Antidepressant treatment and cultural differences - a survey of the attitudes of physicians and patients in Sweden and Turkey

BACKGROUND: The presenting symptoms of depression can be influenced by cultural differences. This study was conducted to compare the presenting symptoms and response to antidepressant medication of patients in Sweden and Turkey, two culturally different European countries. METHODS: Recruitment was triggered when adult patients were diagnosed with a depressive or anxiety disorder by a primary care physician and prescribed an antidepressant. Physicians and patients recorded presenting symptoms and completed relevant questionnaires just before and 8 weeks after starting treatment with an antidepressant. These included the Hospital Anxiety and Depression Scale (HADS), the Clinical Global Impressions (CGI) scale, the Sheehan Disability Scale (SDS), and Likert scales gauging the importance of physical and psychological symptoms. Patients also rated severity of prominent symptoms (depression, anxiety, stress, sleep and pain) from zero to ten. The outcomes were compared between patients from Sweden and Turkey using Fisher's Exact test and two-sample t-tests. RESULTS: The study was conducted in 460 patients (107, 23.3% in Sweden; 353, 76.7% in Turkey). Presenting symptoms differed between Sweden and Turkey, with Turkish patients more likely to present with physical symptoms, and report a higher number of physical symptoms (mean 2.4 vs. 1.4, p < 0.001). In both countries, the diagnosis made by the physician differed from that derived from the HADS score at the start of the study. The HADS diagnosis varied between the countries with significantly different proportions of patients in each country being diagnosed with depression alone, anxiety alone or depression with anxiety. While all symptoms improved after antidepressant treatment in both countries, Turkish patients showed a greater degree of response than Swedish patients in depression (p = 0.048), stress (p = 0.014) and pain (p < 0.001) as measured by the prominent symptoms assessment (PSA). CONCLUSIONS: The presenting symptoms of patients diagnosed with a depressive or anxiety disorder by a primary care physician and prescribed an antidepressant differ between Turkey and Sweden. Patients in Turkey were more likely to present with physical symptoms than patients in Sweden and present with more physical symptoms. After 8 weeks of antidepressant treatment, the improvement from baseline was greater in Turkish patients, and this was reflected in their improved functioning.