Diagnosing and Treating Depression and Anxiety in Patients with Cardiovascular Disorders and Diabetes Mellitus in Primary Healthcare: Is Training of Physicians Enough for Improvement?

Abstract

INTRODUCTION: Common mental disorders — anxiety and depression — are prevalent among patients with cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) and can negatively influence treatment outcomes and healthcare expenses. Despite the importance of management of depression and anxiety in primary care facilities, the diagnostics and treatment of these disorders remain insufficient in the Russian Federation.

AIM: To explore whether the rates of referrals to psychiatrists and indicated pharmacological treatment received due to depression or anxiety among patients with CVD and DM will significantly change in primary healthcare facilities after the training of primary care physicians (PCPhs) to deal with comorbid depression and anxiety (including the algorithm for referral to a psychiatrist).

METHODS: Patients in primary care outpatient settings with diagnoses of CVD and DM passed screening on anxiety and depression using the Hospital Anxiety and Depression Scale (HADS), and information about the indicated treatment for anxiety or depression was collected when present (Sample 1: n=400). The educational programme for PCPhs on the diagnostics of anxiety and depression was then performed, and PCPhs were instructed to refer patients with HADS >7 to a psychiatrist. After the training, the second sample was collected (Sample 2: n=178) using the same assessments as for Sample 1. The independent expert (psychiatrist) evaluated whether the patients had received the indicated pharmacological treatment according to the screening criteria used in the study for anxiety and depression for both samples.

RESULTS: The proportions of patients with borderline abnormal and abnormal HADS scores (>7) were 365 (91.2%) and 164 (92.1%) in Sample 1 and Sample 2, respectively. In Sample 1, among patients with HADS >7, 119 (29.8%) received psychopharmacological treatment, but in only 46 (38.7%) cases was it indicated in compliance with the screening criteria. In Sample 2, among patients with HADS >7, 59 (33.1%) received psychopharmacological treatment, and in only 14 (23.7%) cases was it indicated in compliance with the screening criteria. The differences in the indicated pharmacological treatment were not statistically significant, and no one from Sample 2 with HADS >7 met a psychiatrist through PCPh referral.

CONCLUSIONS: Anxiety and depression are prevalent in patients with CVD and DM treated in primary care facilities, but these patients may not be receiving the indicated pharmacological treatment. Barriers to referral and the use of psychiatric consultation exist despite the focused training of PCPhs and the straightforward referral protocol provided.

Keywords

depression / anxiety / primary care / mental-health education / Russia

References

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[76] Wimalaratne IK, McCarthy J, Broekman BFP, et al. General hospital specialists’ attitudes toward psychiatry: a cross-sectional survey in seven countries. BMJ Open. 2021;11(11):e054173. doi: 10.1136/bmjopen-2021-054173

[77] Tyazhelnikov AA, Kostenko EV, Gushchin MV, Kuznetsova AS. Features of professional burnout and subjectively significant stress factors in doctors who provided remote telemedicine services during COVID-19 pandemic. Medical alphabet. 2021(33):21–25. doi: 10.33667/2078-5631-2020-33-21-25

[78] Aksenova EI, Shkrumyzk AR. Professional’’noe vygoranie meditsinskikh rabotnikov v period pandemii. Byulleten’ Nacional’nogo nauchno-issledovatel’skogo instituta obshchestvennogo zdorov’ya imeni N.A. Semashko. 2021;(4):148–155.

[79] Vistorte AOR, Ribeiro WS, Jaen D, et al. Stigmatizing attitudes of primary care professionals towards people with mental disorders: A systematic review. Int J Psychiatry Med. 2018;53(4):317–338. doi: 10.1177/0091217418778620

[80] Heinz I, Baldofski S, Beesdo-Baum K, et al. “Doctor, my back hurts and I cannot sleep.” Depression in primary care patients: Reasons for consultation and perceived depression stigma. PLoS One. 2021;16(3):e0248069. doi: 10.1371/journal.pone.0248069

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[82] National Collaborating Centre for Mental Health (UK). Common Mental Health Disorders: Identification and Pathways to Care. British Psychological Society; 2011.

[83] Smithson S, Pignone MP. Screening Adults for Depression in Primary Care. Med Clin North Am. 2017;101(4):807–821. doi: 10.1016/j.mcna.2017.03.010

[84] Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience. 2015;17(3):327–335. doi: 10.31887/DCNS.2015.17.3/bbandelow

[85] Townsend N, Kazakiewicz D, Lucy Wright F, et al. Epidemiology of cardiovascular disease in Europe. Nat Rev Cardiol. 2021. doi: 10.1038/s41569-021-00607-3

[86] Khan MAB, Hashim MJ, King JK, et al. Epidemiology of Type 2 Diabetes — Global Burden of Disease and Forecasted Trends. J Epidemiol Glob Health. 2020;10(1):107–111. doi: 10.2991/jegh.k.191028.001

[87] Okunrintemi V, Valero-Elizondo J, Michos ED, et al. Association of Depression Risk with Patient Experience, Healthcare Expenditure, and Health Resource Utilization Among Adults with Atherosclerotic Cardiovascular Disease. J Gen Intern Med. 2019;34(11):2427–2434. doi: 10.1007/s11606-019-05325-8

[88] Chazov EI, Oganov RG, Pogosova GV, et al. Kliniko-epidemiologicheskaya programma izucheniya depressii v kardiologicheskoi praktike u bol’nykh arterial’noi gipertoniei i ishemicheskoi bolezn’yu serdtsa (KOORDINATA): rezul’taty mnogotsentrovogo issledovaniya. Kardiologiya. 2007;(3):28–37.

[89] Oganov RG, Pogosova GV, Koltunov IE, et al. Depressivnaya simptomatika ukhudshaet prognoz serdechno-sosudistykh zabolevanii i snizhaet prodolzhitel’nost’ zhizni bol’nykh arterial’noi gipertoniei i ishemicheskoi bolezn’yu serdtsa. Kardiologiya. 2011;(2):59–66.

[90] Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care. 2002;25(3):464–470. doi: 10.2337/diacare.25.3.464

[91] Breslow AS, Tran NM, Lu FQ, Alpert JE, Cook BL. Depression Treatment Expenditures for Adults in the USA: a Systematic Review. Curr Psychiatry Rep. 2019;21(10):105. doi: 10.1007/s11920-019-1083-3

[92] Deischinger C, Dervic E, Leutner M, et al. Diabetes mellitus is associated with a higher risk for major depressive disorder in women than in men. BMJ Open Diabetes Res Care. 2020;8(1). doi: 10.1136/bmjdrc-2020-001430

[93] Bickett A, Tapp H. Anxiety and diabetes: Innovative approaches to management in primary care. Exp Biol Med (Maywood). 2016;241(15):1724–1731. doi: 10.1177/1535370216657613

[94] Celano CM, Daunis DJ, Lokko HN, Campbell KA, Huffman JC. Anxiety Disorders and Cardiovascular Disease. Curr Psychiatry Rep. 2016;18(11):101. doi: 10.1007/s11920-016-0739-5

[95] Fleury MJ, Imboua A, Aube D, Farand L. Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec. Ment Health Fam Med. 2012;9(2):77–90. PMC3513700

[96] Krasnov VN, Dovzhenko TV, Bobrov AE, et al. Psikhiatriya v pervichnom zvene zdravookhraneniya: novoe reshenie staroi problemy. Sotsial’naya i klinicheskaya psikhiatriya. 2013;23(4):5–13.

[97] Firth J, Siddiqi N, Koyanagi A, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019;6(8):675–712. doi: 10.1016/S2215-0366(19)30132-4

[98] WHO. Mental Health Gap Action Programme (mhGAP): Scaling Up Care for Mental, Neurological and Substance Use Disorders. World Health Organization; 2008.

[99] WHO. WHO Mental Health Gap Action Programme (mhGAP). World Health Organization; 2016.

[100] WHO. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP), version 2.0. World Health Organization; 2016.

[101] Krasnov VN, Bobrov AE, Starostina EG, Dovzhenko TV. Razrabotka mekhanizmov kompleksnoĭ diagnostiki i poliprofessional’nogo vedeniya bol’nykh s nepsikhoticheskimi rasstroĭstvami v usloviyakh pervichnogo zvena zdravookhraneniya. 2010.

[102] Karpenko O, Kostyuk G. Community-based mental health services in Russia: past, present, and future. Lancet Psychiatry. 2018;5(10):778–780. doi: 10.1016/S2215-0366(18)30263-3

[103] Kostyuk G, Karpenko O, Masyakin A, Burygina L. Mental health law in Russia. European Psychiatry. 2019;56:S157–S158.

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Karpenko O.A., Melikhov O.G., Tyazhelnikov A.A., Kostyuk G.P.