Training on the management of depression in primary care in Azerbaijan

Abstract

In 2006, the Azerbaijan Ministry of Health and the World Bank launched the 6-year Health Sector Reform Project (HSRP). The principal goal of the Project is to prepare and implement a fundamental and comprehensive reform of the health system in Azerbaijan, including a major emphasis on strengthening the primary care system (Ministry of Health Project Implementation Unit, 2007). The project envisions the development of a new optimised system of services, with the integration of mental health into general healthcare. In the line of this process, the Public Health and Reform Centre (PHRC) of the Ministry of Health has developed evidence-based clinical practice guidelines on depression, for implementation within primary care (Ministry of Health, 2009). At the same time, representatives from the PHRC and the Departments of Psychiatry and Family Medicine of Azerbaijan Medical University, as well as the State Institute for Advanced Training of Physicians (in cooperation with the World Health Organization Country Office), formed a task force to carry out a survey to assess the need for education in mental health for primary care doctors. A total of 308 primary care doctors (see Table 1) working in 14 settings in different regions of the country were randomly selected and interviewed by the research team.

Table 1. Demographic data of the survey respondents (n = 308).

	Number (%) of participants
Setting location
urban area	186 (60.4)
rural area	122 (39.6)
Gendera
male	138 (45.1)
female	168 (54.9)
Age (years)
up to 30	15 (4.9)
31–40	39 (12.7)
41–50	89 (28.8)
51–60	122 (39.6)
61 and over	43 (14.0)
Years in practice
less than 6	25 (8.1)
6–10	16 (5.2)
11–20	78 (25.3)
21–30	116 (37.7)
over 30	73 (23.7)

^aData not recorded in two instances.

All participants of the survey were asked to fill in a specially designed semi-structured questionnaire consisting of 34 items. Along with items covering personal information and professional responsibilities, the questionnaire included a set of questions about the recognition and treatment of depression in primary care. In addition, it queried the respondents’ opinions and expectations regarding improvements in care provision for patients with depression.

Recognition of depression in primary care

According to international studies, the median prevalence rate for depression around the world is more than 10% in primary care settings (Üstün & Sartorius, 1995). The data obtained from the survey revealed that less than 3% of the population presenting to primary care were recognised as suffering from depression. Although detection rates of depression varied between the different primary care settings, it may be proposed that the vast majority of sufferers are not being identified at the primary care level. In fact, primary care physicians have the difficult task of detecting depression among persons who are applying for services other than psychiatric treatment. Furthermore, patients with depression often present to primary care physicians with somatic symptoms such as poor appetite, weight loss, sleeplessness, fatigue and pain, which may be confused with physical illness. In addition, primary care physicians are highly likely to have patients with dual diagnoses – somatic illness and comorbid depressive disorder – which, in turn, may significantly extend the disability in these patients. In such cases, physicians often attribute the ‘presenting’ depression to the physical illness; thus they consider them as psychological responses secondary to a wide variety of underlying health conditions. Both patients and their doctors tend to ‘normalise’ depressive symptoms as variations of normal mood swings, and thus the prevalence of depression is underestimated (Ismayilov, 2004).

Even when recognised, the type and severity of depressive episodes are not always identified in accordance with the ICD-10 diagnostic criteria. In the present survey, 68% of primary care physicians could identify patients suffering from severe depression, but mild or moderate depressive episodes, as well as depression with atypical features, would generally remain undetected. Furthermore, 54% of primary care physicians were unaware of bipolar depression and they never asked patients about a history of manic episodes. Similarly, approximately only 15% of primary care physicians confirmed that they routinely assessed risk of suicide in patients recognised as having depression.

The treatment of depression in primary care

Despite the availability of clinical practice guidelines on the diagnosis and treatment of depression, primary care doctors have often treated them as academic reference materials, and have been slow to implement their recommendations. Although many patients receive treatment from primary care physicians, there is a lack of evidence that treatment is provided ineffective doses and for adequate periods of time.

In the survey, 30% of primary care physicians reported prescribing antidepressants in their practice. Most of these tended to treat their patients with older classes of drugs, such as tricyclic antidepressants, and only 18.5% prescribed the newer selective serotonin reuptake inhibitors (SSRIs) and serotonin–noradrenaline reuptake inhibitors (SNRIs), which have been shown to be better tolerated than older classes of drug. In general, physicians demonstrated insufficient awareness of safety profile, side-effects and drug–drug interactions of the psychotropic medicines they prescribed. Therefore, many primary care doctors tend to administer very low (i.e. ineffective) doses of antidepressants. They have misconceptions about dosage regimens and rarely focus on adherence issues. Although the guidelines on depression stipulate at least 6 months of maintenance treatment, this period often does not exceed 2 months in primary care, as medication is discontinued after any initial improvement in depressive symptoms.

In some primary care settings the majority of physicians prescribe tranquillisers (benzodiazepines) rather than antidepressants as the first-line treatment for depression. Moreover, 21.9% of physicians who treat depression reported treating it with other medications (e.g. neuroleptics, nootropics and herbal medications) that are not indicated for depression. At the same time, psychological interventions that are effective for depression, such as counselling, cognitive–behavioural therapy, family therapy and interpersonal therapy, are not familiar to most physicians and are not used at primary care level.

In addition, currently in Azerbaijan there is no system in place to monitor or supervise the psychopharmacological or other mental health treatment approaches of primary care physicians.

Training primary care doctors in the management of depression

The problems in the recognition and treatment of depression are caused by inadequate training of primary care physicians, which is often limited to information obtained at the undergraduate level. Moreover, their training in mental health is based within psychiatric institutions and focuses on severe and complicated mental disorders, rather than on the mental health problems commonly encountered in primary care settings. The postgraduate programme for general practitioners that follows graduation from medical university does not include a mental health rotation. In our survey, only 2.3% of primary care physicians had had any postgraduate training in mental health.

In order to prepare primary care practitioners to provide services for patients with depression, ten master trainers from regional primary healthcare settings have been selected and educated to teach primary care doctors. The training is supervised by mental health professionals employed by Health Sector Reform Project Implementation Unit and is based on the Educational Programme on Depressive Disorders of the World Psychiatric Association (Maj et al, 2009), which has four modules:

• overview and fundamental aspects of depression

• physical illness and depression

• depression in specific population groups

• methods of training and education about depression.

The trainees learn general information about depression (epidemiology, clinical features, natural course and outcomes), application of the bio-psychosocial approach to depression, and contemporary classification of depressive disorders. Practical skills in the management of depressive disorders include their recognition, diagnosing depression with the Patient Health Questionnaire (PHQ-9), suicide risk assessment, developing a treatment plan, administering non-pharmacological interventions and antidepressant medications, and referral to specialist care. An emphasis was placed on addressing specific needs of patients (pregnancy, developmental aspects, ageing and comorbid physical illness). Doctors in training should develop proper attitudes towards interpersonal functioning, suicidal ideation and adherence to treatment on the part of patients with depression. An important aspect of the training are the methods of teaching primary care doctors, which include case presentations, role-play, small-group discussions and evaluation of knowledge, skills and attitudes.

Along with this short-term training for already employed primary care doctors, the Department of Psychiatry, Azerbaijan Medical University, in cooperation with the World Health Organization Country Office, has introduced a training programme on the management of depression for graduates in primary care. It is expected that training of primary care doctors on the management of depression will result in the development of whole-person care, reduce the stigma accompanying mental illness and improve access to care for the most vulnerable population groups.