Screening for depression patients in family medicine.

GOAL: The aims are to establish the prevalence of newfound, unidentified cases of depressive disorder by screening with the Becks Depression scale; To establish a comparative relationship with self-identified cases of depression in the patients in the family medicine; To assess the significance of the BDI in screening practice of family medicine. PATIENTS AND METHODS: A prospective study was conducted anonymously by Beck's Depression scale (Beck Depression Questionnaire org.-BDI) and specially created short questionnaire. The study included 250 randomly selected patients (20-60 years), users of services in family medicine in "Dom Zdravlja" Zenica, and the final number of respondents with included in the study was 126 (51 male, 75 female; response or response rate 50.4%). Exclusion factor was previously diagnosed and treated mental disorder. Participation was voluntary and respondents acknowledge the validity of completing the questionnaire. BDI consists of 21 items. Answers to questions about symptoms were ranked according to the Likert type scale responses from 0-4 (from irrelevant to very much). Respondents expressed themselves on personal perception of depression, whether are or not depressed.
RESULTS: Depression was observed in 48% of patients compared to 31% in self estimate depression analyzed the questionnaires. The negative trend in the misrecognition of depression is -17% (48:31). Depression was significantly more frequent in unemployed compared to employed respondents (p = 0.001). The leading symptom in both sexes is the perception of lost hope (59% of cases).
CONCLUSION: All respondents in family medicine care in Zenica showed a high percentage of newly detected (17%) patients with previously unrecognized depression. BDI is a really simple and effective screening tool for the detection and identification of persons with symptoms of depression.

1. INTRODUCTION

Depressive disorder is one of the most severe mental problems. Depression isn’t just one of the illnesses described earlier in the history of medicine, but in most often mental disorders today (1). Ranges from very mild condition that borders to normal to an serious depression with a belief in something that isn’t true. Depression is a disease characterized by lowered mood under the influence of which there are changes in thinking, perception, physical condition, behavior and social functioning of a person. Other symptoms that may be present are sleep disturbances, decreased appetite, decreased concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, black and pessimistic views of the future and the idea of self-harm or suicide. Also may be present various somatic symptoms. Typical symptoms of depression include depression, loss of interest and pleasure, decreased energy and increased fatigue. It is rather a mood disorder, not disorder of thinking or cognitive processes (2, 3, 4, 5). The diagnosis is made regardless of circumstances in which symptoms occur (important external stress factors or other significant psychological factors that could contribute to depressive disorders appears), includes all the individual episodes of various forms of depression (3, 4, 5). It is established when is satisfied the criteria of minimum number of symptoms required for diagnosis and criteria of duration symptoms for a minimum of 2 weeks (2, 3).

The word “depression” comes from the Latin word deprimere–suppressed, dent or crush. The basic characteristics of this disease are feeling sad, pessimistic concerns, self-blame, suicidal ideas, insomnia, anorexia and psychic asthenia. These feelings can be very intensive so that suicide can be considered as the only solution (in 15% of cases) (6, 7, 8, 9, 10, 11).

In Bosnia and Herzegovina, the diagnosis of depression is set according to the international ICD 10 classification, according to which diagnosing the first episode of diseases should be by using code F 32, and all other episodes of illness are marked with code F33 as repeated depressive episodes (2, 3).

Despite the prevalence of depression and the fact that each doctor daily encounters it, unfortunately depression often remains unrecognized. Even in 50% of cases it is not recognized serious form or “Major Depression”. According to some researchers, only ½ of depressed patients are treated in general, and only ¼ is adequately treated, long enough and with enough high doses of the drugs, which induced us to this study (6, 7, 8, 9, 10, 11). We wanted to test the hypothesis that is significant percentage of unrecognized depression in patients who are treated in family medicine.

2. MATERIAL AND METHODS

This study was approved by the Ethics Committee of the Health Center “Dom Zdravlja” in Zenica. It was conducted among patients of the family medicine team in March and April 2009. The chosen method of research was survey of respondents by self-responding questionnaire of Beck Depression Scale and the associated questionnaire. It included 250 users of the outpatient services at age from 20-60 years. Exclusion factor in the study were patients with diagnosed and treated depression or another mental disorder.

Beck Depression Scale

For detection of depression symptoms it was used The Beck Depression Inventory (BDI). Becks scale is now in use as a simple and effective screening tool for the detection and identification of persons with symptoms of depression (Beck, 1961). It contains a total of 21 questions. The main feature of the BDI is to measure the severity of the depression. Symptoms that were evaluated in this questionnaire are: 1) mood disorders; 2) loss of hope; 3) feelings of rejection; 4) inability to enjoy; 5) feelings of guilt; 6) need for punishment; 7) hatred of oneself; 8) self-condemnation; 9) tendency to suicide; 10) tearfulness; 11) irritability; 12) disturbances in relation to the others; 13) indecisiveness; 14) negative self-image; 15) disability for work; 16) disturbed sleep; 17) fatigue; 18) lack of appetite; 19) weight loss; 20) hypochondria; 21) loss of libido. The answer to each question was scored 0-3. Results are calculated by adding the number of responses received. The lowest score is 0, and the 63 is the maximum score. If the score is between 0-10 there is no signs of depression, between 11-16 points indicate mild depression, between 17-20 points depression (a borderline case), from 21-30 points moderate depression, serious depression represents scores of 31-40 and over 41 points to extremely pronounced depression. Anything over 17 points requires professional treatment.

Questionnaire

Questionnaire which was specially created for this study consisted beside respondent opinion that he/she has depression, information about age, sex, education, employment status, marital status, presence of other diseases and medication use.

Statistical analysis of data

For the analysis of results it was used statistical package for social research (SPSS) version 12.0. In the statistical analysis of results were used standard methods of descriptive statistics. To test the statistical significance of differences of selected variables were used nonparametric χ2-tests. Basic socio-demographic data were presented descriptively. Statistical hypotheses were tested at a level of α=0.05.

3. RESULTS

The average age of the patients was 43.28±15.19 years. The presence of depression was explored in a sample of 126 subjects, 51 men and 75 women. With depression there was 58 subjects (46%), 30 women (52%) and 28 men (48%). According to the self-assessment questionnaire 31% of respondents said that they have depression.

In 58 of 126 (46%) of respondents by BDI scores depression was detected in 30 women and 28 men (50% vs. 48%; ratio 1.07, p <0.05, Figure 1). A large number of people before the survey were not considered as depressed (69%), and misrecognition of disease more frequent were women (73%) than men (64%). Comparing the age structure of the respondents, the results have shown that depression is most common between the ages of 30-39 in both sexes (38%). In men, depression often occurs in a period of 30-50 years, equally often in the third and fourth decade of life (36%). Most common in women is between 30-39 years (40%). In relation to employment, more frequent depression is among the unemployed (60%, Table 1).

Figure 1

The prevalence of depression in the total sample of respondents

Table 1

The demographic characteristics of the respondents by gender, age, recognized depression, diagnosed depression, employment situation, the degree of depression (n126).

The leading symptom in a sample of depressed individuals was the loss of hope in both sexes (59%), which is the most common symptom of depression in men (44%), while in women is prevalent mood disorder (70%). The most common symptoms of depression include: mood disorders, loss of hope, inability to work, loss of appetite and loss of libido. The largest number of depressed patients had a loss of hope (34 respondents), which was also the most common symptom in men (15 respondents) while dominant symptom in depressed women was mood disorder (21 respondents, Figure 2).

Figure 2

Distribution of the most frequent symptoms of depression in the total sample

According to the distribution of BDI newfound depression was detected in 33 respondents (57%) with mild depression, 16 respondents (27) with moderate and 9 with a severe form of the disorder. Usually it was present a mild depression (10 %) in both sexes, but severe depression 2 times more common in women (Table 2. Figure 3)

Table 2

BDI classification of depression according to gender. *χ2 test; Kruskal Wallis test

Figure 3

Distribution of respondents to whom is discovered depressive disorder according to the classification of disease (severity and seriousness)

4. DISCUSSION

Depression is a disease with “hundred faces”. It can be represented by different clinical pictures, from melancholy to severe depression. Typical symptoms are: depressed mood, loss of interest and pleasure, decreased energy and increased fatigue. Other common symptoms are: disturbed sleep, reduced or increased appetite, decreased concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, black and pessimistic view of the future and the idea of self-harm and injury (Jakovljevic 1998). It is often thought that depression is just a general malaise, a reflection of lower value or “something that solves with strong will and a firm faith in God”. All of this is because of misconceptions, myths and ignorance about depression in the general population so lot patients don’t seek for professional help. Our research confirmed that. We found that 17% of depressed patients do not considered depression like health problem which needs treatment. In fact, they are likely candidates for preventive activities and timely treatment to combat chronic feedback depressive disorder (12, 13, 14, 15, 16).

According to the results from series of studies conducted that in Europe and worldwide, current prevalence of depressive disorders ranges from 5-10% depending on evaluated population (5, 6, 7, 8, 9). The World Health Organization (WHO) and the World Bank in 1996 published results of the global burden of disease which included 96 most common diseases in the world. Depression is the fourth on the list and it is estimated that it will be relegated to second place by 2020. Study of global burden disease from 2000 estimates that the current prevalence of unipolar depression is 1.8% for men and 3.2% for women. Research results on prevalence of depression depends heavily on the evaluated population. According to the report of ODIN study (European Outcome of Depression International Network) prevalence rates of depressive disorders in five European countries was 8.56%. However, the values vary widely among centers and ranging from 1.8% (urban Spain) to 15.01% in the UK (4). In Croatia the depressive disorders were on second place by hospitalizations in the 2002; women with a share of 16.3% and depressive disorders in man were on fourth place of hospitalizations with a share of 5.4%. Mental health disorders registered in 2008 showed increasing trend compared to 2007 for 16% (5). According to the latest data 40% of population in Bosnia and Herzegovina (BiH) is suffering from depression and it's also approximate prevalence in the world. Access to data of the Institute for Health Protection of Bosnia and Herzegovina (BiH) and analyzing reports about diseases and conditions in the service of primary care (family medicine) has not been possible to get accurate data on the prevalence of depression in BiH, as in Chapter V, section 71st Mood disorders (F30-F39) recorded together (6)

Depression can occur at any age. In previous studies, the highest prevalence was observed in older/middle age (50-64 years), but some recent studies reports gives us information that the highest prevalence is in young adults. This suggests that the average age of newfound was shifted to an earlier age (17, 18, 19, 20).

Women suffering from depression more likely and the ratio is from 1:1.5 to 1:2 compared to men. The results of our study did not show it as indicated by the ratio was statistically significant and amounts 1.07. Maybe men do not seek for help when they have a depressive disorder or its about a stigma (13). Often because of the stigma and misconceptions among people who suffer from symptoms of severe depression (“it does not happen to us”) happens that they never seek for psychiatric help. It also happens that they belittle signs or symptoms and act according to the principle of self-treatment or seek help away from the place of residence. Depressive disorders are of importance in family medicine because they are the most common mental disorders whose incidence has been increasing continuously since the beginning of the last century. Epidemiological studies show that every fifth women and one of ten men during life experienced at least one serious depressive episode. Besides its connected with losing of life joy, according to WHO data, it is the most common cause of work disability in the world. All this leads us to the conclusion that this is a public health problem (19, 20). On the other side, ten years ago it was thought that the treatment of depression can be carried out only by psychiatrists, but because of increasing rate today, the first line of treatment are doctors in primary care and family physicians (2, 3, 4, 5, 21, 22). Depression disorder is relevant for family medicine because it is present in a large number of people, but it is not given enough attention on that. Every patient who suffers from depression is a separate case and every reason human suffering should be a subject of interest for family physicians (1, 2, 17, 19, 20, 21).

5. CONCLUSION

Depression is a common health problem especially for patients in the third decade. Increases the number of men suffering from depression which proved to be true in our research. Depression is more common among unemployed people, so about 60% of depressed patients were unemployed. In both sexes usually occurs mild depression that could be prevented with adequate psychotherapy access and rehabilitation, but applied on time (18). BDI screening would be a good instrument for the suppression of permanent mental disorder in practice of family doctor.