Elsevier

General Hospital Psychiatry

Volume 29, Issue 1, January–February 2007, Pages 25-31
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Prevalence and treatment of depression in a hospital department of internal medicine

https://doi.org/10.1016/j.genhosppsych.2006.08.008Get rights and content

Abstract

Background

Depressive disorders are overrepresented among patients admitted to nonpsychiatric units of general hospitals, but the majority of depressed patients are not identified in this setting. Effective and well-tolerated treatments and reliable diagnostic criteria, together with new assessment tools (self-administered or not), have been developed with encouraging results. Nevertheless, few studies have utilized standardized instruments and extensive clinical interviews by well-trained psychiatrists to assess depression. New research should test these tools in a French-speaking environment.

Methods

The investigation covered 292 patients aged 18–65 who were admitted over a period of 6 months to the internal medicine units of Geneva University Hospitals. Each patient filled in a self-administered questionnaire for depression [Patient Health Questionnaire (PHQ-9)]; 212 patients were also evaluated by a psychiatrist using DSM-IV diagnostic assessment and the Hamilton Depression Rating Scale during the first week of their hospital stay; both assessments were single-blinded.

Results

Psychiatric clinical interviews identified a high proportion (26.9%) of depressive disorders (37% among women) for all diagnoses; 11.3% (17.3% among women) of the patients met the DSM-IV criteria for major depression. The PHQ-9 identified depressive disorders among 34.9% of patients (42% among women) and identified a major depressive syndrome among 18.4% of patients (29.6% among women). Physicians in the internal medicine unit identified only about half the depressive patients; at the time of psychiatric examination, fewer than one in four patients was receiving antidepressant therapy.

Conclusions

Our findings confirm the results of previous investigations, which showed that the failure to detect and treat depression is a major health problem among patients admitted to nonpsychiatric units of a general hospital.

Introduction

Depression is the main reason for contacting consultation–liaison psychiatric services [1]. Nevertheless, the majority of patients admitted to general hospitals with symptoms of depression receive no specific treatment [2], [3]. Physicians in the nonpsychiatric units of university hospitals overlook about half the cases of depression (Table 3); the proportion of missed cases, inappropriate diagnoses and absence of treatment is higher in recent studies [4], [5], [6]. When all is said and done, only about one case of depression in four receives appropriate therapy at the general hospital [5]. This is an important issue since patients with medical problems have a high prevalence of affective disorders [7] and a high proportion develop clinically significant depressive disorders during nonpsychiatric hospitalizations [3], [4], [5], [6], [7], [8], especially in comparison with the proportion among the general population and among those followed up in primary care [2]. Furthermore, a diagnosis of depression during a nonpsychiatric hospital stay is linked not only to poorer social performance and quality of life [5], [9], [10] but also to a less favorable clinical outcome for the basic medical disorder (whatever the latter's severity) [11], [12], to a lengthened hospital stay [13], [14], [15] and to increased hospitalization costs [3]. A significant proportion of patients presenting with a major depressive disorder during the earlier part of their stay at a general hospital show persistent and severe depression on discharge and during follow-up over several months [16], [17]. Current and effective therapies for depression are well tolerated and are, by and large, compatible with nonpsychiatric treatment. A review of several investigations [18] highlights the need to develop more effective evaluation methods and decision processes [19] for those patients hospitalized with depression in general hospitals [3].

Numerous studies based on the above observations have attempted to develop psychometric instruments for the detection of major depression — and of depressive disorders in general — among these subjects [20]. Results have not been entirely satisfactory: important differences persist according to the type of instrument, the way these instruments are applied and the training level of the evaluators. Standard interviews are reliable and efficient but require considerable time and are not readily accessible to standard practice in a nonpsychiatric environment. Conversely, self-administered questionnaires are easier to handle but tend to result in overdiagnosis for depression when compared with structured interviews and do not discriminate well when it comes to the clinical importance of the disorder [21]. In addition, self-administered questionnaires are responsive to different linguistic or cultural contexts.

Depression diagnosis should be therefore performed by well-trained psychiatrists using standard interviews as well as accomplishing a full clinical examination in order to control two important factors: the level of training and the gathering of all necessary information to achieve a complete diagnosis. In view of the above, the general purpose of the present investigation is to assess the prevalence and severity of depression among French-speaking patients admitted to internal medicine units, with the use of various diagnostic tools, including a full clinical examination by a psychiatrist — in addition to the gamut of DSM-IV criteria for mood disorders, the Hamilton Depression Rating Scale (HDRS) and the self-administered French version of Patient Health Questionnaire (PHQ-9) [22], [23]. There is extensive prior work in the area of detection of depression of inpatients, but few investigations use diagnoses provided by well-trained psychiatrists as the gold standard. Furthermore, as far as we know, there are no other prevalence studies investigating French-speaking inpatients in Switzerland that are grounded on DSM-IV criteria established by well-trained psychiatrists as the gold standard. At the same time, this study is the first test of the French translation of the PHQ-9 [24]. Results about sensitivity and specificity of the French language version of the PHQ-9 compared with the gold standard of the diagnosis from psychiatric interview are reported elsewhere [25].

Section snippets

General framework and patient selection

The study was undertaken among patients aged 18 to 65 who were admitted to internal medicine units at the University Hospitals of Geneva (Hôpitaux Universitaires de Genève), a large community hospital (with 2200 beds and 47,000 admissions a year and where all medical specialties are available) that is affiliated with the University of Geneva Medical School. The French version was compiled, according to the state of the art, through several steps of translation and blind back-translation by

Results

The majority of persons investigated were men (61.8%), and the average age was 49.5 years (S.D.=12). Table 2 shows high levels for major depression and for “all depressive disorders.” It also shows a higher prevalence of depression among women, regardless of the assessment tool used. The proportion of major depressive syndromes limited to DSM-IV Criterion A (18.4% for self-assessment with PHQ-9 and 19.8% for assessment by a psychiatrist with DSM-IV) is greater than that of DSM-IV major

Discussion

Our data (Table 2) complete earlier findings (Table 3) and similarly show that, among patients admitted to the internal medicine departments of a major public hospital, standard clinical assessment by a psychiatrist reveals that an important proportion (26.9%) of persons fulfill the criteria for at least one DSM-IV depressive disorder — more among women (37%) than among men (20.6%). Furthermore, about one quarter of depressive subjects have a score greater than 20 on the HDRS — an indication

Conclusions

The present study confirms, in a sample of French-speaking patients, the results of earlier research that had shown high levels of major depression and of depressive disorders as a whole among patients admitted to internal medicine departments of a major general hospital. It also shows that nonpsychiatrist physicians overlook a marked proportion of depression diagnoses recorded by well-trained psychiatrists who perform extensive clinical interviews and use standardized instruments. Our results

Acknowledgments

We acknowledge the support of Professor A. Junod, Director of Internal Medicine Service I. We thank Valerie Burnet and Monique Pascale, psychologists, who ensured the recruitment of patients and Pfizer and the Fonds de péréquation of the University Hospitals, Geneva, which contributed to the costs of this investigation. There are no conflicts of interest.

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