Characteristics of Depressed Patients Treated in Rural Areas of Chile

doi:10.4236/psych.2013.411A003

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Psychology

2013. Vol.4, No.11A, 11-15

Published Online November 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.411A003

Open Access 11

Characteristics of Depressed Patients Treated

in Rural Areas of Chile*#

Ariel Castro-Lara1†, Viviana Guajardo2,3, Rosemarie Fritsch2,4,

Ruben Alvarado3, Graciela Rojas2

1Investigations Support Office, Clinical Hospital, Universidad de Chile, Santiago, Chile

2Clinical Hospital, Faculty of Medicine, Universidad de Chile, Santiago, Chile

3School of Public Health, Faculty of Medicine, Universidad de Chile, Santiago, Chile

4Psychiatry Department, Faculty of Medicine, Universidad de Los Andes, Santiago, Chile

Email: †[email protected]

Received September 19th, 2013; revised October 21st, 2013; accepted November 18th, 2013

mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-

vided the original work is properly cited.

Objective: To describe a group of depressed patients that participated in a clinical intervention to improve

depression treatment in rural areas. Materials and Methods: It is a clinical intervention for depressed pa-

tients from 15 rural hospitals. The principal outcome is depressive symptomatology measured with the

Beck Depression Inventory (BDI), and the secondary outcome is quality of life. The intervention consists

of a collaborative program between primary care teams and specialized teams, with support from an elec-

tronic platform and a call center. Results: 254 subjects—13.8% men and 86.2% women—were recruited,

with an age range between 18 and 65 years. The majority had a stable partner and attended high school.

Homemakers made up 47.4% of the sample, and 38.7% were employed. The average BDI score was 29.8

(s. d. = 9.2). There was a history of previous depressive episodes in 42.9% of the cases, 37.4% presented

severe suicide risk, and 59.1% had a comorbid anxiety disorder. Conclusion: It is a clinical sample of pa-

tients with severe depressive symptoms who are treated by primary care physicians in rural zones. The

sample had comorbid anxiety and poor quality of life associated with their mental illness.

Keywords: Depression; Mental Health; Rural Health

Introduction

Depression is a highly disabling condition and a public

health problem, due to its high prevalence, long duration, and

recurrence. It is estimated that by 2012, depression will be the

second leading cause of years lost to disability for both sexes

worldwide (Murray & Lopez, 1996, 1997).

Population-level studies carried out in Chile have calculated

a prevalence of approximately 5% in the general population and

30% in the population served by the public primary care system

(Florenzano, Acuña, Fullerton, & Castro, 1998; Kohn et al.,

2005; Rojas, Araya, & Fritsch, 2000; Sartorius et al., 1993).

In light of this issue, in 2001, the Chilean Ministry of Health

created the “program for the detection, diagnosis, and treat-

ment of depression in primary care,” and in June 2006, as part

of a health reform, depression care for individuals over 15 years

of age was incorporated into the country’s Explicit Health

Guarantees (Law GES), thereby assuring universal access to

depression treatment (Ministry of Health, 2012).

The Ministry of Health Clinical Guidelines for the Treatment

of Individuals with Depression gives primary care teams the

central role of detecting, diagnosing, and treating depression.

The most complex cases are referred to specialized mental

health centers, which also support the primary care teams with

their work (Ministry of Health, 2009)

This article describes a sample of depressed patients treated

in small, rural community hospitals, belonging to the regional

health services of Reloncaví, Ñuble, and Coquimbo, Chile. The

sample forms part of an investigation to measure the effective-

ness of a collaborative telepsychiatry program between com-

munity hospital care teams and a specialized mental health

team to improve the management of depression.

This study will characterize patients who received treatment

for depression in rural zones of Chile, with the aim of support-

ing the adaption and optimization of the national recommenda-

tions for depression treatment in particular populations.

Metodology

A baseline evaluation was carried out with patients who en-

tered depression treatment in each community hospital (N = 15)

pertaining to the health services of Coquimbo, Ñuble, and Re-

loncaví, Chile. These establishments are not currently super-

vised by specialized mental health professionals.

The clinical trial measured the effectiveness of a collabora-

tive telepsychiatry program between primary care teams of

rural community hospitals and a specialized mental health team

from the Clinical Hospital of the Universidad de Chile to im-

prove the management of depression.

*Funding: FONDECYT 1100205.

#Conflicts of Interest: None.

†Corresponding author.

A. CASTRO-LARA ET AL.

At the local level, teams from the community hospitals in

charge of the depression management program invited patients

who fit the ICD-10 criteria (WHO, 1992) for a depressive epi-

sode, who were between 18 and 65 years of age, and who had

had not been in treatment in the past two weeks, to participate

in the collaborative program. If they accepted, potential par-

ticipants were carefully read the informed consent form, ap-

proved by the Ethics Committee of the Clinical Hospital of the

Universidad de Chile, and if they agreed to participate, their

data were entered into an online platform, designed for this

study (Figure 1). A specially trained interviewer then contacted

the patients by telephone to assess if they fit the study’s inclu-

sion and exclusion criteria, to evaluate their quality of life and

depressive symptomatology—confirming the diagnosis of a

depressive episode, and to collect socio-demographic data and

information on any previous history of depression.

The baseline evaluation interview collected the patients’

socio-demographic information and psychiatric history and

included sections of the Mini International Neuropsychiatric

Interview (MINI) (Sheehan et al., 1998), for the psychiatric

diagnosis; the Beck Diagnostic Inventory (BDI) (Beck, Steer, &

Carbin, 1998), to assess depressive symptoms; and the Short

Form Health Survey (SF-36) (Ware, Kosinski, & Keller, 1994),

to measure quality of life.

The BDI is a self-administered instrument, with 21 items,

(a)

(b)

Figure 1.

Electronic platform of the intervention.

that measures depressive symptomatology. It has been widely

used around the world, and its psychometric properties are well

known. In Chile, it has been previously applied in primary care

(Alvarado, Vega, Sanhueza, & Muñoz, 2005).

The SF-36 is a self-administered questionnaire, used to as-

sess quality of life. It has 36 questions that measure 8 health

concepts or dimensions—physical functioning, physical role

functioning, bodily pain, general health perceptions, vitality,

social role functioning, emotional role functioning, and mental

health—and the perception of change in health status over the

past year. The standard version—the validated questionnaire

validated in Chile by Inostroza and used in primary care (Inos-

troza, 2006)—uses a recall period of four weeks.

The MINI, SF-36, and BDI have also been previously used

in Chile by some of the investigators who carried out the cur-

rent study (Rojas et al., 2007; Rojas, Araya, & Lewis, 2005).

Results

The sample consisted of 254 patients (86.2% women and

13.8% men), with an average age of 41.3 years (s. d. = 12.5),

ranging between 18 and 65 years. The majority of the partici-

pants had a stable partner (41.3% married and 11.0% cohabi-

tating). In terms of education, 44.1% had completed secondary

school, 37.8% primary school, and 14.6% higher education,

while 3.5% reported being illiterate. Homemakers made up

47.4% of the sample, and 38.7% worked (Table 1).

Table 1.

Socio-demographic characteristics of the sample N = 254.

Factor % (N)

Men 13.8 (35)

Sex Women 86.2 (219)

Age (Range) 41.3 (18 - 65)

Single 22.8 (58)

Cohabiting 11.0 (28)

Married 41.3 (105)

Divorced/Separated 19.3 (49)

Marital status

Widowed 5.5 (14)

Illiterate 3.5 (9)

Incomplete Primary 24.0 (61)

Complete Primary 13.8 (35)

Complete Secondary 32.3 (82)

Incomplete Secondary 11.8 (30)

Education

level

Post-Secondary 14.6 (37)

Homemaker 47.4 (120)

Student 4.0 (10)

Employed 38.7 (98)

Unemployed 8.3 (21)

Occupation

Retired/on pension 1.6 (4)

Open Access

A. CASTRO-LARA ET AL.

The sample had an average BDI score of 29.8 points (s. d. =

9.2), and according to the instrument, 8.4% of the participants

had a mild depressive episode, 22.2% had a moderate depres-

sive episode, and 68% had a major depressive episode. A his-

tory of previous depressive episodes was reported by 42.9% of

the participants.

The results of the MINI revealed that 192 of the participants

(75.6% of the sample) were at risk of suicide: 26.4% had low

risk, 11.8% had moderate risk, and 37.4% had high risk. Addi-

tionally, 59.1% of the sample had a comorbid anxiety disorder

(Table 2).

According to the SF-36, the sample scored an average of

49.0 points in the social functioning dimension, 22.8 points in

the emotional role functioning dimension, 49.4 points in the

mental health dimension, and 52.1 points in the vitality dimen-

sion (Table 3). The average SF-36 mental component of health

summary score was 29.2 (s. d. = 9.2), and the average physical

component of health summary score was 48.0 (s. d. = 8.3).

Table 4 and Figure 2 show that the relationship between the

average BDI scores of the sample and the SF-36 mental com-

ponent of health summary score is inverse and statistically sig-

nificant (Pearson Correlation = −0.212, bilateral p-value =

0.001).

A linear prediction model was applied, using the BDI score

as the independent variable and the mental health component as

the dependent variable, to obtain a statistically significance

relationship. This adjustment resulted in the following parame-

ters for the mental component of health: b0 = 35.6 and b1 =

−0.213 (F = 11.428; p = 0.001).

Discussion

This study was carried out in rural community hospitals lo-

cated in small towns in the northern, southern, and central

Table 2.

Clinical characteristics of the sample N = 254.

Variable % (N)

History of Depressive Episodes 42.9% (109)

Comorbid Anxiety Disorder 59.1% (150)

No Risk 24.4 (62)

Low Risk 26.4 (67)

Moderate Risk 11.8 (30)

Suicide Risk

High Risk 37.4 (95)

Table 3.

Quality of Life variable scores related to mental health (SF-36).

Dimension Average Score (CI 95%)

Vitality 52.1 (50.26 - 53.89)

Social Functioning 49.0 (47.45 - 50.61)

Emotional Role 22.8 (18.71 - 26.92)

Mental Health 49.4 (47.75 - 51.05)

Mental Health Summary Component 29.2 (28.09 - 30.40)

Table 4.

Quality of Life variable scores related to mental health (SF-36).

Pearson

Correlation

p-value

(Bilateral)

Beck Total Basal 1

PCS—Baseline −0.052 0.421

MCS—Baseline −0.212 0.001

Physical Functioning—Baseline −0.317 <0.001

Social Functioning—Baseline 0.085 0.186

Physical Functioning Role—Baseline −0.163 0.011

Mental Functioning Role—Baseline −0.300 <0.001

Mental health—Baseline −0.065 0.309

Vitality—Baseline 0.187 0.003

Pain—Baseline −0.001 0.982

General Health—Baseline 0.982

Change in Health—Baseline 0.280 <0.001

Figure 2.

Association between total Beck score (BDI and the Mental Component

Summary score of the SF-36).

zones of Chile that provide both inpatient and outpatient care

services. There is currently no published data on the patient

population treated in these rural centers, which do not receive

specialized supervision for the detection, diagnosis, and treat-

ment of depressed patients.

The sample of this study is only made up of the 15 partici-

pating community hospitals, and thus, the results are not gener-

alizable, as the sample is not representative of all community

hospitals throughout the country.

The majority of patients treated in these centers are women,

consistent with the national and international literature, which

indicates that women are more likely to suffer from depression

than men are (Patel, Araya, De Lima, Ludermir, & Todd, 1999)

(Rojas, Araya, & Lewis, 2005) and that women seek treatment

more often than men do (Gómez Gómez, 2002). Furthermore,

Open Access 13

A. CASTRO-LARA ET AL.

past research has shown that, in Chile, these depression risk and

treatment access gaps between women and men are greater than

in European countries. Nevertheless, it is probable that, in addi-

tion to the aforementioned points, this difference is explained

by the barriers men face to access treatment, due to the health

centers’ hours of operation.

The study sample is clinically complex, with depressive epi-

sodes accompanied by suicide risk, comorbid anxiety disorders,

significant associated disability, and a previous history of de-

pression. Upon comparison to the 2011 study by Alvarado et al.,

which evaluated the national depression program in urban pri-

mary care clinics (Alvarado & Rojas, 2011), the sample from

this study, treated in rural community hospitals, had a higher

percentage of severe depression, a finding which should be

taken into account when designing methodologies to optimize

depression treatment for this particular population.

It is likely that in more rural zones, where these community

hospitals are located, patients face obstacles to access special-

ized treatment, given that two known treatment barriers are

distance and cost considerations (Luo & Wang, 2003; Men-

donza-Sassi & Béria, 2001; Rosenberg, 1998).

Only 24.4% of patients in the sample did not present suicide

risk. A study carried out by Escobar and Rojas found that 2.6%

of the 2008-2009 discharges from a rural hospital were patients

with suicidal behavior, approximately 70% of whom were

women. In addition, close to 60% of the patients had a history

of psychiatric disorders, and of those, 26.5% had a previous

depressive episode. Strikingly, only 24.48% of the patients

hospitalized in the rural community hospitals were evaluated by

a specialized mental health professional (Escobar & Rojas,

2010). The high rate of attempted suicide in Chile has been

previously described (Moyano Díaz & Barría, 2006; Tomas

Baader et al., 2011). Sociopolitical explanations attribute this

phenomenon to economic indicators of increasing inequality,

job insecurity, interpersonal distrust, and weakening social

networks (Moyano Díaz & Barría, 2006).

This study found a correlation between the intensity of de-

pressive symptoms, according to the BDI, and the SF-36 qual-

ity of life components. The sample’s SF-36 scores revealed

significant degrees of disability, and as the participants’ sever-

ity of symptoms increased, they had worse quality of life. It is

noteworthy that the majority of previous studies that have

shown this correlation between depressive symptomatology and

the SF-36 were carried out in urban populations (Friedman,

Conwell, & Delavan, 2007).

These results indicate that primary care teams in these rural

health centers, with little mental health skills training, are treat-

ing clinically complex patients, necessitating collaboration and

networking with specialized professionals. There has yet to be

sufficient research into what treatment alternative is most effec-

tive and what barriers exist to achieve collaboration with spe-

cialized secondary care teams and to ensure successful referral

of complex cases. Collaborative initiatives between primary

care and mental health professionals have shown positive re-

sults in terms of reduced referral time, treatment duration,

number of visits, and costs associated with treatment (Gilbody,

Bower, Fletcher, Richards, & Sutton, 2006; Van Orden, Hoff-

man, Haffmans, Spinhoven, & Hoencamp, 2009). Similar ini-

tiatives, which have also incorporated telemedicine, have pro-

duced good results in terms of improved mental health status,

quality of life, and user satisfaction (Fortney et al., 2007).

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