Journal of Affective Disorders 105 (2008) 235 – 240

www.elsevier.com/locate/jad

Brief report
Patient education and group counselling to improve the treatment of
depression in primary care: A randomized controlled trial
Maja Hansson ⁎, Owe Bodlund, Jayanti Chotai
Division of Psychiatry, Department of Clinical Sciences, University of Umeå, 901 87 Umeå, Sweden
Received 16 December 2006; received in revised form 6 April 2007; accepted 8 April 2007
Available online 16 May 2007

Abstract

Background: The Contactus program for depressed patients in primary care, consists of six lectures about depression, each
followed by a group discussion. The aim of this study was to investigate if Contactus can improve treatment outcome in
comparison to a control group.
Methods: Forty-six primary care centres in Sweden, each randomly allocated either to the Contactus group or to the control group,
included depressed patients, 205 in the Contactus group and 114 in the control group. Besides regular treatment of depression, the
Contactus group participated in the educational program. At start and after 6 weeks, patients filled in a questionnaire and the self-
reports: HADS (Hospital Anxiety and Depression Scale) and GAF-self (Global Assessment of Functioning).
Results: After 6 weeks, clinically depressed patients (HAD-depression score N10) had a mean improvement in HAD-D of 4.6 in
Contactus vs. 3.0 in controls ( p = 0.02), and 72% vs. 47% considered themselves to feel better ( p = 0.01). Increase in GAF score
was 11.8 vs. 5.8 ( p = 0.04), respectively. According to HADS, 55% in Contactus were responders vs. 29% among controls
( p = 0.006), and 42% vs. 21% ( p = 0.02) were in remission.
Limitations: Only 40% of the patients in Contactus and 35% among controls were clinically depressed according to the HADS
(N 10 points) at inclusion.
Conclusions: Patient education and group counselling contributes significantly to better improvement among depressed patients.
Group treatment is inexpensive and could be implemented in the routine care of depressed patients in primary care.
© 2007 Elsevier B.V. All rights reserved.

Keywords: Depression; Patient education; Group counselling; Primary care

1. Introduction Sartorius et al., 1996; Lepine et al., 1997; Kringlen et al.,

Lifetime risk of having a depression is high and the
disorder is often recurrrent. The point prevalence of
depression in the general population is around 5%
whereas 15% in primary care (Kessler et al., 1994;
⁎ Corresponding author. Division of Psychiatry, University Hospital,
901 87 Umeå, Sweden. Tel.: +46 90 785 6324; fax: +46 90 135324.
E-mail address: maja.hansson@psychiat.umu.se (M. Hansson).
0165-0327/$ - see front matter © 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2007.04.007
2001; Wittchen et al., 2001a,b; Kessler et al., 2005).
Several Swedish studies have shown that at least one
in four of patients visiting primary health care centres
(HCC) suffer from depression or anxiety. Most depres-
sed patients seeking HCC state somatic rather than psy-
chological problems and only half of them are identified
as depressed. Of these, about half receive adequate treat-
ment (Bodlund, 1997; Schulberg et al., 1997; Bodlund
et al., 1999; Wittchen and Pittrow, 2002; Allgulander
and Nilsson, 2003; Nordström and Bodlund, in press).
236 M. Hansson et al. / Journal of Affective Disorders 105 (2008) 235–240

Although improvement (response) is often achieved in
60–70% among those treated with adequate doses, only
about 35% will reach remission (Anderson, 2001; Thase
et al., 2001; Simon et al., 2002; Åkerblad et al., 2003;
Trivedi et al., 2006).
In Sweden, the sick leave rate has increased
dramatically due to mental disorders like depression,
anxiety and burn-out syndromes. If these patients were
identified and treated better, it is likely that the number
of patients on sick leave would decrease, thereby
lowering the economic burden for the society.
Numerous studies have shown that a combination of
pharmacological treatment and cognitive-behaviour
therapy (CBT) gives the best treatment outcome and
prevention of relapse (Fava et al., 1996; DeRubeis et al.,
1999; Swedish Council on Technology Assessment in
Health Care, 2004). However, since there is a huge lack
of resources to offer CBT, the most feasible treatment
strategy in primary care would be a combination of
antidepressants (AD) and supportive follow-ups with a
cognitive approach.
Therefore, a need for collaborative care for depression
in primary care, which includes educational and organi-
zational interventions, has been increasingly emphasized
(Gilbody et al., 2003; Bower et al., 2006). Collaborative
care is often targeted at multidisciplinary health care
professionals, leading to high clinical benefits at a low
increment in health care costs (Katon et al., 2005; Simon
et al., 2001a,b; Katzelnick et al., 2000).
Educational programs for several other disorders, for
example asthma and chronic pain, have been shown to
improve treatment outcome, compliance, and coping
with the symptoms (Wilson et al., 1993; Arnstein,
2004). Similar studies addressing depression are scarce,
but these studies indicate, however, better coping of
depressive symptoms and improved compliance (Brown
et al., 2001; Saver et al., 2007; Simon et al., 2001a,b;
Unutzer et al., 2001; Katon et al., 1999).
In the present cluster randomized controlled trial, we
evaluate an intervention strategy for treatment of depres-
sion in primary care, called Contactus, comprising patient
education and group counselling in addition to “treatment
as usual”, in relation to “treatment as usual” only.
2. Method
initiated treatment for depression, but the Contactus
group also participated in lectures and group discussions
as described below. The subjects comprised 205 patients
in the Contactus program and 114 patients as controls.
Inclusion criteria were age 18–69 years, clinically
diagnosed as depressed by the GP, and considered
suitable to participate in a group. Neither the severity of
the depression nor any other treatment prescribed, were
any exclusion criteria. Therefore, both groups contained
patients who were on antidepressants and/or had
psychotherapy in parallel.
Informed consent was obtained. At baseline and after
6 weeks, all the patients responded to self-rating scales
and a questionnaire about their occupation, medication,
psychotherapy, sick leave and change in health status
over time.
2.2. Self-rating scales
HADS (Hospital Anxiety and Depression Scale) is a
widely used instrument by physicians both in hospitals
and primary care to screen for patients with depression
and/or anxiety (Zigmond and Snaith, 1983). The scale
consists of 7 statements concerning depression (HAD-D
subscale) and 7 statements concerning anxiety, where
the respondent indicates how much it applies to him or
her (0 for lowest, 3 for highest). A score of 8 to10 indi-
cates a mild disorder, and a score of at least 11 suggests a
clinically evident disorder.
GAF-self (Global Assessment of Functioning) is a
self-rating version of axis V of the DSM-IV (APA,
American Psychiatric Association, 1994). It has been
evaluated earlier (Bodlund et al., 1994), showing good
concordance with expert evaluation.
Table 1
Treatment of the Contactus group and control group at inclusion
Contactus (N = 205) Controls (N = 114)
All Women Men All Women Men
(N = 156) (N = 49) (N = 76) (N = 38)
Psychotherapy 9.3 9.6 8.2 7.9 10.5 2.6
(%)
Antidepressant 85.6 82.8 93.9 76.8 71.6 86.8
(AD) (%)

Of those (%):
2.1. Subjects
SSRI 75.2 76.4 72.1 77.1 84.0 60.0
Venlafaxin 14.3 13.6 16.3 10.0 6.0 20.0
Forty-six HCC from all over Sweden were involved Mirtazapin 5.6 4.2 9.3 5.7 4.0 15.0
in the study. Each HCC was randomly allocated either Other 5.0 5.9 2.3 5.7 6.0 5.0
to the Contactus group or to the control group, i.e. a Number of 48 54 31 56 66 34
weeks on AD
cluster randomization. Both groups continued with their
 M. Hansson et al. / Journal of Affective Disorders 105 (2008) 235–240 237

Fig. 1. Change in HAD-D scores after 6 weeks among patients with HAD-D N 10 at inclusion. A value under zero means improvement.

2.3. The Contactus intervention strategy 3. Results

Contactus is a 6-week program where patients meet
once a week to attend a lecture on topics like diagnosing
and treating depression, non-pharmacological alterna-
tives, medical insurance/economical aspects, etc. Discus-
sions after each lecture in groups of 8–10 patients are led
by a social worker and/or a nurse. The group meetings are
characterized by support and by sharing experiences. The
desired goal of the Contactus program is to improve the
care of depressed patients in primary care, facilitate early
identification, and improve treatment compliance.
2.4. Statistical analysis
The statistical analyses were performed by the SPSS
version 10. Differences between groups were tested by
the t-test and correlations were evaluated by the Pearson
coefficient r.
The number of dropouts from start to the 6-week
follow-up was 17.3% in the Contactus group, and 8.1%
in the control group. The dropouts did not, in any
relevant aspect, differ significantly from patients who
completed the study.
Females were predominant, 76% in Contactus and
67% in the control group. The mean ages were 43 and
45, respectively. In the Contactus group, 85.6% were on
antidepressants and 9.3% had ongoing psychotherapy,
compared to 76.8% and 7.9% among the controls. The
differences between the groups were not statistically
significant. Most patients were on AD since a long time
(mean 1 year), and only 9.1% had started AD-treatment
within the last 4 weeks. Ongoing treatments at baseline
are given by Table 1.
At inclusion, the mean HAD-D score was 9.2 (SD ±
4.4) in both groups. Forty percent of the patients in

Fig. 2. How the patients felt, subjectively after 6 weeks. The question was: “How has your condition changed from six weeks ago?”.
238 M. Hansson et al. / Journal of Affective Disorders 105 (2008) 235–240
Fig. 3. Response and remission rates among clinically depressed patients (HAD N 10 and GAF b 80).
Contactus and 35% among controls had a HAD-D ≥ 11.
The mean GAF score was 62 (SD ± 15.0) in both groups.
In the following we only analyse patients who at that
start had a HAD-D ≥ 11, i.e. clinically depressed
patients.
As depicted by Fig. 1, depressed patients had a mean
reduction in HAD-D of 4.6 in Contactus vs. 3.0 in
controls ( p = 0.02) after 6 weeks.
Fig. 2 depicts response to the question: “How has
your condition changed from six weeks ago?”. In the
Contactus group, 72% considered themselves feeling
better or much better vs. 47% among the controls
( p = 0.01). Increase in the mean GAF score was 10.6 vs.
5.4 respectively.
Improvement according to HAD-D correlated sig-
nificantly positively with GAF-increase (r = 0.53,
p = 0.00) and with the response of feeling better or
much better (r = 0.39, p = 0.00).
Among patients with HAD ≥ 11 and GAF score b 80,
the proportion of those who responded to treatment
(response defined as a reduction of the HAD-D score
with at least 5 points), as well as remission rate
(HAD b 8) was significantly higher in the Contactus
group. Fifty-five percent obtained treatment response in
Contactus vs. 29% among controls ( p = 0.006). The
remission rate was 42% vs. 21% (p = 0.021) (Fig. 3).
Improvement in functioning according to the GAF-scale
was 11.8 (SD ± 14.5) in Contactus and 5.8 (SD ± 14.9)
among controls ( p = 0.04). No significant differences
were seen between the sexes or between those who were
on antidepressants or not.
At inclusion, 52.7% in the Contactus group were on
sick leave vs. 38.6% among the controls. During the
6 weeks follow-up, further 6.2% from the Contactus
group vs. 30.0% from the control group had been put on
a sick list ( p = 0.004).
4. Discussion
This naturalistic study shows that depressed patients
in primary care benefit from the Contactus program in
addition to conventional treatments of depression. After
6 weeks, the improvement according to HAD-scores in
the Contactus group was significantly higher than the
control group. The proportion of patients reporting feel-
ing better/much better, obtaining response or remission
and also improvement in functioning according to GAF,
were all about twice as high in the Contactus group
compared to the controls. Six weeks is usually enough to
evaluate the response to treatment, but remission takes
longer. It can take 3–6 months to achieve full remission.
On the other hand, most of these patients had been
treated with AD for a long time and these patients did
not tend to show substantial differences in outcome
compared to patients treated with AD for only a month.
Our interpretation is that addition of the Contactus
program was a beneficial complement that facilitated
remission.
During this 6-week program a decrease in sick leave
among those in the Contactus group could not be seen, but
on the other hand we saw an increase in sick leave among
the controls. This suggests that the Contactus program
would prevent further cases to be put on the sick list.
Seventy-three percent of the patients were women,
giving a women to men ratio of 2.7, compared to the
ratio 1.7 reported among the depressed in the general
 M. Hansson et al. / Journal of Affective Disorders 105 (2008) 235–240
population (Kessler et al., 1994). It is possible that
depressed men are more reluctant and wait longer before
they seek help. This suggestion is further supported by
our study, where men showed a tendency of higher
depression scores compared to women (9.8 vs. 9.0) and
were on antidepressants more frequently (91% vs. 79%).
A challenge for primary care is to identify more men
with depression and to offer a treatment program which
also attracts them. We found no sex differences as
regards the benefits of the Contactus program.
The high correlations between the patients' self-
report on improvement in their mental health and the
HAD- and GAF scores, shows that these self-rating
scales are valuable complements in recognizing patients
with depression and anxiety. If the scales are used
repeatedly they would also work well as measures of
treatment outcome over time.
There are a few studies that evaluate patient education
for depressed patients, but these were different from the
interventions of the present study. One study of the cost-
effectiveness showed clinical benefits and low increase in
costs of an intervention program for elderly in primary
care where patients were offered education, support of
antidepressant medications and brief psychotherapy
(Katon et al., 2005). Another study, comparing elderly
depressed who were offered disease management pro-
gram with a group receiving usual care, showed no
significant difference in clinical outcome or cost-ef-
fectiveness (Bosmans et al., 2006).
A limitation of our study was that the HCC were
randomly allocated between Contactus and control, but
not the individual patients. However, it would have been
difficult to obtain patient groups of suitable size
otherwise. On the other hand, the 46 HCCs of the
study were distributed widely over the country in both
urban and rural areas.
Another limitation was the criterion of participation.
Patients that the GP considered clinically to suffer from
depression were asked to participate. However, only
35–40% of the subjects could be classified as having
current depression when using the HAD-scale. To
optimize the Contactus program the inclusion criterion
could be, say, HAD-D N 7. A problem with the HAD-
scale is that there is no consensus about the decrease
required for defining response. Here, we defined
“response” as a decrease in HAD-D score by at least 5
points. When using the classical definition as 50%
reduction of symptoms, (as done in the HAM-D or
MADRS scales) the difference between the two groups
remained, but to a lower level.
Due to economic constraints, very few patients can
obtain CBT in general. Treatment of depression is often
239
limited to a combination of antidepressants and sup-
portive follow-ups. Remission rates are often too low
and relapse is common. The Contactus program may be
a realistic and useful complement to the routine treat-
ment of depression in primary care. This program offers
the patients support and more knowledge about their
illness, which has been shown to work for other di-
seases. The program involves several professionals such
as nurses and welfare officers, and so it does not put
extra unbearable demands solely on the physicians.
Many participants of the Contactus program stated
that “sharing experiences” and “meeting other people in
the same or similar situation” was very valuable and
supportive.
Acknowledgements
Grants from the Division of Psychiatry, University of
Umea, Sweden. We also would like to thank Wyeth
Corp. (who initiated the Contactus program) for
practical support, collecting the formulas and forward-
ing them to us.
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