Abstract Background Family doctors’ (FD) attitudes likely play an important role in the recognition and management of depression. Objective The purpose of the study was to prospectively analyse the short-term and long-term impact of a specifically designed training program on attitudes towards depression among FDs. Methods A prospective, educational intervention, single group pre- and post-test study with three assessments (pre, post, and 6-month follow-up) was conducted. Participants included 1322 certified FDs who had enrolled voluntarily in a structured postgraduate training in depression. This course was mainly practical and guided by case reports and real clinical experiences. The course was based on Patient’s Unmet Needs and Doctors Educational Needs (PUNS & DENS) methodology. Primary outcome was assessed through the Depression Attitudes Questionnaire (DAQ). In total, 970 subjects completed the pre–post assessments, and 787 also completed the 6-month follow-up. Results After training, FDs positively changed their attitudes towards the management of depression. A significant change was observed in 18 of 20 items of the DAQ. The distinction between unhappiness and depression was initially found to be difficult in 41% of FDs. After the course, the percentage was reduced to 27%. Agreement with the statement that ‘psychotherapy is an exclusive practice of specialists’ strikingly changed from 57% to 23%. Minimal differences were noted between the post-training assessment and the 6-month follow-up. Conclusions Attitudes towards depression in FDs can be modified by a structured training program, and this change is maintained over the long term. A short training in psychotherapy (cognitive-behavioural, problem-solving based and psycho-educative oriented) significantly increases the confidence of FDs in treating depression. Attitudes, depression, education, postgraduate training, primary care, psychotherapy Introduction Depression is one of the most common disorders in the general population, with a lifetime prevalence varying from 10.6% to 16.2%, making it the second leading direct cause of global disease burden (1,2). Depression is particularly prevalent in primary care (PC), which is a key setting for its recognition and management (3,4). However, it has been estimated that one-third of patients with major depression (MD) are not diagnosed and therefore properly treated in the PC setting (5). This issue may be explained by different reasons based on national/regional variations. In our public heath system, it is possible to imply the potential relevance of the great number of patients that a family doctor (FD) has to attend in each clinic with reduced consultation duration per patient and their limited specific training in mental health. In addition, self-stigma affecting/limiting problem disclosure and/or societal stigma and/or negative attitudes affecting clinicians’ attitudes and behaviours have also been considered as a barrier in the patient’s diagnosis and management (1,6). In recent years, it has been described that FDs may overdiagnose depression. This overdiagnosis is subject to criticisms of over-medicalization of daily life and adaptive negative emotions (7). Family physicians appear to respond to meaningful clinical cues in assigning the diagnosis of depression to distressed and impaired patients (8,9). Consequently, a priority for improving the quality of the service of the health care systems is to increase the ability of FDs to address mental health and specifically depression (10). Several organizational and educational strategies to improve the management of depression have been proposed. The reported results support a shift of focus from simple education approaches to more complex interventions, wherein provider (and patient) education plays an important part that involves broader organizational changes that most importantly involve collaborative care arrangements (11–13). This implementation of training programs should be accompanied by an accurate evaluation of educational effect and the impact on clinical practice. In assessing the impact of an educational program on the management of depression, different outcome measures have been used, including the prescription of antidepressants, knowledge about depression, use of assessment scales, adherence to clinical practice guidelines or suicide rates associated with depression (14). However, it has been suggested that the clinical management of depression is greatly influenced by the doctor’s attitudes towards this condition and their views about how it should be managed. Some studies have focused attention on examining these attitudes using standardized measures to better understand the role that attitudes may play in the processes of communication, engagement and treatment decisions (15,16). An empathic attitude of the GP and a more holistic view of presenting problems and patient needs appear to increase the recognition of depression; in contrast, an exclusive concern for organic diseases has the opposite effect (17). It has been suggested that these GPs’ attitudes are associated with previous training in mental health. In retrospective studies with family physicians, the completion of some non-structured training in mental health (including short seminars, continuing education programs, training in psychotherapy and Balint groups) was positively associated with both professional ease and a medication approach to treating depression (18). The aims of this prospective, educational intervention, single group pre- and post-test study were as follows: (i) to analyse the attitudes towards depression of a large sample of certified and experienced specialists in Family Practice; and (ii) to prospectively analyse the short-term and long-term impact of a specifically designed training program on attitudes towards depression of FDs. The postgraduate university course was followed by 1322 FDs, and we analysed their attitudes before starting and at the end of the course. In addition, we investigated the persistence of the effect over 6 months following the end of the course. Methods Participants Participants included 1322 certified and experienced FDs, distributed throughout the country. Inclusion criteria were as follows: (i) a certified specialist in Family Practice; (ii) active work in the Spanish National Health System; and (iii) minimal clinical experience of 5 years. Doctors who were a psychiatrist or psychologist were excluded. Written informed consent was obtained from each participant, and institutional review board approval by the Ethics Committee of the Universidad de Alcalá was obtained. Study design In this prospective, educational intervention quasi-experimental study, participants were invited to complete the Depression Attitude Questionnaire (DAQ) before starting the educational intervention following a 12 ECTS (European Credit Transfer and Accumulation System) postdoctoral program in depression, as detailed later in the text. The participant has to re-complete the questionnaires within the first 30 days (±7 days) and 6 months (±15 days) after finishing the program. Intervention The training program titled ‘Diagnostic and therapeutic skills: the depressed patient in Primary Care’ was a postgraduate course officially approved by the University of Alcalá (Madrid, Spain), and it was conducted from March 2012 to December 2012. The course was accredited with 12 ECTS (European Credit Transfer and Accumulation System) and was structured in four modules: (i) under/overdiagnosis of depression and patient communication: attitudinal elements; (ii) depression diagnosis and differential diagnosis; (iii) treatment: psychopharmacology and cognitive, including behavioural and problem-solving therapies; and (iv) symptomatic and functional recovery. The character of the training was eminently practical based on patient case reports and clinical experiences. The methodology was based on PUNS & DENS (Patient’s Unmet Needs and Doctors Educational Needs (19)). The process involves self-analysing where a patient may not have received the optimal advice or treatment. Based on that information, the doctor identifies his/her own educational need. The process involves personal learning, indirectly driven by patients and self-select areas of weakness. The course flexibly combines face-to-face sessions and online learning. Each module is accompanied by a case report that is extracted from the general practice, which works as a learning guide. Online communication between teachers and students facilitates the exchange of ideas and allows students to access learning materials beyond school hours and develop interchanges with peers and teachers. Instruments Socio-demographic and professional data of the participating physicians were collected. The Spanish version of the Depression Attitude Questionnaire (DAQ) (20,21) was administered before, after and 6 months after the course. The DAQ is a self-report measure originally designed and initially used to examine the attitudes of GPs towards depressive illness. This questionnaire has been subsequently used with psychiatrists, general medical and nursing staff. Adapted versions of the DAQ have been developed to study the views of physicians in several countries. Researchers have used the questionnaire since its development in 1992 to measure clinicians’ attitudes towards depression and its management. Despite its extensive use, the questionnaire has modest internal consistency, and controversy exists about its factor-structure. The DAQ initially identified a four-component solution involving treatment preference, professional ease, the potential for illness course to be modified and confidence in recognizing and differentiating depression from unhappiness. However, subsequent studies have identified differing factor-structures including three-, four- and five-component models (22–24). The Spanish validation reported a Cronbach alpha coefficient for the 20 items of 0.551, and six components were identified in the factorial analysis, which accounted for 56.2% of the variance (21). The original version contains 20 items rated on a Likert scale with five options: completely agree, somewhat agree, neither agree nor disagree, tend to disagree and strongly disagree (20). We also assessed the satisfaction with the training using a 0–10 scale of overall satisfaction with the course, its usefulness for clinical practice and teacher quality. Data analysis Tables and lists have been prepared in accordance with the principles of ICH E3 guidance. The analysis was performed using the SAS System 9.2. Categorical variables were described by the absolute frequency and percentage of relative frequency, whereas quantitative variables were described by the mean and standard deviation when variables had symmetric distribution and by the median and interquartile range when the distribution was asymmetric. Score changes for each item before and after training are presented in a contingency table. To analyse possible differences between pre- and post-training scores, the Bhapkar test was used (using the ‘proc CATMOD’ in the SAS statistical software). As our primary outcome, participants’ DAQ responses were also classified into one of three categories: ‘disagree’ (including ‘tend to disagree’ and ‘strongly disagree’), ‘neutral’ (neither ‘agree nor disagree’) and ‘agree’ (including completely agree and somewhat agree). The reliability coefficient was calculated using Cronbach’s alpha value. A linear regression analysis was performed to examine which variables were associated with the mean change between baseline and final scores. Results In total, 1322 participants were enrolled in the study and completed the questionnaire at baseline. Moreover, 970 participants completed both the pre- and post-training assessments (73.4% of total), and 787 completed the follow-up evaluation 6 months after completing the course (59.5% of total). The participants were medium age FDs (mean 47 years). The participants were predominantly females (67%) with a marked clinical experience (mean 18 years), with a majority with some mental health training five years before the study (55.5%), as shown in Table 1. Interestingly, no significant differences were noted between the demographic and professional variables measured between participants who only completed the DAQ at baseline (352 FDs) with respect to those who completed both the pre- and post-training course questionnaire (970 FDs). No significant differences were noted in the demographic and professional variables of the FDs who completed the three phases of the study (pre-, post-training and after 6 months of follow-up) (787) and those who only responded to the DAQ at pre- and post-training times (Tables 1 and 2). Table 1. Demographic and professional characteristics of the family doctors included in the study Pre-training Pre- and post-training Pre- and post-training and after 6 months of follow-up Participants Participants Participants No Yes No Yes N = 1322 352 970 183 787 Age (years) Mean (SD) 47 (8.56) 47 (8.16) 47 (8.69) 48 (8.42) 46 (8.72) Median 48.00 48.00 48 48 48 95% CI (mean) (46.24, 47.17) (45.94, 47.76) (46.11, 47.21) (46.11, 47.21) (45.72, 46.94) Gender (%) Female 67.8 68.1 67.7 69.9 67.2 Male 32.2 31.9 32.3 30.1 32.8 Clinical experience (years) Mean (SD) 18 (8.87) 18 (8.79) 18 (8.90) 19 (8.87) 17 (8.87) 95% CI (mean) (17.17, 18.14) (17.07, 18.99) (16.97, 18.09) (17.74, 20.33) (16.56, 17.80) Median 18.00 18.00 18.00 20.00 17.00 RIQ (Q25, Q75) (10.00, 25.00) (10.00, 25.00) (10.00, 25.00) (14.00, 26.00) (10.00, 24.00) Mental health training in the last 5 years (%) No 44.5 43.3 44.9 43.7 45.2 Yes 55.5 56.7 55.1 56.3 54.8 Pre-training Pre- and post-training Pre- and post-training and after 6 months of follow-up Participants Participants Participants No Yes No Yes N = 1322 352 970 183 787 Age (years) Mean (SD) 47 (8.56) 47 (8.16) 47 (8.69) 48 (8.42) 46 (8.72) Median 48.00 48.00 48 48 48 95% CI (mean) (46.24, 47.17) (45.94, 47.76) (46.11, 47.21) (46.11, 47.21) (45.72, 46.94) Gender (%) Female 67.8 68.1 67.7 69.9 67.2 Male 32.2 31.9 32.3 30.1 32.8 Clinical experience (years) Mean (SD) 18 (8.87) 18 (8.79) 18 (8.90) 19 (8.87) 17 (8.87) 95% CI (mean) (17.17, 18.14) (17.07, 18.99) (16.97, 18.09) (17.74, 20.33) (16.56, 17.80) Median 18.00 18.00 18.00 20.00 17.00 RIQ (Q25, Q75) (10.00, 25.00) (10.00, 25.00) (10.00, 25.00) (14.00, 26.00) (10.00, 24.00) Mental health training in the last 5 years (%) No 44.5 43.3 44.9 43.7 45.2 Yes 55.5 56.7 55.1 56.3 54.8 Pre-training: March 2012; post-training: December 2012; follow-up: May 2013. View Large Table 2. Comparison of demographic and professional characteristics of family doctors who completed and did not complete the educational intervention Completers, N = 970 Non-completers, N = 352 Total, N = 1322 Test P-value Age (years), Mean (SD); 95% CI 47 (8.69); (46.11, 47.21) 47 (8.16); (45.94, 47.76) 47 (8.56); (46.24, 47.17) ANOVA F value = 0.06 0.943 Gender (female) 657 (67.7%) 228 (68.1%) 885 (67.8%) Chi square = 0.012 0.993 Clinical experience Mean (SD) (years); 95% CI 18 (8.9); (16.97, 18.09) 18 (8.79); (17.07, 18.99) 18 (8.87); (17.17, 18.14) ANOVA F-value = 0.39 0.675 Mental health training in the last 5 years (yes) 534 (55.1%) 190 (56.7%) 724 (55.5%) Chi square = 0.279 0.868 Completers, N = 970 Non-completers, N = 352 Total, N = 1322 Test P-value Age (years), Mean (SD); 95% CI 47 (8.69); (46.11, 47.21) 47 (8.16); (45.94, 47.76) 47 (8.56); (46.24, 47.17) ANOVA F value = 0.06 0.943 Gender (female) 657 (67.7%) 228 (68.1%) 885 (67.8%) Chi square = 0.012 0.993 Clinical experience Mean (SD) (years); 95% CI 18 (8.9); (16.97, 18.09) 18 (8.79); (17.07, 18.99) 18 (8.87); (17.17, 18.14) ANOVA F-value = 0.39 0.675 Mental health training in the last 5 years (yes) 534 (55.1%) 190 (56.7%) 724 (55.5%) Chi square = 0.279 0.868 Statistical significance P < 0.05 (in bold). View Large Baseline attitudes towards depression are presented in Table 3. In total, 40% of the 1322 FDs included in the study recognized difficulties in the diagnosis of depression (Item 5), and approximately 1 out 5 (18.5%) believed that depression is associated with ‘poor stamina dealing with difficulties’ (Item 7). In total, 23.8% of FDs expressed that they do not feel comfortable dealing with depression (Item 9), and 44.7% believed that psychotherapy should be performed by a specialist (Item 19). Scores for DAQ items were not associated with the FD’s gender, age or clinical experience. Table 3. Responses to the Depression Attitudes Questionnaire (DAQ, five categories): numbers of family doctors expressing agreement with subscale’s statements before, after training and 6 months later Pre-training, N = 970 Post-training, N = 970 Bhapkar test, P-value Post-training, N = 787 6 months, N = 787 Bhapkar test, P-value Subscale 1: Depression as a disease (Items 1, 2, 4, 5, 6, 7, 8, 10 and 11) Completely agree 131.2 174.6 0.0087 144.1 141.5 0.2014 Somewhat agree 333.3 373.6 305.8 301.2 Neither agree nor disagree 179.6 130.7 102.2 106.5 Tend to disagree 247.6 202.7 163.7 164.3 Strongly disagree 49.2 49.1 39.1 42.3 Subscale 2: Aptitudes (Items 9, 13 and 15) Completely agree 100.3 128.6 0.0018 104 104.1 0.6725 Somewhat agree 286 355.6 292 290.6 Neither agree nor disagree 196.6 174.6 139.3 146 Tend to disagree 262.3 210.6 174 163.6 Strongly disagree 124.6 100.3 77.6 82.6 Subscale 3: Treatment (Items 3, 12, 14, 16, 17, 18, 19 and 20) Completely agree 84.6 154.3 0.05 121.6 132 0.153 Somewhat agree 345.6 421.3 339.3 325.3 Neither agree nor disagree 239.6 179.6 150 148 Tend to disagree 234.3 162 135.6 141.6 Strongly disagree 65.6 52.6 40.3 42 Pre-training, N = 970 Post-training, N = 970 Bhapkar test, P-value Post-training, N = 787 6 months, N = 787 Bhapkar test, P-value Subscale 1: Depression as a disease (Items 1, 2, 4, 5, 6, 7, 8, 10 and 11) Completely agree 131.2 174.6 0.0087 144.1 141.5 0.2014 Somewhat agree 333.3 373.6 305.8 301.2 Neither agree nor disagree 179.6 130.7 102.2 106.5 Tend to disagree 247.6 202.7 163.7 164.3 Strongly disagree 49.2 49.1 39.1 42.3 Subscale 2: Aptitudes (Items 9, 13 and 15) Completely agree 100.3 128.6 0.0018 104 104.1 0.6725 Somewhat agree 286 355.6 292 290.6 Neither agree nor disagree 196.6 174.6 139.3 146 Tend to disagree 262.3 210.6 174 163.6 Strongly disagree 124.6 100.3 77.6 82.6 Subscale 3: Treatment (Items 3, 12, 14, 16, 17, 18, 19 and 20) Completely agree 84.6 154.3 0.05 121.6 132 0.153 Somewhat agree 345.6 421.3 339.3 325.3 Neither agree nor disagree 239.6 179.6 150 148 Tend to disagree 234.3 162 135.6 141.6 Strongly disagree 65.6 52.6 40.3 42 Items 2, 3, 5, 6, 7, 10, 11, 13, 14, 16, 17, 19 and 20 are negative. Pre-training: March 2012; post-training: December 2012; follow-up: May 2013. Statistical significance P < 0.05 (in bold). View Large No significant differences were noted between the answers obtained in the DAQ between the 970 participants who responded to the post-training questionnaire and the 352 participants who failed to respond to the second phase of the study. We analysed the effects of a training program in these attitudes of FDs towards depression. We analysed the change response in the three domains explored by the DAQ (‘depression as disease’ (Items 1, 2, 4, 5, 6, 7, 8, 10 and 11), ‘aptitudes’ (Items 9, 13 and 15) and ‘treatment’ (Items 3, 12, 14, 16, 17, 18, 19 and 20) (16). Statistically significant changes were noted in the three domains after the intervention. An analysis by subdomains of the answers and percentages obtained in the DAQ (three categories) completed by 970 FDs before and early after the course are reported in Table 3. In 18 out 20 items of the questionnaire, a significant change was observed. Through this item-by-item analysis, we observed a significant increase in the percentage of participants who agree with the statements in Items 1, 8, 9, 12, 13, 15 and 18. We observed a significant decrease in the percentage of the participants who agree with the statements in Items 3, 5, 6, 7, 10, 11, 14, 16, 17, 19 and 20. Significant changes were not noted in Items 2 and 4. The average satisfaction with the training was 8 out of 10. In total, 88.7% of respondents provided a rating of 7 or greater. Internal consistency of the questionnaire was modest, with a Cronbach’s alpha coefficient of 0.56. According to the factorial analysis performed on the DAQ, we found that the 20 items can be explained by six factors. These six factors explained 51.52% of the variance. Once the varimax rotation was applied to the model, we interpreted the components of each factor as follows: Factor 1: Items 19, 20 and 3 (explained variance: 15.62%); Factor 2: Items 11, 8, 10, 7, 5 and 6 (explained variance: 9.51%); Factor 3: Items 9, 15 and 13 (explained variance: 9.03%); Factor 4: Items 14, 16 and 12 (explained variance: 1.64%); Factor 5: Items 18, 4 and 17 (explained variance: 5.40%); and Factor 6: Items 1 and 2 (explained variance: 5.17%). We conducted item-by-item linear regression to analyse variables associated with this pre-, early, and post-interventional course change. In Items 5, 9, 12, 13, 14 and 19, the baseline value exhibited a statistically significant association with the observed change. In Items 13 and 14, the overall satisfaction with the training also exhibited a statistically significant association with the dependent variable. Other measures (such as age, gender or clinical experience) were not associated with this short-term effect of the training program. Finally, we studied the long-term persistence of this educational effect through a 6-month follow-up in 787 FDs. Significant differences between the early post-training assessment and the 6-month follow-up were identified in only 2 of the 20 DAQ responses. In Items 8 and 16, a significant decrease was observed in the percentage of the participants who agreed with the statement (P < 0.001; P = 0.003, respectively). In the remaining DAQ items, no significant differences were observed between both visits. All items exhibited a very small score change (always between −2 and +3 about ±100), except Item 8 with a mean change of −6 (yet still a small difference). A more detailed analysis of these maintained changes in the DAQ (five categories) in the most clinically relevant items is presented in the Supplementary Material. Discussion In this prospective study with a large sample of certified FDs, we demonstrated that attitudes towards depression can be modified by a structured training program and that this change is maintained over the long term. The educational impact of the training course is independent of the FD’s gender, age or years of clinical experience. Attitudes towards depression were initially assessed in a large population of 1322 FDs, which represents to date the largest sample size of studies using the DAQ (15,21). A relevant percentage of these FDs recognized difficulties in the comprehension and diagnosis (see Items 3, 4, 5 and 7) and management of depression (Items 13–20). Interestingly, these attitudes were not associated with the FD’s gender, age or clinical experience. Overall, attitudes towards depression were positively modified after the implementation of the educational program, and these changes were particularly striking in some items. As an example, the distinction between unhappiness and suffering from MD was initially difficult for 41% of FDs. After the course, the percentage was reduced to 27%. This training improvement may be strongly relevant in a crowded care setting with numerous emotional complaints regarding vital adversity, where there is a risk of overdiagnosis and overtreatment of depression, reaching a medicalization of everyday life. Agreement with the statement that psychotherapy is an exclusive practice of specialists strikingly changed from 57% to 23%. This finding leads to another controversial aspect of the management of depression in PC, namely the disproportionate use of exclusive pharmacological strategies compared with other interventions (25). Consistent with previous studies (26), our data demonstrate that training in psychotherapy (cognitive-behavioural, problem-solving based and psycho-educative oriented) significantly increases the confidence of FDs in treating depression. This attitude is more congruent with the latest international recommendations for the treatment of mild and moderate depression (25) and expressed preferences of patients (27). We also found that the impact of the program and the ability to improve professional skills were independent of age and years of practice, suggesting that these features are not limiting factors in learning and improvement of attitudes. These results reinforce the need for continuous training for medical professionals in clinical practice, regardless of their age and experience. Although previous studies have positively evaluated the impact of specific training in depression for FDs, our study has distinctive features. First, our study has a large sample size (N = 970 in the pre-post study) and representativeness of the sample for general clinical practice in Spain. Second, the following content of the training program represents distinctive features: structured, innovative, based on reflective learning and PUNS & DENS methodology, a duration of 2 months and officially accredited by the Postgraduate School of the University of Alcalá. In this sense, the positive results of this study should not be automatically generalized to any other training for depression, especially programs with an exclusive theoretical content. In contrast, the idea of doctors learning from their everyday work with patients should be accepted as a crucial part of their professional development, as this study suggests. It should be noted that professionals included in the study expressed their desire to follow a specific course of mental health and were not randomly assigned. Another limitation may lie in the psychometric characteristics of the DAQ questionnaire: heterogeneity of factor solutions, low internal consistency of these solutions (with Cronbach alpha values of less than 0.7) and items related to specific professions (15,21). Regarding the DAQ, a simple self-administered questionnaire is likely an incomplete method of evaluating a complex concept such as ‘attitude’ (16). However, the use of a standard questionnaire, even at the risk of excessive simplification, provides knowledge of some aspects of the doctors’ attitudes regarding depression and allows comparison of the results with other previously published data. In Spain, the training program of the Residence in Family and Community Medicine provides a 3-month rotation with the mental health team. After specialization, continuous training in mental health is not mandatory. Courses or activities organized by universities, professional associations, scientific societies and hospitals are occasionally held. The main conclusion of our work is to highlight the importance of providing specific educational programs on depression and mental health in general to FDs given that they can change their attitudes and perceived management skills and ultimately may help achieve better healthcare. Furthermore, a positive change in attitudes regarding depression in FDs can be obtained after years of clinical practice. Some potential weaknesses of the design of this study should be noted. The pre-test/post-test method used to evaluate this intervention is widely used in educational research and represents a low-cost, feasible approach for the initial examination of effects. However, this research design is subject to clear risks of bias due to the absence of a control group. Uncertainty exists in whether observed changes are the result of history, maturation or testing effects. For example repeated measurements using the same instrument might produce biased results given participants’ repeated exposure and familiarity with the measurement affecting their responses (28). Supplementary material Supplementary data are available at Family Practice online. Declaration Funding: The study was funded by departmental resources. Ethical approval: The study was approved by the Ethical Committee of the University of Alcalá. Conflict of interest: In the last 3 years, R. Manzanera has received honoraria from the Spanish Ministry of Science, NHS England, and Eli & Lilly Spain. Guillermo Lahera has received honoraria as a researcher, lecturer or consultant from Carlos III Health Institute, Janssen, Lundbeck and Otsuka. M. 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Family Practice – Oxford University Press
Published: Feb 1, 2018
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