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Guest Editorial
Needed: Clinical Research in Mood Disorders

Martin Alda, Michael Bauer

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In Review
The Antisuicidal and Mortality-Reducing Effect of Lithium Prophylaxis: Consequences for Guidelines in Clinical Psychiatry

Bruno Müller-Oerlinghausen, Anne Berghöfer, Bernd Ahrens

(PDF)

Lithium Augmentation Therapy in Refractory Depression: Clinical Evidence and Neurobiological Mechanisms
Michael Bauer, Mazda Adli, Christopher Baethge, Anne Berghöfer, Johanna Sasse, Andreas Heinz, Tom Bschor

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Prophylaxis Latency and Outcome in Bipolar Disorders
Christopher Baethge, Leonardo Tondo, Irene M Bratti, Tom Bschor, Michael Bauer, Adele C Viguera, Ross J Baldessarini

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Review Paper
Clinical Features of Bipolar Disorder With and Without Comorbid Diabetes Mellitus

Martina Ruzickova, Claire Slaney, Julie Garnham, Martin Alda

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The Cortisol Awakening Response in Bipolar Illness: A Pilot Study

Dorian Deshauer, Anne Duffy, Martin Alda, Eva Grof, Joy Albuquerque, Paul Grof

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Implementing Quality Management in Psychiatry: From Theory to Practice—Shifting Focus From Process to Outcome

Brent M McGrath, Raymond P Tempier

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Original Research
Mental Disorders and Reasons for Using Complementary Therapy

Badri Rickhi, Hude Quan, Sabine Moritz, Heather L Stuart, Julio Arboleda-Flórez

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Readiness to Participate in Psychiatric Research Daniele Zullino, Philippe Conus, François Borgeat, Charles Bonsack
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Toward Benchmarks for Tertiary Care for Adults With Severe and Persistent Mental Disorders
Alain D Lesage, Daniel Gélinas, David Robitaille, Éric Dion, Diane Frezza, Raymond Morissette

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Brief Communication
Patient Attitudes Regarding Causes of Depression: Implications for Psychoeducation

Janaki Srinivasan, Nicole L Cohen, Sagar V Parikh

(PDF)


Book Reviews
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Helping the Helpers Not to Harm: Iatrogenic Damage and Community Mental Health.
Reviewed by
Peter Moore, MD, FRCPC

L’Homme de Vérité.
Revue par
Maurice Dongier, MD, FRCPC


Letters to the Editor
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Re: The Combined Use of Atypical Antipsychotics and Cognitive-Behavioural Therapy in Schizophrenia

Reply: The Combined Use of Atypical Antipsychotics and Cognitive-Behavioural Therapy in Schizophrenia

Re: Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists

Reply: Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists

Re: Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists

Reply: Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists

Breath-Holding in Anxiety Disorders

Bright Light, Serotonin Turnover, and Psychological Well-Being

Brief Communication

Patient Attitudes Regarding Causes of Depression: Implications for Psychoeducation

Janaki Srinivasan, MD, FRCPC1, Nicole L Cohen, MA2, Sagar V Parikh, MD, FRCPC3

 

Objectives: Patient attitudes toward mental illness are an important determinant of treatment compliance and treatment outcome. A patient’s age, sex, style of thinking, lifestyle, and beliefs all may influence perceptions. This study aimed to determine patient attitudes.

Method: Patients with a depressive disorder (n = 102) who were referred for psychiatric consultation and treatment to a community general hospital psychiatric outpatient clinic completed a 9-item self-report questionnaire to determine their perceptions of the biological, psychological, cognitive, and spiritual causes of their depressive disorder.

Results: Women were more likely to endorse their depressive disorder as related to a biological abnormality. With respect to age, older individuals were less likely to identify cognitive factors and loss of spirituality as causal factors in their depression.

Conclusions: A relation exists between demographic variables, including sex and age, and beliefs about causes of depression and related disorders. These findings have implications for refining patient psychoeducation.

(Can J Psychiatry 2003:48: 493–495)

Click here for author affiliations.

Clinical Implications

  • Perceptions of causes of mental illness are an important determinant of treatment adherence.

  • Patients’ perceptions of the cause of their depression should be evaluated.

  • Psychoeducation should incorporate patients’ attitudes and beliefs regarding their illness.

Limitations

  • We only assessed patients who were referred for a mood disorder consultation.

  • We used a survey questionnaire rather than a formal, validated instrument.

  • There was no control or comparison group.


Key Words
: depressive disorders, psychoeducation, treatment compliance, medication compliance, patient attitudes, patient preferences, treatment preferences, major depression

Résumé : Attitudes des patients quant aux causes de la dépression : implications pour la psychoéducation

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.

Method

Subjects
Subjects were consecutive outpatients from a community general hospital psychiatric outpatient clinic who were referred for psychiatric assessment for a depressive disorder. We gave the questionnaire to 110 patients, and 102 valid questionnaires were endorsed. The sample comprised 67 women (65.7%) and 35 men (34.3%) with a mean age of 41.1 years (SD 11.5, range 21 to 72). The DSM-IV diagnoses were unipolar depression (n = 85), bipolar depression (n = 14), and dysthymia (n = 3).

Study Design
To determine patient perceptions of the causes of their depressive disorder in biological, psychological, cognitive, and spiritual dimensions, we gave the patients a 9-item self-report questionnaire that rated the extent to which they believed each factor to be responsible for causing their depression according to a 10-point Likert scale (with 0 = “not at all” and 10 = “definitely”) (see Table 1 for scale items). Subjects completed the self-report questionnaire just prior to their assessment.

Table 1  Patient questionnaire: perceptions of the causes of their depressive disordera

Using the scale below, indicate the extent to which you believe each of the following factors is responsible for causing your depression.

1.  I have a biological abnormality (for example, chemical or hormonal imbalance).

2.  I was born with genes that make me more prone to developing depression.

3.  The way I evaluate or think about my experiences caused my depression.

4.  My depression is due to my personality make-up or temperament.

5.  Stress and negative life experiences caused my depression.

6.  My depression stems from an imbalance in energy or flow.

7.  I’m depressed because I lost touch with my spiritual core or faith in God.

8.  Unhealthy or dysfunctional relationships caused my depression.

9.  My depression is the result of an unhealthy lifestyle (for example, poor diet and lack of exercise).

aPatients rated factors according to a Likert scale where 0 = “not at all” and > 10 = definitely

Results

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).

Table 2  Mean (SD) scores on scale items

Items

Mean (SD)

Biological abnormality

Genes

Cognitive style

Personality make-up or temperament

Stress or negative life events

Imbalance in energy or flow

Spiritual core or faith in god

Unhealthy or dysfunctional relationships

Unhealthy lifestyle

4.48 (3.71)

4.32 (3.74)

 5.61 (3.11)

4.19 (3.11)

6.55 (3.08)

3.58 (3.33)

1.94 (2.73)

4.81 (3.42)

2.90 (3.09)

Conclusion

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.


References

1. Offord D, Boyle M, Campbell D, Cochrane J, Goering P, Lin E, and others. Ontario Health Survey, Mental Health Supplement. Ontario Ministry of Health. Toronto: Queen’s Printer for Ontario: 1994.

2. Robins LH, Locke BA, Regier DA. An overview of psychiatric disorders in America. In: Robins LN, Regier DA, editors. Psychiatric disorders in America: the epidemiological catchment area study. New York: Free Press; 1991. p 24–75.

3. Parikh SV, Lam RW, and the CANMAT Depression Work Group. Clinical guidelines for the treatment of depressive disorders: I. Definitions, prevalence, and health burden. Can J Psychiatry 2001;46(Suppl 1):13S–20S.

4. Mintz J, Mintz LI, Arruda MJ, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry 1992;49:761–8.

5. Parikh SV, Lesage AD, Kennedy SH, Goering PN. Depression in Ontario: under-treatment and factors associated with antidepressant use. J Affect Disord 1999;52(1–3):67–76.

6. Lepine JP, Gastpar M, Mendlewicz J, Tylee A. Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). Int Clin Psychopharmacol 1997;12:19–29.

7. Dwight-Johnson M, Sherbourne CD, Liao D, Wells KB. Treatment preferences among depressed primary care patients. J Gen Intern Med 2000;15(8):527–34.

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.

Author(s)

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

e-mail: janaki_srinivasan@camh.net

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