Actions Taken to Cope with Depression in Patients Seeking Specialist Care

Abstract

Objective: To assess the rates and perceived effectiveness of actions used to cope with depression and the factors influencing these in an outpatient sample seeking help for depression.

Method: One hundred and seventy-six patients (74 male, 102 female) aged 16–82 years (M=42, SD=14.4 years) with a major depressive episode (DSM-IV criteria) were assessed using a number of measures that covered sociodemographics, history of psychiatric illness, actions taken to alleviate depression and their perceived effectiveness. Logistic regression analyses assessed age, gender and illness characteristics associated with the use and perceived effectiveness of strategies adopted to manage depression.

Results: Medical interventions were used and perceived to be effective in alleviating depressive symptoms by most of the sample, as were self-help and complementary therapies. Sociodemographic and illness-related characteristics had a significant influence, with younger age and having experienced an episode of anxiety disorder found to be the strongest predictors for the use of coping strategies. Being female was the strongest predictor for their effectiveness.

Conclusion: A range of actions for depression, including medical and complementary interventions, were used and found to be helpful in a sample that had sought professional help for depression. Gender, age, depression and anxiety factors were all found to predict the use and perceived effectiveness of these strategies.

Keywords

depression help-seeking coping health services needs

Depression is the leading cause of disability [1,2], and is second only to hypertension as the most common chronic condition seen in general practice [3]. Professional helpseeking is an important aspect of treatment, with GPs providing more than three-quarters of mental health services in the Australian community [4]. Although there is strong evidence supporting pharmacological and psychosocial treatments for depression [5], studies using community samples suggest that the lay public is often unaware of the benefits associated with these forms of treatment [6].

In addition to seeking professional help, individuals employ a diverse range of self-help and complementary help-seeking strategies to cope with symptoms of anxiety and depression. This includes relaxation therapy, taking vitamins and engaging in regular exercise [7]. Although two-thirds of patients visiting a conventional mental health provider report the concurrent use of complementary therapies [8], fewer than 40% disclose this to their doctor [9]. Thus it is important to acknowledge and understand the range of measures that individuals use to cope with depression, both to maximize their benefit and understand the process by which patients deal with their disorder [10].

To date, much of the research in this area has been carried out in community samples [11]. This paper focused on the coping strategies used by those who had a diagnosis of depression and who were attending a specialized mood disorders unit for further assistance with managing their illness. We specifically sought to examine what strategies patients used in an effort to alleviate their symptoms, and further, to investigate the helpfulness of each of these strategies. Sociodemographic and illness-related differences were examined with reference to each of these research questions.

Material and methods

Sample

A sample of 239 consecutive attendees was referred by general practitioners and psychiatrists for diagnostic and management advice for a depressive disorder to the tertiary referral Mood Disorders Unit (MDU) at a Sydney teaching hospital. The study group consisted of 176 outpatients (74 male, 102 female) aged 16–82 years (M=42.9, SD=14.4 years) who fitted the diagnostic criteria for a primary DSMIV depressive disorder and had complete data for the questions relevant to the current study. Written informed consent was obtained from all participants.

Clinical assessment and measures

Data were collected (from July 2001 to February 2004) from questionnaires completed by the patients prior to the consultation, and from patient interviews conducted by research assistants and consultant psychiatrists. The patients underwent a comprehensive assessment detailed elsewhere [12]. The structured interview assessed DSM-IV lifetime diagnoses of depressive episodes and anxiety disorders using the computerised Composite InternationalDiagnostic Interview(CIDI), version 2.1 [13]. More complex clinical features of the current depressive episode, including DSM-IV assignment of melancholia or non-melancholia, were measured by the administration of the 21-item Hamilton Rating Scale [14] and the 18-item CORE instrument [15].

Patients completed self-rating scales in a series of questionnaires developed by the MDU. These questionnaires assessed sociodemographic information, current and past psychiatric history, and coping strategies employed by the patient during times of depression. Participants indicated what strategies they had used from a list of 21 items and were also given the option to specify any other methods they had used if these were not included in the original list. Patients rated whether such strategies were helpful on a dichotomous scale (helpful/not helpful). The items included in this questionnaire had been modelled from previous studies [7] and modified to suit the current sample.

Statistical analyses

Multiple logistic regression analyses were carried out to determine if the predictor variables of gender, age, lifetime history of anxiety, the presence of melancholic depression and repeated episodes of major depression were associated with (i) the use of specific actions to alleviate depression and (ii) the perceived helpfulness of these actions.

Results

Of the 176 who participated in the study, all had a diagnosis of DSM-IV major depression, 74% of the sample (n=131) had experienced a least one previous episode prior to attending to MDU, and 73% (n=129) had at least one DSM-IV anxiety disorder in their lifetime. Thirty per cent of the sample (n=53) had clinical features qualifying for a diagnosis of melancholic depression, whereas the remainder were diagnosed with non-melancholic depressive subtype (n=123).

Strategies used to assist with depression

The strategies used to assist with depression are ranked in order of reported frequency (Table 1). As expected in a sample referred to the MDU by GPs or psychiatrists, the use of antidepressants was very high (98%). Other frequently cited strategies used for coping with depression included talking to family (84%), reading about the problem (82%) and learning relaxation (64%). Although most of these strategies were common in both sexes, women were more than twice as likely to have visited a naturopath.

Table 1.

Predictors of employing actions to cope with depression: odds ratios (with 95% CIs) using multiple logistic regression analyses

	Sociodemographic variables			Depression-related variables
	% Used	Female gender	Age	MD episodes 1 vs 2 or more	Non-melancholic vs melancholic depression	Anxiety disorder Presence/absence
Take antidepressants	97.7	0.45 (0.43–4.71)	1.02 (0.29–3.56)	0.00 (0.00–0.00)	0.43 (0.06–3.20)	3.33 (.433–25.57)
Consult psychiatrist	89.2	0.52 (0.17–1.57)	1.13 (0.62–2.05)	0.55 (0.49–2.07)	2.45 (0.67–8.97)	0.79 (0.24–2.57)
Consult GP	83.8	1.24 (0.51–3.02)	0.72 (0.41–1.29)	0.66 (0.22–1.94)	0.52 (0.22–1.27)	2.49∗ (1.02–6.07)
Talk to family	83.5	1.36 (0.59–3.13)	0.61 (0.35–1.07)	0.52 (0.18–1.52)	1.32 (0.54–3.27)	1.23 (0.50–2.98)
Read about the problem	82.4	1.84 (0.82–4.15)	0.76 (0.45–1.28)	0.74 (0.28–1.92)	0.57 (0.25–1.28)	1.31 (0.55–3.08)
Seek counselling	71.6	1.62 (0.63–4.17)	1.53 (0.85–2.76)	1.21 (0.41–3.62)	0.72 (0.34–1.52)	4.96 (1.11–22.14)
Talk to friends	70.5	1.25 (0.63–2.49)	0.52∗∗ (0.33–0.83)	1.13 (0.52–2.46)	0.66 (0.33–1.35)	0.94 (0.44–2.00)
Take time off work	70.5	0.93 (0.47–1.85)	0.64∗ (0.41–0.99)	0.85 (0.39–1.86)	1.23 (0.59–2.54)	1.50 (0.73–3.09)
Learn relaxation	68.2	1.88 (0.95–3.72)	1.07 (0.71–1.63)	0.59 (0.27–1.31)	1.34 (0.64–2.81)	2.78 (1.36–5.65)
Reduce commitments	68.2	1.13 (0.58–2.21)	0.77 (0.51–1.17)	0.70 (0.32–1.52)	0.95 (0.47–1.90)	1.66 (0.82–3.36)
Consult psychologist	59.1	0.67 (0.35–1.28)	0.79 (0.54–1.76)	0.77 (0.37–1.60)	1.49 (0.75–2.97)	2.36∗ (1.18–4.73)
Have a drink	54.0	1.02 (0.54–1.93)	0.66∗ (0.44–0.98)	2.26∗ (1.09–4.68)	0.90 (0.46–1.78)	2.07∗ (1.02–4.17)
Take sleeping pills	52.3	1.70 (0.90–3.19)	1.46 (0.99–2.15)	0.94 (0.46–1.89)	0.76 (0.39–1.48)	1.05 (0.53–2.09)
Increase physical activity	50.0	1.08 (0.58–2.03)	0.85 (0.58–1.24)	1.32 (0.66–2.66)	1.23 (0.64–2.38)	1.47 (0.75–2.91)
Admitted to hospital	46.6	0.90 (0.48–1.71)	0.98 (0.66–1.44)	1.24 (0.60–2.54)	2.83∗∗ (1.44–5.60)	1.48 (0.73–2.98)
Have a massage	42.0	1.35 (0.70–2.60)	1.31 (0.87–1.95)	1.76 (0.83–3.73)	0.63 (0.31–1.26)	2.72∗∗ (1.26–5.81)
New recreations	30.1	1.62 (0.81–3.24)	0.93 (0.62–1.42)	1.02 (0.47–2.19)	0.59 (0.28–1.27)	0.83 (0.40–1.73)
Smoke more	29.5	0.68 (0.34–1.35)	0.84 (0.55–1.28)	1.40 (0.63–3.10)	0.39∗ (1.17–0.88)	1.54 (0.70–3.39)
Practice yoga	28.4	1.69 (0.82–3.46)	1.13 (0.73–1.73)	1.58 (0.68–3.67)	1.45 (0.70–2.98)	1.92 (0.84–4.38)
Consult naturopath	26.7	2.34∗ (1.10–4.96)	1.09 (0.70–1.68)	0.96 (0.42–2.16)	0.99 (0.46–2.10)	1.68 (0.73–3.85)
Use special diet	14.2	1.62 (0.63–4.17)	1.53 (0.85–2.76)	1.21 (0.41–3.62)	0.79 (0.30–2.11)	4.96 (1.11–.22.14)

p< 0.05; ∗∗ p< 0.01; ∗∗ p<0.001; bold font represents significant values.

Age, history of MD or anxiety and depression subtype also predicted the actions patients took to cope with depression. An increase in agewas associated with a decrease in communication with friends, taking less time off work, and being less likely to use alcohol to cope. Drinking was twice as common among those with recurrent episodes of depression. In terms of depression subtypes, those with melancholic depression had higher rates of hospitalisation and non-melancholics smoked more to assist in reducing their symptoms. Patients with a history of anxiety disorders were more likely to have consulted a GP or psychologist, have a massage or use alcohol to alleviate their depression compared to those without a history of anxiety disorders.

Strategies perceived as helpful for depression

The three most helpful activities (reported in Table 2) were seeing a psychiatrist (67%), taking antidepressants (63%) and consulting a psychologist (60%). Women were more likely to report actions relating to professional help-seeking as helpful, including being admitted to hospital, consulting a psychiatrist and receiving counselling. Younger people were more likely to report counselling and learning relaxation techniques as helpful. Thosewith a diagnosis of melancholic depression reported drinking alcohol as more helpful. Due to the small number of patients completing the item ‘special diet’, this was not analysed in a logistic regression.

Table 2.

Predictors of the helpfulness of actions to cope with depression: odds ratios (with 95% CIs) using multiple logistic regression analyses

	Sociodemographic variables			Depression related variables
	% Found helpful†	Female gender	Age	MD episodes 1 vs 2 or more	Non-melancholic vs melancholic depression	Anxiety disorder Presence/absence
Consult psychiatrist	66.9	2.38∗(1.17–4.85)	1.03 (0.66–1.61)	0.77 (0.35–1.71)	1.38 (0.64–2.97)	1.59 (0.75–3.36)
Take antidepressants	63.2	1.90 (0.99–3.66)	1.15 (0.77–1.74)	1.66 (0.81–3.41)	0.88 (0.44–1.78)	0.75 (0.36–1.56)
Consult psychologist	59.2	1.47 (0.64–3.36)	1.03 (0.62–1.71)	0.75 (0.30–1.89)	1.62 (0.67–3.91)	1.36 (0.51–3.62)
Read about the problem	58.6	0.85 (0.42–1.73)	1.15 (0.75–1.76)	1.10 (0.51–2.37)	1.06 (0.50–2.24)	0.83 (0.38–1.80)
Seek counselling	58.1	2.97∗∗ (1.31–6.77)	1.85 (1.12–3.05)	0.39∗ (0.15–0.99)	1.22 (0.51–2.92)	0.62 (0.22–1.75)
Admitted to hospital	57.8	3.99∗∗ (1.51–10.54)	0.79 (0.43–1.47)	0.65 (0.21–1.99)	1.42 (0.52–3.88)	0.60 (0.19–1.89)
Increase physical activity	56.8	1.14 (0.46–2.87)	0.94 (0.54–1.63)	1.83 (0.63–5.31)	0.68 (0.27–1.74)	1.39 (0.50–3.85)
Consult GP	55.0	1.16 (0.58–2.34)	1.31 (0.86–1.98)	0.70 (0.32–1.51)	1.20 (0.57–2.53)	0.46 (2.10–1.04)
Have a massage	54.1	2.19 (0.80–6.01)	0.98 (0.51–1.90)	1.61 (0.48–5.42)	0.96 (0.32–2.84)	1.87 (0.52–6.76)
Take sleeping pills	53.8	0.52 (0.21–1.31)	1.48 (0.82–2.66)	1.20 (0.43–3.36)	2.27 (0.84–6.13)	1.41 (0.52–3.85)
Talk to friends	49.2	0.63 (0.29–1.35)	1.27 (0.80–2.01)	1.21 (0.52–2.84)	1.49 (0.65–3.40)	0.67 (0.30–1.53)
Talk to family	47.3	0.62 (0.31–1.26)	1.06 (0.69–1.62)	1.40 (0.64–3.06)	1.57 (0.76–3.23)	0.63 (0.29–1.35)
Reduce commitments	42.1	0.79 (0.36–1.74)	1.20 (0.76–1.91)	1.74 (0.72–4.21)	0.68 (0.30–1.56)	0.79 (0.33–1.87)
Learn relaxation	41.7	1.34 (0.58–3.05)	2.13 (1.25–3.62)	1.25 (0.52–3.03)	1.72 (0.76–3.87)	1.28 (0.49–3.35)
Practice yoga	39.2	4.06 (0.89–18.51)	1.47 (0.66–3.29)	0.44 (0.08–2.50)	0.54 (0.14–2.10)	2.08 (0.38–11.32)
Have a drink	38.5	0.66 (0.26–1.69)	0.73 (0.41–1.30)	1.93 (0.58–6.35)	3.78∗∗ (1.41–10.10)	1.11 (0.35–3.49)
Take time off work	37.9	0.62 (0.29–1.35)	1.01 (0.63–1.61)	1.90 (0.78–4.61)	1.36 (0.61–3.03)	1.07 (0.44–2.56)
New recreations	30.9	1.33 (0.34–5.20)	1.17 (0.55–2.51)	1.70 (0.36–8.06)	0.13 (0.02–1.19)	1.31 (0.33–5.02)
Smoke more	27.5	0.49 (0.11–2.16)	1.19 (0.50–2.86)	3.18 (0.47–21.48)	2.18 (0.44–10.80)	0.30 (0.06–1.51)
Consult naturopath	19.1	0.33 (0.05–2.37)	0.66 (0.22–2.04)	0.00 (0.00–0.00)	2.94 (0.49–17.61)	0.57 (0.04–7.80)

∗ p< 0.05; ∗∗ p< 0.01; ∗∗ p< 0.001.

† Frequencies are obtained from the proportion of the sample who had used the intervention; bold font represents significant values.

Discussion

The rates of use of complementary interventions reported in this study are relatively high in comparison to earlier reports taken from the general population [16]. This is interesting given that virtually all participants had been prescribed an antidepressant and were attending the MDU, implying high acceptance of standard professional treatments. Practitioners should, therefore, recognise that their patients are likely to have tried at least one form of complementary therapy, even if this is not disclosed during treatment [17].

Differences relating to sociodemographic and illnessrelated characteristics were frequently recorded. In particular, younger patientsmore frequently talked to friends and took time off work, and ‘had a drink’ to cope with their depression. A history of anxiety disorder was a major determinant of the types of strategies used, both in terms of clinical actions (consulting aGP or psychologist) and complementary actions (such as having a massage). Those with anxiety disorders and with repeated depressive episodes used alcohol to cope with their depression, while patients with non-melancholic depression were more likely to smoke than their melancholic counterparts. These results highlight the need for clinicians to enquire about substance use and, furthermore, encourage individuals with a depression and/or smoking history not to recommence the habit when depressed as it is likely to exacerbate their problems and impair their ability to overcome depression [18,19].

Being female was the most significant predictor of perceived benefits of particular interventions. Females found consulting a psychiatrist or counsellor and being admitted to hospital to be more helpful than males. A previous study using a similar sample of 98 men and 172 women from the MDUreported that whereas men andwomen had very similar experiences of depression (when examined for duration, depression type and severity prior to treatment), their repertoires for dealing with depression significantly differed [12]. These findings support previous literature indicating that gender is a major determinant of professional help-seeking rather than actual depressive experience [7,20,21].

Few differences were recorded for the helpfulness of interventions between groups based on the number of previous episodes, on the type of depression experience, or whether patients had experienced an anxiety disorder. Complementary medicines were just as frequently used and found to be as helpful as the clinical interventions. These results may be due to the changing profile of complementary medicine, with activities such as yoga now being used more commonly in the general community. Increasing physical activity was also popular, with over half the patients indicating they had tried this to reduce their depression. Although there were no differences in exercise usage or perceived helpfulness between those with melancholic and non-melancholic depression, it is plausible that the mechanisms of how exercise helps may differ. Those with melancholic depression may find that it gives relief from lethargy, whereas those with nonmelancholic depression may find that it assists in reducing emotional dysregulation. While the positive effects of exercise on depression have been shown in a number of reviews [22], the quality of the studies does not allow researchers to conclude whether the benefits are direct or indirect (e.g. through increasing social interactions) [23].

Although the majority of patients had talked to family and friends about their depression, less than half had found it helpful. This is in contrast to receiving information through reading, a strategy thatwas used and found to be helpful to patients regardless of gender, age or depression experience. Reading about themental illness is likely to encourage patients to consider more treatment options [6] and providing information has been linked to an increase in help-seeking behaviour [6,24,25]. Although we are mindful of the need to consider the characteristics of the depressive episode [26], education may be of particular value for those with non-melancholic depression and with significant anxiety. These results also highlight the importance of making information available to those whomthe depressed person is likely to turn, as individuals with good social support are more likely to seek professional help for mental problems [27], which further point toward the importance of a supportive informed social network.

Although this paper is limited in that these results are highly specific to those seeking specialist care, there are several important ‘take home’ messages from this paper. Professional intervention remains a fundamental part of treating depression, yet self-help and complementary therapies are used and perceived to be just as helpful as orthodox treatments by many patients. Although this paper is not intended to provide recommendations of treatment, it should be beneficial among professionals for appreciating the use and helpfulness of a range of coping strategies. This should potentially complement and enhance patients’ prescribed treatment regime, as well as assist their significant others in providing helpful advice and encouragement as well as more general social support.

Footnotes

Acknowledgements

The work is supported by NHMRC Program Grant 222708 and by an Infrastructure Grant from the Centre for Mental Health, NSW Department of Health.

References

1. Andrews

Hall

Teesson

Henderson

. The mental health of Australians. Commonwealth Department of Health and Aged Care, Canberra 1999.

2. Murray

Lopez

. The global burden of disease. World Health Organization, Geneva 1996.

3. Whooley

Simon

. Managing depression in medical outpatients. New England Journal of Medicine 2000; 343: 1942–1950.

4. Parslow

Jorm

. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry 1008; 34: 997–1008.

5. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression . Australian and New Zealand clinical practice guidelines for the treatment of depression. Australian and New Zealand Journal of Psychiatry 2004; v38: 389–407.

6. Jorm

Griffiths

Christensen

Korten

Parslow

Rodgers

. Providing information about the effectiveness of treatment options to depressed people in the community: a randomized controlled trial of effects on mental health literacy, help-seeking and symptoms. Psychological Medicine 2003; 33: 1071–1079.

7. Jorm

Griffiths

Christensen

Parslow

Rogers

. Actions taken to cope with depression at different levels of severity: a community survey. Psychological Medicine 2004; 34: 293–299.

8. Kessler

Soukup

Davis

Foster

Wilkey

Van Rompay

Eisenberg

. The use of complementary and alternative therapies to treat anxiety and depression in the United States. American Journal of Psychiatry 2001; 158: 289–294.

9. Weier

Beal

. Complementary therapies as adjuncts in the treatment of postpartum depression. Journal of Midwifery and Women's Health 2004; 49: 96–104.

10.

10. McKendree-Smith

Floyd

Scogin

. Self-administered treatments for depression: a review. Journal of Clinical Psychology 2003; 59: 275–288.

11.

11. Jorm

Medway

Christensen

Korten

Jacomb

Rodgers

. Public beliefs about the helpfulness of interventions for depression: effects on actions taken when experiencing anxiety and depression symptoms. Australian and New Zealand Journal of Psychiatry 2000; 34: 619–626.

12.

12. Wilhelm

Roy

Mitchell

Brownhill

Parker

. Gender differences in depression risk and coping factors in a clinical sample. Acta Psychiatrica Scandinavica 2002; 106: 45–53.

13.

13. WHO . Composite International Diagnostic Interview, Version 2.1. World Health Organisation, Geneva 1996.

14.

14. Hamilton

. Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 1967; 6: 278–296.

15.

15. Parker

Hadzi-Pavlovic

Melancholia D

. A disorder of movement and mood. A phenomenological and neurobiological review. Cambridge University Press, New York 1996.

16.

16. Unutzer

Klap

Sturm

Young

Marmon

Shatkin

Wells

. Mental disorders and the use of alternative medicine: results from a national survey. American Journal of Psychiatry 2000; 157: 1851–1857.

17.

17. Eisenberg

Kessler

Van Rompay

Kaptchuk

Wilkey

Appel

Davis

. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Annals of Internal Medicine 2001; 135: 344–351.

18.

18. Wilhelm

Arnold

Niven

Richmond

. Grey lungs and blue moods: smoking cessation in the context of lifetime depression history. Australian & New Zealand Journal of Psychiatry 2004; 38: 896–905.

19.

19. Roy

Parker

Mitchell

Wilhelm

. Depression and smoking: examining correlatetes in a subset of depressed patients. Australian and New Zealand Journal of Psychiatry 2001; 35: 329–335.

20.

20. Kessler

McGonagle

Swartz

Blazer

C.B

. Sex and depression in the National Comorbidity Survey I. Lifetime prevalence, chronicity and recurrence. Journal of Affective Disorders 1993; 29: 85–96.

21.

21. Bland

Newman

Orn

. Help-seeking for psychiatric disorders. Help-seeking for psychiatric disorders. Canadian Journal of Psychiatry 1997; 42: 935–942.

22.

22. Lawlor

Hopker

. The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomised controlled trials. British Medical Journal 2001; 322: 763–766.

23.

23. McNeil

LeBlanc

Joyner

. The effect of exercise on depressive symptoms in the moderately depressed elderly. Psychology and Aging 1991; 6: 487–488.

24.

24. Jorm

Korten

Jacomb

Christensen

Rodgers

Pollitt

. “Mental health literacy”: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia 1997; 166: 182–186.

25.

25. Goldney

Fisher

Wilson

. Mental health literacy: an impediment to the optimum treatment of major depression in the community. Journal of Affective Disorders 2001; 64: 277–284.

26.

26. Parker

. Classifying depression: Should paradigms lost be regained?. American Journal of Psychiatry 2000; 157: 1195–1204.

27.

27. Roness

Mykletun

Dahl

. Help-seeking behaviour in patients with anxiety disorder and depression. Acta Psychiatrica Scandinavica 2004; 111: 51–58.