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Research report

Training primary care physicians in Chile in the


diagnosis and treatment of depression
Benjamin Vicente
a,

, Robert Kohn
b
, Itzhak Levav
c
, Francisco Espejo
d
,
Sandra Saldivia
a
, Norman Sartorius
e
a
Departamento de Psiquiatria y Salud Mental, Universidad de Concepcion, Casilla 160-C, Concepcion, Chile
b
Brown University Department of Psychiatry and Human Behavior, Providence, RI, USA
c
Ministry of Health, Jerusalem, Israel
d
Servicio de Salud Valparaiso, Valparaiso, Chile
e
Department of Psychiatry, University of Geneva, Switzerland
Received 10 August 2005; received in revised form 10 July 2006; accepted 11 July 2006
Available online 22 August 2006
Abstract
Objectives: This study evaluated the results of a brief 2-day educational training program for Chilean primary care physicians that
measured changes in knowledge, attitudes and practice. This World Psychiatric Association (WPA) program was adopted to
overcome diagnostic and treatment problems that are found among primary care practitioners.
Methods: 37 primary care physicians from two cities in Chile and 2589 patients participated. Physician's knowledge, attitudes and
clinical practice were assessed 1 month prior and 1 month following the training program. In addition, the patients that visited the
clinic during a typical week completed depression symptom self-ratings, including the Zung and a DSM-IV/ICD-10 major
depression checklist at both times.
Results: The results suggested that, with this group of Chilean doctors, the WPA program was effective in improving knowledge
about depression and in changing some disorder-related attitudes. In addition, it had some limited impact on actual clinical practice,
although the rate of diagnosis remained stable and the post-training agreement between physician diagnosis and patient self-report
remained low. The physicians seemed more confident in treating patients and demonstrated increased use of antidepressant agents.
Conclusion: The inclusion of primary care physicians is a central component of any initiative to reduce the treatment gap and lag of
depression, but their competence to play a crucial role remains limited. Further training of primary care physicians to improve the
management of major depression continues to be needed.
2006 Elsevier B.V. All rights reserved.
Keywords: Primary care; Depression; Education; Diagnosis; Attitudes; Knowledge
1. Introduction
Most individuals with depression are seen in the
primary care setting, while only a minority turn to
mental health specialists for help (Hans-Ulrich et al.,
2001). In Chile, over 55% of those who had major
depression go untreated (Vicente et al., 2002). Approxi-
mately 9.2% of Chileans suffer from major depression
during their lifetime (Vicente et al., 2002). These rates
are higher within the primary health care system; in
Santiago, primary care centers 15.8% prevalence rate for
Journal of Affective Disorders 98 (2007) 121127
www.elsevier.com/locate/jad

Corresponding author. Tel./fax: +56 41 2312799.


E-mail address: bvicent@udec.cl (B. Vicente).
0165-0327/$ - see front matter 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2006.07.006
depressive disorders was found in a WHO multi-center
study (Ormel et al., 1994).
Despite the high prevalence rate of the disorder in the
primary care setting, the diagnosis and treatment of
depression is insufficient. General practitioners fail to
detect depression in over half of their patients and
provide adequate treatment to only about one-third of
them (Coyne et al., 1995). As a result, patients whose
disorder are unrecognized or managed by an inade-
quately trained physician have poor outcomes (Schon-
feld et al., 1997).
Training programs are needed to promote positive
attitudes and increase the knowledge with regard to the
detection and treatment of depression; however, the
utility of educational programs on the treatment of
depression by primary physicians still requires further
investigation. Some studies have shown improvement in
doctor-patient communication (Roter et al., 1995),
short-term benefits in adhering to clinical guidelines
(Tiemens et al., 1999), as well as cost savings, by
demonstrating population decreases in sick leave,
inpatient treatment, reduced suicide and increased
psychopharmacological prescriptions (Rutz et al.,
1992). Other studies, however, have not demonstrated
an improvement in psychopharmacological prescribing
habits nor in the rate of diagnosis (Thompson et al.,
2000) and in cost savings (Kendrick et al., 2001).
The objective of this study was to evaluate the
effect of the educational training program for depres-
sion designed by the World Psychiatric Association
(WPA) among Chilean primary care physicians. This
was a brief 2-day program designed to be implemen-
table in a real world setting, as it was unrealistic to
expect primary care physicians to suspend their
practices and be unreimbursed for a longer period for
a more intensive training program. The study evaluated
changes in knowledge, attitudes and clinical practice
including the recognition of depression as part of a
multinational program in Latin America (Levav et al.,
2005).
2. Methods
2.1. Study sites
The study was conducted in two cities, Concepcion
and Valparaiso. Six primary health clinics were used in
each city.
Concepcion has a population of 435,000 inhabi-
tants. It is mainly an industrial area with a well-
developed network of primary care services with 22
health centers and one secondary level health care
facility. There are 46 inpatient psychiatric beds in the
city with little intermediate mental health resources
and no emergency services.
Valparaiso has a population of 447,000 inhabitants,
with an economy based on its port and service sector. It
has a well-developed network of primary health care
services with 22 health centers and two secondary-level
care centers. It has a psychiatric hospital with 103 beds,
without emergency services.
2.2. WPA training module
The WPA training module was administered in a
seminar organized by the site coordinator, an experi-
enced psychiatrist. The WPA/PTD Educational Program
on depressive disorders was used to train 19 GP from
Concepcin and 18 from Valparaiso. The course was
given over a period of 2 days for a total of 10 h. The
training week followed the first evaluation of patients
and preceded the second one by 4 weeks. The course
was conducted in each site by two clinical psychiatrists
one of them with considerable experience in primary
care settings. The content of the seminar focused on how
to diagnose major depression, the available treatment
interventions, how to appropriately dose antidepressants
and the side-effects of specific pharmacological agents.
The addition of case histories allowed for an interactive
seminar in a friendly atmosphere. The attendees also
received a printed copy of the materials reviewed.
2.3. Assessment of the training program
Phase 1, an assessment was made of the clinical
practice of the physician 1 month prior to the
educational program during a typical week. All non-
emergency patients aged 15 and older attending the
clinics during the week were administered a ques-
tionnaire, which included socio-demographic items, the
Zung Depression Scale (Zung et al., 1965), and a
symptom checklist that enabled making an approx-
imate DSM-IV and ICD-10 diagnoses for a major
depressive episode. The physicians, blind to the
patient's response, were asked to report on the pre-
sence of a psychiatric disorder, including the diagnosis
of major depression. In addition, the physicians
documented the prescription of psychotropic medica-
tions, the referral of the patient to a mental health
specialist and the provision of supportive therapy. The
physicians were also given a questionnaire to assess
their knowledge and attitudes about depression. The
knowledge component consisted of eight multiple-
choice questions based on a clinical vignette. The sum
122 B. Vicente et al. / Journal of Affective Disorders 98 (2007) 121127
of correct responses was used to derive a score on the
knowledge test. The 10 items investigating attitudes
about depression are listed in Table 3. The responses
ranged from agree to disagree on a 10-point scale. The
dosages and type of antidepressants dispensed in each
of the clinic's pharmacies during the 1-week period
were gathered.
During the following month, the physicians partici-
pated in the WPA educational program. Upon conclu-
sion of the training session, the physicians completed a
questionnaire about their opinions of the program. Phase
2, a repeat evaluation, was conducted 1 month following
the educational program using the same methods as in
Phase 1.
In Concepcion, a control group was included to
investigate whether the changes in the measures of
knowledge, attitudes or clinical practices were not a
result of repeated tests. The control group did not
undergo the educational program and were analogously
evaluated across two time periods 1 month apart. In this
site, 10 physicians acted as controls and 9 completed the
training program.
2.4. Statistical procedures
Change in the doctors' knowledge and attitudes
between Phases 1 and 2 were evaluated using paired t-
tests. Changes for individual knowledge items were
evaluated using McNemar's chi-square. Differences in
clinical practice across the two phases were determined
by Person's chi-square. Diagnostic agreement was
assessed using the kappa statistic, to correct for chance
agreement.
Differences in knowledge and attitudes between the
control and the trained physicians in Concepcion were
assessed using independent t-tests. Changes in clinical
practice in diagnosis, prescription of antidepressants and
referral were evaluated by creating an interaction term
between phase of the study and belonging to the
intervention or control group using logistic regression.
Table 1
Patients by socio-demographic characteristics: Phase 1 and Phase 2
Variable Phase 1 (%),
n=1243
Phase 2 (%),
n=1346
Chi-square df p
Site
Concepcion 43.3 56.0 41.93 1 0.0001
Gender
Male 23.6 27.3 4.64 1 0.03
Marital status
Never married 21.4 20.5 4.48 5 0.48
Married 51.6 53.7
Common-law 4.6 4.2
Widowed 15.2 15.5
Separated 6.8 6.1
Divorced 0.4 0.1
Education
None 8.4 10.0 4.26 4 0.37
14 years 21.3 22.1
58 years 34.1 33.4
912 years 31.4 30.9
13 years 4.8 3.6
Occupation
Professional 0.7 0.6 21.16 8 0.007
Semi-professional 1.3 1.1
Administrative 7.3 6.5
Skilled manual 6.9 7.4
Unskilled manual 67.7 66.1
Student 2.6 1.8
Other 7.4 11.7
Retired 1.0 0.3
Unemployed 5.1 4.5
Mean (S.D.) Mean (S.D.) t-test df p
Age 50.817.2 52.917.3 3.1 2585 0.002
123 B. Vicente et al. / Journal of Affective Disorders 98 (2007) 121127
3. Results
3.1. Demographic and practice characteristics
A total of 37 physicians participated in the study (19
Concepcion, 18 Valparaiso). Over half of the physicians
were males (54.1%, n=20). The physicians averaged
34.27.9 years of age. On average, they had been
practicing for 7.56.9 years and worked in their
respective clinics for 2.33.0 years. Nearly all, 75.7%
(n=28), were employed full-time. In Phase 1, 1243
patients were evaluated and 1346 in Phase 2.
There were differences between the patients selected
for Phases 1 and 2. Age, site, gender and occupation
were statistically different between the two time periods,
but not marital status and education (Table 1).
The physicians reported that 13.818.6% of their
consultations were due to depression and were found to
have diagnosed 23.126.1% of their patients with the
disorder. The physicians also reported prescribing
antidepressants to 43.044.4% of their patients who
had depression and referred 23.136.7% to mental
health professionals. The physician's reports of their
clinical practice did not differ statistically between the
two sites. There were no statistically significant changes
in the rates of diagnosis of depression or treatment by
the physicians following the educational program.
3.2. Knowledge and attitudes
Fifty-eight percent (n=21) of the doctors admitted
that their medical education did not equip them to
diagnose depression, and 77.8% (n=29) stated they did
not have the knowledge to treat depression. There was a
modest but statistically significant increase in knowl-
edge following the training (Phase 1: 6.11.3, Phase 2:
6.61.3, paired t-test =2.3, df =35, p<0.03). Those
who initially had low scores in knowledge showed the
largest increase (r =5.0, n=36, p<0.001). Only one of
the knowledge questions independently showed a
statistically significant improvement: the efficacy of
prescribing serotonin re-uptake inhibitors in depressed
patients following a cardiac event (McNemar's chi-
square=6.23, p<0.02).
Two of the attitudinal questions were significantly
different following the educational program, after
Bonferonni correction for multiple comparisons
( p<0.005). The physicians agreed more often with the
statements: it was easy to differentiate between sadness
and depression, and they were less likely to believe that
only psychiatrists should administer antidepressants
(Table 2).
Some physicians' socio-demographic and practice-
related profiles, e.g., gender, age, years in practice and
number of years working in the clinic were related to
their knowledge and attitudes, and to its respective
changes. There were no significant differences between
the two cities, Concepcion and Valparaiso. Female
physicians scored higher at baseline on the knowledge
items (t =2.09, df =35, p<0.04), but not after training.
The longer the physician worked in the clinic the more
likely depression was viewed as a character flaw at
baseline (r =0.40, p<0.16). The older and the longer
the physician was in practice the stronger their belief
that antidepressants should only be prescribed by a
psychiatrist (r =0.41, p<0.02; r =0.42, p<0.01).
These attitudinal differences were not seen following
training.
Time constraint to attend to patient's emotional
problems was the chief reason given as the primary
barrier to diagnosing depression. This was followed
by limited education about the disorder, somatic
Table 2
Attitudes about depression among physicians (N=33)
Item Phase 1 Phase 2 t-test df p
It is easy to differentiate
between a patient who
is sad and one who is
depressed
4.52.2 6.52.0 3.77 32 0.001
Depression is a way that
weak people confront
life's problems
2.53.0 1.82.5 1.26 32 0.219
I am comfortable addressing
the problems of patients
with depression
4.92.5 5.52.2 1.54 32 0.134
Depression reflects a
personality character
in the patient that is
not easy to change
2.02.7 1.72.1 0.55 32 0.590
Working with depressed
patients is difficult
5.92.8 6.32.4 0.85 32 0.401
It is gratifying to invest time
in treating depressed
patients
5.52.4 6.71.9 2.72 32 0.010
Psychotherapy has no place
for depressed patients
2.72.9 2.32.4 0.79 32 0.433
Antidepressants produce
satisfactory results in
treating depressed patients
7.42.0 7.91.8 1.24 32 0.225
Psychotherapy of depressed
patients should be left to
the specialist
3.93.5 4.03.4 0.10 32 0.921
It is better that a depressed
patient who needs
antidepressant is treated
by a psychiatrist
3.23.1 1.62.2 3.50 32 0.001
Means and standard deviations, paired t-test results.
124 B. Vicente et al. / Journal of Affective Disorders 98 (2007) 121127
equivalents manifested in the disorder, stigma and the
associated vegetative symptoms of the disorder, respec-
tively. Of these diagnostic-related barriers, 83.8%
(n=31) ranked time as the primary problem during
Phase 1. During Phase 2, the proportion lowered to
61.1% (n=22) (paired t-test =3.08, df =35, p<0.004).
3.3. Changes in clinical practice
The physicians diagnosed depression in approximately
14% (n=176) to 15% (n=204) of the patients in both
phases (Table 3). The physicians in Valparaiso diagnosed
depression in both phases at a higher rate than Concepcion
(Phase 1: chi-square=18.48, df =1, p< 0.001; Phase 2:
chi-square=59.28, df =1, p<0.0001), and unlike Con-
cepcion did show a statistically significant increase in
diagnosing depression between the two phases (chi-
square=6.59, df =1, p<0.01). In contrast, over 30% of
the patients reported a level of depressive symptoms
consistent with the diagnosis using one of the three
diagnostic criteria (ICD, DSM-IV, ZUNG). A non-
significant increase in physicians' diagnoses between
the two phases for both sites combined was seen
following the training session. However, the patients'
self-reported rate was significantly lower for most
diagnostic categories in Phase 2. The rate of diagnosis
rose by 1.0% for the physicians between Phases 1 and 2,
the self-reported patient rate fell substantially more, e.g.
DSM-IV 10.8%. Agreement between the physician and
patient self-reported diagnosis remained poor and
showed no improvement following the educational
program.
The patients that were diagnosed with depression by
the physicians following the training program were less
likely to be referred to mental health professionals
(26.1%, n=46, Phase 1 versus 12.7%, n=26, Phase 2;
chi-square =11.03, df =1, p<0.001). There was a
significantly higher rate of prescribing antidepressants
in Phase 2 (46.6%, n=82 versus 57.4%, n=117; chi-
square 14.39, df =1, p<0.04), but less supportive
therapy was provided to the patients (45.5%, n=80
versus 29.4%, n =60; chi-square =10.45, df =1,
p <0.001). The use of benzodiazapines among
depressed patients did not significantly decrease
(21.6%, n=38 versus 17.2%, n=35), nor did the rate
of those only receiving benzodiazapines without anti-
depressants (17.0%, n=16 versus 14.9%, n=13).
Statistically significant differences across the two sites
were seen in each of the clinical measures, but not in the
direction of the changes.
3.4. Control sample in Concepcion
There were no statistically significant differences
between the socio-demographic or practice features
between the 10 physicians in the control sample and
the 9 who underwent the educational program. The
group that underwent the training program did have a
significantly higher improvement in knowledge com-
pared to the control group (t-test =2.12, df =17,
p<0.05). A significant change score among the 10
items tapping attitudes was only found for the statement
that depression was the way weak people confront life's
problems; those that underwent the training were less
likely to endorse this statement (t =2.24, df =16,
p<0.04). Logistic regression with phase-by-intervention
control group interaction suggested that the use of
antidepressants for the patients whose physicians
thought that they were depressed did increase following
the training program (=1.63, S.E. =0.87, p<0.06).
This interaction term was not significant for improving
Table 4
Trained versus control physicians' clinical practice in Concepcion,
Chile
Phase 1 Phase 2
Trained Control Trained Control
Number of patients 240 378 367 350
Diagnosed by physician
with depression
7.5 8.5 5.4 10.0
Use of antidepressant 27.8 37.5 60.0 31.4
Referral to mental health
specialist
55.6 75.0 10.0 45.7
Table 3
Rate (%) of diagnosis of depression by physician and patient's
self-report
Diagnostic
criteria
Phase 1
(n=1243)
Phase 2
(n=1346)
Change Chi-square
(df =1)
p
Physician 14.2
a
15.2
a
1.0 0.51 0.474
Patient
DSM-IV 46.8 36.0 10.8 31.05 0.0001
ICD-10
mild
8.8 9.4 0.6 0.27 0.600
ICD-10
moderate
24.9 20.6
a
4.3 7.01 0.008
ICD-10
severe
34.1 25.0 9.1 25.64 0.0001
Zung mild 22.6

24.1 1.5 0.86 0.354


Zung
moderate
34.2
a
26.9
a
7.3 15.95 0.0001
Zung severe 24.7
a
18.5
a
6.2 14.75 0.0001
a
Significant greater (p<0.05) in Valparaiso.

Significant greater (p<0.05) in Concepcion.


125 B. Vicente et al. / Journal of Affective Disorders 98 (2007) 121127
the diagnostic rate of depression or changing the rates of
referrals to mental health specialists (Table 4).
3.5. Evaluation of the program
Satisfaction with the program was high. Training was
highly rated by doctors/students most considering it
short and not covering sufficiently the psychotherapeu-
tic aspects of depression treatment. Most of the
respondents, 77.1% (n=27), stated they would repeat
the program, 97.1% (n=34) would recommend it to a
colleague, and 85.7% (n=30) would use it to train
others. A majority of the physicians, 85.7% (n=30),
believed their ability to treat depressed patients had
improved.
4. Discussion
There was evidence that the WPA educational
program was effective in improving knowledge about
depression and changing some of the attitudes about the
disorder among these Chilean physicians; however,
there was limited evidence of its favourable impact on
actual clinical practice. The change in knowledge,
although significant, was small; only a few of the
attitude items were found to change with the training
program. As for clinical practice, there was no evidence
that the rate of diagnosis increased. Agreement
remained low between physician diagnosis and patient's
self-reported depressive symptoms compatible with a
diagnosis of depression.
The rate of antidepressant use was shown to rise
significantly from Phase 1 to Phase 2. The use of
supportive therapy, however, fell for unclear reasons. A
possible indication that the physicians had more
confidence in treating patients with depression was
noted in the reduction of referrals to mental health
specialists. The participants clearly reported that the
educational program was beneficial.
This study had several limitations. The change in
physician's clinical care was examined across two cross-
sectional points in time. Such an approach permits
evaluation of improvement in rates of clinical diagnoses,
prescribing habits and referral patterns, but does not
provide longitudinal data on whether the management of
individuals identified with depression has changed.
Improvement in diagnosis was measured by examining
the rate of physician diagnosis compared to the rate of
self-reported symptoms consistent with a depressive
disorder among patients. The demographic differences
between the patients across phases may indicate a
different patient population seen in the two phases and
may be the reason for the lower patient reported
diagnosis in Phase 2. A better measure would have
been the use of a confirmatory structured diagnostic
interview; however, this was not feasible due to the
volume of patients recruited and the constraints of the
primary care clinics. The study was limited to only a 1-
month follow-up of the physicians. Although some
modest changes were noted a month following the
educational training, it remains unclear if this would be
sustained over time. Studies that have examined the
sustainability of educational programs over time have
been negative and recommended periodic retraining to
maintain the gains (Tiemens et al., 1999), although the
benefit of additional training beyond the original
educational program is not substantiated in the
literature.
More promising are initiatives that have included
physician training with other enhancements to promote
detection and continued management of depression.
Programs that have incorporated patient education of
diagnosed individuals to promote treatment adherence
(Rost et al., 2001), trained a specific clinical expert in
the practice setting to detect depression (Wells et al.,
2000), provided psychiatric consult-liaison to the
primary care physician (Bodlund et al., 1999), and had
the physician use a depression detection screening tool
(Brody et al., 1998) have all been shown to be
beneficial. These approaches are not always doable in
many developing countries or in deprived areas where
resources are scarce in particular for mental health care,
clinical practices are not well staffed, and the avail-
ability of psychiatrists to provide consultation rarely
exists.
The programs designed as continuing medical
education are advantageous in that they cost little for
the local authorities to implement, and are acceptable to
physicians; however, may not be adequate. A meta-
analysis of such programs suggested that like the WPA
program only those programs that are interactive effect
change in professional practice and on occasion health
care outcomes (Davis et al., 1999). Future programs
need to be of sufficient duration and include sufficient
active participation, to effect meaningful change in
skills and attitudes (Hodges et al., 2001), and to be
longitudinal in nature.
Such programs may improve knowledge and atti-
tudes among primary care physicians, but may be not
sufficient to bridge the treatment gap. More often than
not the primary care practitioner has learned about
psychological and psychopathological issues in clinical
situations vaguely related to their future locus of
practice. Indeed, most physicians in Chile, and often
126 B. Vicente et al. / Journal of Affective Disorders 98 (2007) 121127
elsewhere, are trained in mental hospitals, settings
where patients and their problems are totally different to
those the general practitioner will encounter in daily
practice. Perhaps, in addition to trying to retrain
physicians, the time has come to locate medical training
in psychiatry where it belongs.
Acknowledgements
Partial funding was provided by the World Psychia-
tric Association, Eli Lilly Foundation and PAHO
Project 99.087.022-4. Updated versions of the materi-
als used in the WPA training program are available at
www.wpanet.org.
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