Major depression ranks among the most prevalent mental health disorders in Ontario (1) and North America (2,3). It is a major contributor to workplace disability, family dysfunction, and individual suffering (4). According to the Mental Health Supplement of the Ontario Health Survey, the major depression 1-year prevalence rate was 4.1%; one-half of affected individuals did not seek mental health treatment, 22.2% received some type of counselling intervention without any medication, another 18.0% received antidepressants, and 8.7% received anxiolytics without antidepressants (5).
A large European study, Depression Research in European Society (DEPRES), mirrors these findings: prevalence rates are high, only 43% of those affected seek treatment, and just 25% receive antidepressants (6). Patient preferences may offer one explanation for the low use of medication: several studies have shown that patients prefer counselling (7,8). Another study indicates that, even when patients begin medication treatment, compliance dwindles quickly (9). Such preferences imply that patient perceptions may not include a typical biological-disease model of depression (which would highlight the importance of medication). In turn, the disease model chosen by a patient will influence treatment compliance and medication use in direct proportion to how well the medication fits the model.
To understand patient attitudes regarding causes of depression and to determine patient perceptions of depression in biological, psychological, cognitive, and spiritual dimensions, we surveyed a representative patient group referred from a community hospital for assessment for depression. Patient age, sex, style of thinking, lifestyle, or beliefs may all influence patient perceptions. In this exploratory survey, we wished to document the various patient perspectives and to speculate on the implications of such perspectives for treatment preference, treatment delivery, and medication compliance.
Table 2 represents the mean scores on the 9 items. The most highly endorsed item by both sexes was “Stress and negative life experiences caused my depression,” while the least-endorsed item by both sexes was “I’m depressed because I lost touch with my spiritual core or faith in God.” We computed correlation coefficients between age and the 9 scale items. The results of the correlational analyses showed that older individuals were less likely to identify cognitive factors (r = –0.213, df 100, P = 0.033) and loss of spirituality (r = –0.208, df 100, P = 0.037) as causing their depression. We conducted a 1-way analysis of variance to evaluate the relation between sex and each scale item. Women were more likely to endorse having a biological abnormality as a cause of their depression (F1 = 4.872, P = 0.030). There was a trend toward women being more likely to endorse the way they evaluate or think about their experiences as a cause of their depression (F1 = 2.999, P = 0.086).
Among the mysteries of depression treatment are the low treatment rate and the low compliance with medication, even when treatment begins. We designed our survey to identify key patient perspectives on the etiology of depression descriptively, from the broad domains of biological, psychological, cognitive, and spiritual causes. Our results show that, first, no single cause dominated the ratings; that is, patients scored no cause higher than 6 out of 10 on the Likert scale. Our findings and results indicate that patient perceptions of their depression are polyfactorial. Only 2 domains, cognitive attributional style and stress or negative life events, are seen as even partly causing depression. Patients did not particularly endorse the dominant biomedical explanation of depression, which proposes that biological abnormalities are central. Patients also strongly rejected attributing depression to spiritual deficits or to an unhealthy lifestyle. Variations on these themes were played out by sex and age, with women more likely to endorse biological causes. Older patients were less likely to identify loss of religious faith as contributory to depression but were more likely to endorse cognitive attributional styles as etiologically relevant.
These findings suggest that patient models of depression are frequently nonbiomedical; such models will lead patients to avoid standard biomedical treatments (for example, antidepressant medication). The implications for health education are obvious: assessing a patient’s explanatory model for depression will allow for proper psychoeducation (10). Our survey also suggests significant variation in patient explanatory models by sex and age. Once proper psychoeducation occurs, there will be scope for proper treatment—either psychotherapy or medication, as appropriate.
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8. Priest RG, Vize C, Roberts A, Roberts M, Tylee A. Lay people’s attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313:858–9.
9. Cohen NL, Parikh SV, Kennedy SH. Medication compliance in mood disorders: Relevance of the Health Belief Model and other determinants. Primary Care Psychiatry 2000;6:101-10.
10. Naidoo J, Wills J. Health promotions for practice. Philadelphia: Harcourt Brace and Company; 1994.
Manuscript received January 2003, revised, and accepted February 2003.
Previously presented at the 51st Annual Meeting of the Canadian Psychiatric Association; November 2001; Montreal (QC).
1. Staff Psychiatrist, Depression Clinic, Centre for Addiction and Mental Health, Toronto, Ontario.
2. Department of Psychiatry, University Health Network; Department of Psychology, York University, Toronto, Ontario.
3. Department of Psychiatry, University Health Network, University of Toronto, Toronto, Ontario.
Address for correspondence: Dr J Srinivasan, Centre for Addiction and Mental Health, Mood and Anxiety Program. 250 College Street, Toronto, ON M5T 1R8
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