Журнал депрессии и тревоги
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ISSN: 2167-1044
ISSN: 2167-1044
Michael Kraus
Introduction: Major depression (MD), as a frequent and severe mental disorder, poses important challenges in psychiatric specialist care (SC) as well as in primary medical care (PC). Comparative course data are scarce, but are relevant in order to identify particular needs in health care development. For this, our analysis in an urban Middle East setting aims at providing socioculturally context-related data.
Method: Outpatient samples of subjects with current MD (31 in SC and 38 in PC) were naturalistically followed-up in 4-monthly intervals for one year. Included were only participants with an initial BDI-21-score of at least 17, an age between 18 and 65 years, without psychotic disorders, and with at least two follow-up examinations. Potential predictive variables assessed at baseline included items on sociobiography and psychopathology; parameters regarding treatment (in which participants’ choices were not being limited by the study protocol) were added during the observation time. Severity of depressive symptoms was assessed by the HAM-D-17. Two course groups were compared: those with remissive course, displaying at least one full or partial remission during the follow-up period (RC) against those with non-remissive course (NR).
Results: The SC and PC samples did not differ in their initial HAM-D-17, antidepressant prescription rates, adherence to medication, age, gender, or income distribution. While SC participants received more often higher doses of antidepressants, had more suicidal symptoms, and a worse general health, the most striking difference were the much lower educational levels among the PC participants. In the mean 11-month observational period, rates of RC were higher in SC (71% vs. 47%; p: 0.048). In logistic regression analysis, RC was predicted best by higher education, better marriage concord, and an urban context of origin. Some other gender- and marriage-related parameters (women aged 30 years and more, marital violence, in parts also being divorced or widowed) emerged as predictors with lower prognostic impact. The choice of PC treatment might have been determined in parts by lower education, lack of full health insurance status, and presence of somatization disorder comorbidity.
Discussion: The naturalistic one-year course of MD is poor in PC and not much better in SC. While treatment variables were not particularly linked with the course, lower education was a strong negative prognostic parameter and might explain most of the PC setting’s disadvantage. Indicators of marriage functioning turned out to be the second prognostically relevant area, with alarming high rates of violence and discord. These, together with other genderrelated variables, point to sociocultural conditions which might bring about increased risk for MD chronicity for affected individuals. Improvements in these areas could result in more mental health benefit than optimized medication and should therefore be pursued within mental and general health care.
Limitations: The small sample size impedes generalizations. Scoring of marriage-related parameters was based on a semi-structured interview with only broad classifications. The future application of more sophisticated tools will further help to define high-risk characteristics for MD chronicity in the individual’s close social context.