Préconisations pour la prise en charge de la dépression dans le cadre des soins primaires : analyse systématique de la littérature

Abstract

La dépression constitue à l’heure actuelle un réel problème de santé publique associé à des coûts de santé très élevés et à des répercussions importantes dans la vie du patient et de son entourage. Un des enjeux est d’identifier les prises en charge les plus adaptées en fonction du stade de la maladie et de préciser la place des différents acteurs. Cette revue systématique de la littérature propose d’établir un panorama des méthodes de prise en charge en soins primaires ayant montré leur efficacité dans les cas de symptomatologie dépressive (syndromique et sub-syndromique). Les bases de données PubMed, Cochrane, PsycInfo/PsycArticles et Cairn, ont été interrogées entre 2006 et 2016. Sur la base de 591 articles correspondant à l’algorithme de recherche, 27 articles dont 23 essais cliniques et 4 revues de la littérature ont été intégrés à l’analyse. Nos résultats suggèrent qu’il existe trois types de dispositifs efficaces : les thérapies guidées, non-guidées et le suivi par entretien téléphonique. La majorité d’entre eux reposent sur les principes des thérapies cognitivocomportementales. Au regard des enjeux cliniques et économiques de la dépression, cet article cible des recommandations concernant la prise en charge de première intention de la symptomatologie dépressive chez l’adulte.

Currently, depression is a real public health problem associated with very high healthcare costs and a significant impact on the patient's daily life and their entourage. One of the challenges is to identify psychological support devices according to the stage of the disorder and to also specify the role of different actors. This systematic literature review aims to establish an overview of the effective methods of intervention in primary care in cases of depressive symptoms (subsyndromal and syndromal depression). PubMed, Cochrane, PsycInfo/PsycArticles and Cairn were searched for articles published between 2006 and 2016 containing the following words in the title according to the algorithm: [Health promotion (title)] OR [prevention (title)] OR [primary care (title)] AND [depression (title)]. Based on 591 items matching the search algorithm, 27 items including 23 clinical trials and 4 literature reviews were included in this analysis. The results suggest that there are three types of effective prevention devices: guided therapies, self-help therapies, and monitoring by telephone interview. The majority of them are based on the principles of cognitive behavioral therapy. Guided therapies take place in direct interaction with a therapist who is physically present by videoconference or phone. Effective guided therapies are cognitive behavioral therapy (CBT), problem-solving therapy (PST), and psychoeducation. Self-help therapies are standardized psychological interventions based on the total or partial autonomy of the patient. These mechanisms include: (1) bibliotherapy (book or manual); (2) DVDs or audio CDs; (3) websites; (4) computer software (CD-ROM). In addition, a follow-up by phone can be recommended. During structured and regular (monthly) telephone calls, a professional monitors the development of symptoms and supports adherence to treatment, as necessary. Four literature reviews were also considered (Bortolotti et al., 2008; Cape et al., 2010; Martin et al., 2009; McNaughton, 2009). The results of the analysis corroborate the elements presented above. Indeed, bibliotherapy, websites and computer programs are included in the effective unguided therapies. Software is the most recommended media for people with marked symptoms requiring longer-term care. Intensive guided therapies, lasting a maximum of 3 months, provide the best level of support for patients, with greater effectiveness for CBT and PST approaches. Among all the devices, it seems that the “Website” has the most relevant efficiency – acceptability – cost ratio in the context of the prevention of depression in the general population. It constitutes an interactive and multimodal format combining different media, from video to quizzes via discussion forums. Compared to other devices, it improves accessibility to information with regular updates. The diversification of connected devices (Smartphone, Tablet, Smart Watch) leads to the development of applications. This “online” format seems well accepted by users although it is preferable to associate this type of therapy with follow-up by a professional. This type of device has different aims: self-observation and assessment of symptoms: what are they? What is their frequency, intensity?; knowledge of strategies to deal with stress in different contexts: work, social relationships, couple relationships, etc.; identification of resource professionals and different kinds of possible support; break down of isolation through a virtual community. Given the clinical and economic issues of depression, this article provides recommendations for the treatment of adult depression in primary care.