using a logistic regression model. In this model, female gender [odds ratio (OR) = 2.1, 95% CI 1.4–3.2] and severe physical illness versus no illness (OR = 2.3, 95% CI 1.0–4.9) were significantly associated with current depression. Disability and frequency of medical consultation were significantly higher in patients with depression than in those not depressed (Table 2).
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Discussion |
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The present study is the first national survey on depressive disorders in primary care in Italy, and one of the few ever published in the literature. The overall prevalence of ICD-10 current depression was 8.4%. This estimate is rather stable throughout the country, and can be considered as a reliable proxy for the morbidity that Italian PCPs observe in their current practice. Moreover, it is in line with the worldwide prevalence of 10.4% reported in the WHO PPGHC Study,1 using the same diagnostic criteria. Previous single-site Italian studies indicated a lower prevalence of depression (4.7% in Verona1 and 3.3% in Bologna2). These lower figures may depend on the fact that the studies were conducted in two wealthy north-eastern towns, with well-developed public psychiatric services and with a long-standing collaboration between psychiatry and primary care.
Physical co-morbidity of depressive disorders in primary care has been investigated extensively, but results are still controversial. Previous studies1,2 found a weak association between physical illness and psychiatric disorders, suggesting that in primary care psychiatric disorders are in most cases independent of physical ill health. However, studies focused on subsamples of PCP patients with physical illness consistently observed psychiatric co-morbidity.8 The results of the present study show that a relationship between physical illness and current depression exists, but is limited to cases with severe physical illness, while mild and moderate physical illness is not associated with a higher prevalence of depression. Co-morbid patients, who deserve special attention and integrated treatment from PCPs, are, however, a small minority of the cases of depression seen by our PCPs (6%). The majority (94%) of patients with depression are not affected by severe physical illnesses and, in these cases, the depressive disorder represents the main health problem.
As reported in a number of studies,1,9 depression was associated with significant disability. Although depression is mild in most cases, the proportion of depressed patients with significant disability was ~3-fold that among patients without depression. Depression also accounted for an increased frequency of medical consultations.10 Our study showed that 27.7% of patients with current depression were frequent PCP attenders, as compared with 12.8% of the non-depressed patients. These data underline the importance of proper management of this disorder in primary care. Somatic presentation may hinder recognition and management of depression in primary care. Only 41% of depressed patients presented with psychological distress or family problems, while the rest of the sample did not complain overtly about psychological problems. Our results suggest that, in the absence of serious illness, an increased number of visits may represent an indicator of depression, whatever the reason for consultation.
Some methodological limitations in our study must be acknowledged. We did not include a sample of GHQ-12 low scorers, which might have led to an underestimation of the prevalence of depression. Characteristics of patients who refused to participate in the study were not recorded. Also, PCPs were not selected randomly, but were enrolled on the basis of their willingness to participate, which might reflect their interest in and sensitivity to psychological problems.
In conclusion, the relevance of depression observed in the present study calls for health policies addressing this problem. We believe that large studies such as the present one can improve the knowledge and may contribute to modify the attitude of PCPs who provide care for patients with depression.
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Acknowledgments |
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We thank Paolo Carbonatto, Mauro Pigni, Mauro Bertoluzza, Marcello Zancan, Romano Paduano, Alberto Gianmarini Barsanti, Giuseppe Landini, Giancarlo Rasconi, Mario Vichi, Luigi Milani, Damiano Volpone, Pasqualino Lalli, Nicola Tarallo, Gaetano Piccinocchi, Salvatore Moretti, Cosimo Nume, Gennaro Gadaleta Cardarola, Antonio Pompeo Coviello, Bruno Cristiano, Francesco Anello, Sebastiano Romano, Antonio Pinna, Tiziano Scarponi, Alessandro Rossi and Emilio Angioli for study co-ordination. This project was carried out with the support of the Italian Society of General Practitioners and the commitment of the participating PCPs. The study was funded by an Eli-Lilly grant.
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References |
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1 Üstün TB, Sartorius N. Mental Illness in General Health Care: An International Study. Chichester: John Wiley, 1995: 323–334.
2 Berardi D, Berti Ceroni G, Leggieri G, Rucci P, Ustun B, Ferrari G. Mental, physical and functional status in primary care attenders. Int J Psychiatry Med 1999; 29: 133–148.[Web of Science][Medline]
3 Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992; 14: 237–247.[Web of Science][Medline]
4 Spitzer RL, Williams JBW, Kroenke K et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. J Am Med Assoc 1994; 272: 1749–1756.
5 Goldberg DP, Williams P. A User's Guide to the General Health Questionnaire: GHQ. NFER-Nelson: Windsor (UK), 1988.
6 Janca A, Ustun TB, Early TS, Sartorius N. The ICD-10 symptom checklist. A comparison to the ICD-10 classification of mental and behavioral disorders. Soc Psychiatry Psychiatr Epidemiol 1993; 28: 239–242.[Medline]
7 World Health Organization. International Classification of Diseases (10th version). Geneva: WHO.
8 Kisely SR, Goldberg DP. Physical and psychiatric comorbidity in general practice. Br J Psychiatry 1996; 169: 236–242.
9 Wells KB, Stewart A, Hays RD et al. The functioning and well-being of depressed patients. Results from the medical outcomes study. J Am Med Assoc 1989; 262: 914–919.
10 Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community. J Am Med Assoc 1992; 267: 1478–1483.
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