ArticlesTreating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial
Introduction
Depression is a major public health problem in rich and poor countries, and is especially common in women, and in particular in women who are socially disadvantaged.1, 2, 3, 4 In primary care, depression is highly prevalent and almost twice as common in women as in men.5 Access to mental-health specialists in developing countries is inadequate, especially for the poorest sectors of society, so most depression is treated in primary care. However, management of depression in primary care is disorganised and often ineffective in rich and in poor countries. Depression is often unrecognised, and initiation and adherence to effective treatment is usually poor.5, 6, 7, 8, 9 Results of clinical trials and comparative studies have shown the potential effectiveness of drug treatment or brief structured psychotherapy.10, 11, 12, 13 Unfortunately, this potential is seldom realised. Treatment of depression often consists of more than one therapeutic component used as part of a complex sequence of management decisions with the ultimate goal of overall improvement. Thus, in sequential, multicomponent programmes (stepped-care model), patients without severe depression receive low-intensity treatment, which is followed-up with intensive management if they do not respond.14 Some components, such as systematic monitoring and brief psychological interventions, can be effectively delivered by trained non-medical personnel, reducing costs and demands on family practitioners.15, 16
Primary-care clinics are the main source of care for almost every poor person in Chile. These clinics are underfunded and insufficiently resourced, but most have nurses, social workers, auxiliary nurses, midwives, and doctors. Primary-care physicians are in short supply and most have little formal training in primary care. These doctors typically see six-to-ten patients per hour. Most clinics have established programmes, usually led by nurses, for chronic medical conditions, but not for depression. Most primary-care physicians spend less than 2 years in primary-care posts, whereas nurses and social workers stay much longer. Specialty mental health care is available on referral, but waiting times for an initial consultation typically exceed 2 months.
We designed a multicomponent, stepped-care programme to improve treatment practices for depression and the efficiency with which resources are used. In keeping with these goals, the programme was led by a trained non-medical health worker; a doctor was involved only if medication was needed for patients with severe depression. We aimed to compare the effectiveness of this stepped-care programme with usual care in primary-care management of depression in low-income women.
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Participants
We enrolled participants in three primary-care clinics in deprived urban areas of Santiago, Chile, between March, 2000, and November, 2001. The clinics were representative of Santiago primary-care clinics in terms of resources and of clinical and sociodemographic characteristics of patients.17 We used a two-stage screening process to identify female primary-care patients aged 18–70 years with current major depressive illness. Consecutive female patients were approached while they were waiting
Results
Figure 2 shows the trial profile. 3560 consecutive female patients completed initial screening. 1731 (49%) scored at least 5 in the GHQ-12. 1635 (94%) returned for the second GHQ-12, but only 722 (44%) were still above the threshold. All patients received an appointment for a baseline assessment within 48 h, but only 375 were interviewed before a sufficient number of women had been recruited. Recruited and non-recruited patients had similar GHQ-12 scores. Of those interviewed, 240 (64%) were
Discussion
Our results show a large and significant difference in favour of the stepped-care programme compared with usual care, consistent across all assessed outcomes, and stable during 6 months of follow-up. Rates of participation in the intervention programme were high, and participation in blinded outcome assessments exceeded 85% in both groups. The programme widened the role and responsibilities of non-medical workers and increased the participation of patients in their own treatment. These features
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