détails de la fiche synthèse
Référence complète de l'étude
Houle, J., Villaggi, B., Beaulieu, M.-D., Lespérance, F., Rondeau, G., & Lambert, J. (2013). Treatment preferences in patients with first episode depression. Journal of Affective Disorders (accepté pour publication).
Préblématique et cadre théorique
In Canada, over one out of ten people (12%) will suffer from depression at one point in their lives (Patten et al., 2006). This mental disorder is characterized by a strong recurrence rate. During the first year following recovery, between 21% and 37% of patients experience a second episode of depression and this rate can reach 85% after 15 years (Hardeveld et al., 2010). Psychotherapy and antidepressants are the two main treatments for depression (CANMAT, 2009). In order to avoid relapses, people suffering from depression must properly adhere to their prescribed treatment. In the case of antidepressants, the recommended minimum duration of treatment is 6 to 12 months, yet 30% of patients stop taking their medication in the first 30 days and over 40% stop in the first three months (Olfson et al., 2006). As for psychotherapy, according to Canadian recommendations a minimum of 12 visits are needed, but only 60% of patients having begun psychotherapy receive this much treatment (Duhoux et al., 2012)
Under current guidelines, health professionals and, in particular, physicians need to take patient preferences into account in order to encourage adherence and effective treatment of depression (Trivedi et al., 2007; APA, 2000; NICE, 2009). Patients obtaining their preferred treatment (whether psychotherapy or pharmacotherapy) is associated with the best clinical results, particularly in terms of better remission rates but also in terms of a more significant reduction in depressive symptomatology (Clever et al., 2006; Gelhorn et al., 2011; Kocsis et al., 2009; Loh et al., 2007; Lin et al., 2005; Mergl et al., 2011). Persons suffering from depression often have very clear preferences (Churchill et al., 2000; Dwight-Johnson et al., 2000) and want to play an active role in treatment selection (Stacey et al., 2008; Arora and McHorney, 2000). While physicians generally prefer antidepressants, patients often prefer psychotherapy (Van Schaik et al., 2004; Löwe et al., 28; Khalsa et al., 2011; Churchill et al., 2000; Dwight-Johnson et al., 2000; Iacoviello et al., 2007; Mergl et al., 2011).
The rare studies that have examined the predictors of preferences in treatment of depression indicate that women are more likely than men to prefer psychotherapy (Churchill et al., 2000; Dwight-Johnson et al., 2000; Garcia et al., 2011; Givens et al., 2007; Khalsa et al., 2011), but few studies have examined the influence of education and income level (Morey et al., 2007). People who prefer antidepressants to psychotherapy tend to subscribe more to biomedical explanations of illness (Khalsa et al., 2011; Garcia et al., 2011), but representations concerning the illness’s chronic nature, seriousness and consequences have not been associated with treatment preferences. Prior studies dealt with samples that were very heterogeneous in terms of treatment history. We know nothing of the preferences of individuals with a newly diagnosed first episode of depression when they are offered treatment for the first time. Primary care physicians rarely consider the treatment preferences of their depressed patients (Young et al., 2008). Better knowledge of the factors associated with the preferences expressed by patients could prove useful to physicians. It could help them tailor their discussions with patients to treatment preferences and provide appropriate information that supports shared decision making.
Méthodologie de l'étude
Description de la ou des méthodes utilisées
Illness representations of depression (IPQ-R), treatment acceptability and preferences were assessed in 88 newly diagnosed patients with first episode depression. Other measures recorded: gender, age, education level, income, psychiatric comorbidity, depressive symptomatology (PHQ-9), a family history of depression, and current treatment of depression. Multiple logistic regression was used to identify factors associated with a preference for psychotherapy.
Échantillon(s) et période(s) de collecte des données
A total of 480 persons contacted the research coordinator to participate to the study, 337 were excluded for not meeting our inclusion criteria, and 55 refused to participate after being informed of the participation expected from them. Participants were recruited from September 2010 to April 2012. A financial compensation of $20 was offered for completing the questionnaire. A total of 88 persons participated in the study (61% participation rate).
Results suggest that most persons with newly diagnosed first episode depression prefer one of the two recognized treatments over the other. This preference is influenced by several factors, including the person’s gender, level of education, and family history. It is also strongly influenced by the patient’s personal evaluation of certain characteristics of the treatment, i.e. its effectiveness, appropriateness, suitability, ease of adherence and convenience.
Psychotherapy is the preferred mode of treatment among individuals with a newly diagnosed first episode of depression, despite the fact that it is considered more demanding than antidepressants. This study therefore confirms prior observations in samples of persons who were not clinically depressed or not formally diagnosed (Van Schaik et al., 2004; Löwe et al., 28; Khalsa et al., 2011; Churchill et al., 2000; Dwight-Johnson et al., 2000; Iacoviello et al., 2007; Mergl et al., 2011). Antidepressants are perceived by persons in a first episode of depression as having serious side effects, and this perception may help make antidepressants less preferred as a treatment. Physicians do not provide their patients with much information when they prescribe antidepressants (Young et al., 2006). However, many patients could be reassured if they received education on the side effects of antidepressants, combined with an opportunity to modify the treatment if it proves too toxic. This approach could change their preferences. When physicians provide information to their patients on antidepressant treatment (minimum required duration, expected side effects, the need to continue treatment even if they start to feel better), patients are better informed and more likely to demonstrate better adherence to treatment (Brown et al., 2007; Bull et al., 2002; Bultman and Svarstad, 2000; Lin et al., 1995).
These results also suggest that individuals who prefer psychotherapy are at a disadvantage compared to those who prefer antidepressants. Only 50% of the participants who preferred psychotherapy received it, compared to 96% of the persons who preferred medication. Many factors may help explain this situation. First, it is more difficult to gain access to psychotherapy than it is to antidepressants, which are available at a modest cost in all pharmacies. Significant barriers can adversely affect the accessibility of psychotherapy, including its cost, time constraints, lack of knowledge about how to go about consulting with a recognized psychotherapist, the difficulty finding such a resource person nearby, waiting lists for consultations, etc. (Mohr et al., 2006; Mohr et al., 2010). It is also possible that physicians do not recommend psychotherapy to patients suffering from depression or do not refer them to professionals deemed able to provide psychotherapy, such as psychologists or social workers (Piek et al., 2011; Richards et al., 2004; Wang et al., 2003). But psychotherapy is effective in primary care, particularly when patients are referred by their family physicians (Cuijpers et al., 2009). Neighbourhood medical clinics rarely have psychologists on-site, easily accessible to patients. Physicians would undoubtedly be more inclined to refer their patients to psychologists if they are regularly in contact with psychologists, such as by working in the same clinic (Craven and Bland, 2006).
This study indicates that three out of four women prefer psychotherapy to antidepressants, while men are more evenly split between the two types of treatment. Previous studies have shown that being female is positively associated with a preference for psychotherapy (Churchill et al., 2000; Dwight-Johnson et al., 2000). Since women are more likely to talk about their emotions and distress (Komiya et al., 2000; O’Loughlin et al., 2011), it is possible that the ease with which they express feelings may explain part of this preference. However, even though men’s reticence to ask for professional psychological assistance when they are experiencing emotional distress has been well documented (Berger et al., 2005; MacKenzie et al., 2006; Mojtabai et al., 2006; Oliffe et al., 2012; Johnson et al., 2012; Pedersen and Vogel, 2007), it is surprising to observe that close to half of the men in our sample (43%) preferred psychotherapy. These results therefore qualify the literature on men’s lack of interest in psychotherapy. It is important that physicians, when making diagnoses of depression, take the time to confirm with their male patients whether they have a preference for psychotherapy and, if they do, to propose resources that could help them gain access to this type of treatment. Physicians are less likely to refer men to psychotherapy than they are to refer women (Alvidrez and Arean, 2002).
This study has revealed an association between level of education and treatment preference. Individuals with a university degree are more likely to prefer psychotherapy than those with less education. There are several potential explanations for this finding. Psychotherapy requires talking about your suffering, emotions and problems. Patients must be able to express themselves well, and be ready to spend a considerable amount of time and energy treating their depression. These two characteristics may be more often found in people with more formal education. Furthermore, a university degree usually leads to a higher salary, which removes or at least considerably reduces the financial obstacle to receiving psychotherapy.
According to this study, someone with a family member who has already suffered from depression is more likely to prefer psychotherapy. It is possible that such individuals consider talking about their depression less of a taboo; family experience may have reduced the stigma surrounding the illness (Wang and Lai, 2008). They may also attribute their depression to events in their childhood that they would like to explore in psychotherapy.
Representations of depression are also associated with treatment preferences. These results indicate that persons who prefer psychotherapy believe that their depression has more serious consequences on their lives than those who prefer antidepressants. These individuals are more inclined to attribute their depression to social causes, such as marital, family or interpersonal problems. These representations may make a patient more motivated to undertake psychotherapy and to invest the time, money and energy required to learn different strategies for solving problems in their personal relationships and mitigate the negative impacts of their depression. Antidepressants act on depressive symptomatology but not on the individual’s ability to maintain harmonious relationships. Knowledge of patients’ representations of illness may help physicians recommend treatment that their patients will find more appropriate and will not abandon prematurely. Shared decision making needs to be encouraged, due to its positive impact on adherence to treatment and clinical results (Kocsis et al., 2009; Clever et al., 2006; Loh et al., 2007; Lin et al., 2005; Mergl et al., 2011).
It is important that physicians, when making diagnoses of depression, take the time to confirm with their male patients whether they have a preference for psychotherapy and, if they do, to propose resources that could help them gain access to this type of treatment. Physicians are less likely to refer men to psychotherapy than they are to refer women (Alvidrez and Arean, 2002).
Hommes (47) et femmes (41) adultes de la région de Montréal, Outaouais et de la Capitale-Nationale nouvellement diagnostiqués d’un premier épisode de dépression.
Objectifs et hypothèses
This study examines treatment preferences among individuals treated in primary care for a first episode of a major depression. It has two objectives: (1) to describe perceptions of psychotherapy and antidepressants among individuals with a newly diagnosed first episode of depression; (2) to identify the main correlates of treatment preferences, including patient characteristics (sex, age, level of education, income and psychiatric comorbidity), illness representations and perceived social stigma.
Mots-clésPréférence, traitement, dépression, patients, Montréal, Outaouais, Capitale-Nationale, Hommes