TUGAS TRANSLATE JURNAL

Adaptation and psychometric evaluation of the

Italian version of the depression attitude
questionnaire (DAQ)
Sighinolfi, C; Norcini Pala, A; Casini, FAuthor Information ; Haddad, M; Berardi,
DAuthor Information ; et al. Epidemiology and Psychiatric Sciences 22.1 (Mar
2013): 93-100.

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Adaptasi dan evaluasi psikometri dari versi Italia

dari kuesioner sikap depresi (DAQ)
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Penerjemah
Sumitro Hadiwarsito
NIM: G2A016999

PROGRAM SARJANA ILMU KEPERAWATAN

FAKULTAS ILMU KEPERAWATAN DAN KESEHATAN
UNIVERSITAS MUHAMMADIYAH SEMARANG
http://unimus.ac.id
2016
 HASIL TRANSLATE

Judul:

Adaptasi dan evaluasi psikometri dari versi Italia

dari kuesioner sikap depresi (DAQ)

Abstrak

Bertujuan. Untuk memvalidasi versi Italia dari 'depresi sikap kuesioner'

(DAQ), untuk menilai sifat psikometrik dan mengevaluasi (PCPs) pendapat dan
sikap dokter perawatan primer 'terhadap depresi. Metode. Versi Italia dari DAQ
diciptakan dan kemudian diberikan kepada sampel yang representatif dari PCPs
bekerja di wilayah Emilia-Romagna. Hasil. Temuan berasal dari versi Italia dari
DAQ menunjukkan solusi tiga faktor (percaya diri profesional, pandangan negatif
dan sikap biologis), luas mirip dengan studi sebelumnya dan dengan indeks fit
diterima. Hasil penelitian kami menunjukkan bahwa PCPs menganggap depresi
sebagai isu yang semakin penting untuk praktek klinis sehari-hari mereka. Sebagian
besar dari mereka percaya pada efektivitas antidepresan dan dianggap pengobatan
psychopharmacological yang sesuai untuk PCPs untuk melakukan. Namun,
sebagian besar responden PCP berpikir bahwa psikoterapi harus diserahkan kepada
spesialis. Temuan kami menunjukkan orientasi lazim pada aspek biokimia dari
depresi dan penggunaan pengobatan antidepresan. Kesimpulan. The PCPs 'sikap
dan pendapat terhadap depresi merupakan aspek penting dari pemahaman dan
respon terhadap kondisi umum dan melumpuhkan ini mereka. Versi Italia dari DAQ
tampaknya menjadi instrumen yang tepat dan berguna untuk membantu
pemahaman pandangan PCPs 'dan potensi kebutuhan untuk pengembangan
profesional lebih lanjut.

Naskah Lengkap:

Pengantar

Depresi adalah kondisi luas dan melumpuhkan dikelola terutama oleh dokter
perawatan primer (PCPs). Baru-baru ini MEMPREDIKSI Penelitian yang
dilakukan dalam perawatan primer di enam negara Eropa, menemukan tingkat
prevalensi 6-bulan depresi berat berkisar dari 6,5 sampai 18,4% pada wanita dan
4,4-12,7% pada pria (King et al. 2008). Namun, manajemen depresi dalam
perawatan primer sering dianggap tidak memuaskan karena kurang pengakuan
kasus (BARBUI & Tansella, 2006; Balestrieri et al 2007.), Dan penyediaan
memadai baik pengobatan psychopharmacological atau psikososial (Hirschfeld et
al. 1997; Lecrubier 2007). Masalah-masalah ini mungkin terkait dengan waktu yang

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terbatas untuk mengevaluasi dan mengobati depresi, pendidikan profesional miskin
tentang psikiatri, kurangnya pelatihan dalam komunikasi dan keterampilan
interpersonal, dan sikap dokter terhadap penyakit mental, serta keengganan pasien
untuk menyajikan dan mengungkapkan kesulitan emosional - yang mungkin terkait
dengan stigma yang terkait dengan masalah kesehatan mental.

pendapat dan sikap untuk depresi PCPs 'cenderung menjadi penting untuk
identifikasi dan pengobatan selanjutnya kondisi ini, serta untuk pengembangan
hubungan dokter-pasien. Sejumlah penelitian yang telah menyelidiki sikap dokter
untuk depresi telah menggunakan kuesioner ad hoc yang dibangun oleh para
peneliti (Orrell et al 1995;. McCall et al, 2002;. Richards et al 2004.) Dan hanya
digunakan dalam proyek yang mereka dikembangkan. Problematik, pendekatan ini
tidak memungkinkan perbandingan antara kelompok dan pengaturan yang berbeda,
atau di waktu. Instrumen yang paling banyak dilaporkan dalam literatur adalah
'depresi sikap kuesioner' (DAQ), yang dikembangkan di Inggris (Botega et al. 1992)
dan telah digunakan dalam berbagai pengaturan yang berbeda dan disiplin klinis.

Sebelumnya studi tentang sifat psikometrik DAQ ini

DAQ adalah instrumen self-penyelesaian yang terdiri 20 laporan tentang depresi

tentang etiologi, tentu saja, pilihan pengobatan, dan peran PCP, spesialis kesehatan
mental dan perawat; jawaban setiap item ditandai pada skala analog visual, di mana
'sangat tidak setuju' ditandai pada 0 mm dan 'sangat setuju' pada 100 mm. DAQ
diciptakan untuk mengevaluasi sikap PCPs 'depresi dan pada awalnya diuji pada
sampel dari 72 PCPs diambil secara acak dari Medical Research Council Inggris
kerangka penelitian praktek umum (Botega et al. 1992). analisis faktor awal
berdasarkan sampel ini mengakibatkan solusi empat komponen utama, akuntansi
untuk 43% dari varians, yang terdiri dari: 'antidepresan / psikoterapi' yang
diidentifikasi sikap PCP terhadap pengobatan; 'Kegelisahan profesional' yang
menunjukkan kenyamanan PCP dalam menangani pasien depresi; 'Tentu saja tak
terelakkan depresi' menunjukkan sikap pesimis PCP terhadap depresi dan
'identifikasi depresi' yang menunjukkan kepercayaan dokter dalam membedakan
depresi dari ketidakbahagiaan. Sebuah analisis selanjutnya menunjukkan bahwa
PCPs dapat dikelompokkan menjadi tiga kelompok yang berbeda atas dasar sikap
mereka. Grup A memiliki pendekatan simpatik dan mendukung terhadap depresi
dan kurang kemungkinan untuk meresepkan antidepresan; Kelompok B melihat
depresi sebagai penyakit organik terbaik menanggapi antidepresan; Kelompok C
dianggap merawat pasien depresi sebagai sangat menuntut dan tidak
menguntungkan (Botega & Silveira, 1996).

Ross et al. (1999) digunakan DAQ untuk menilai hubungan antara sikap dan
praktek klinis antara 407 PCPs di Glasgow menggunakan sketsa depresi, dan
mengidentifikasi alternatif solusi tiga faktor: 'Tentu saja tak terelakkan depresi',
'kepercayaan profesional' dan 'model sosial depresi '. Faktor-faktor ini tampaknya
terkait dengan perilaku klinis. Sebagai contoh, PCPs dengan skor yang lebih tinggi
pada 'tentu saja tak terelakkan depresi' kurang mungkin untuk membahas penyebab

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non-fisik gejala termasuk faktor sosial dan peristiwa kehidupan, sementara mereka
dengan 'model sosial depresi' tinggi skor kurang mungkin untuk meresepkan obat-
obatan psikiatri. Richards et al. (2004) digunakan DAQ dalam survei dari 420 PCPs
di Australia. Mereka menemukan solusi empat faktor terhitung sekitar 42% dari
varians: 'General Practitioner (GP) tak berdaya', 'GP usaha', 'orientasi psikososial'
dan 'orientasi biologis'. Dalam penelitian ini, PCPs dengan pengetahuan kurang dan
kepercayaan dalam manajemen pasien depresi lebih mungkin untuk merujuk
mereka ke psikiater. Selain studi dari dokter, DAQ juga telah digunakan dengan
sampel perawat (Payne et al, 2002;. Haddad et al 2007, 2010.). Konsisten, studi ini
menunjukkan solusi tiga atau empat faktor sangat mirip dengan yang ditemukan
dengan PCPs.

Baru-baru ini, analisis dikumpulkan (Haddad et al 2011.) Data DAQ yang ada
diperoleh dari 12 studi (1543 dokter; 984 perawat) mencoba untuk menyelesaikan
inkonsistensi psikometri jelas dalam penelitian sebelumnya, dengan ukuran sampel
yang lebih memadai. Temuan menunjukkan bahwa beberapa item yang berlebihan
dan menunjukkan struktur dua-faktor kemungkinan dengan nilai konsistensi
internal dari 0,59 ( 'kepercayaan dalam peran profesional') dan 0,61 ( 'pandangan
positif dari depresi dan manajemen'); nilai alpha Cronbach untuk skala keseluruhan
(dibatasi 9 item) adalah 0,64.

Tujuan dari penelitian ini adalah untuk memvalidasi versi Italia dari DAQ, untuk
menilai sifat psikometrik dan menggunakan instrumen ini untuk menyelidiki sikap
PCPs 'terhadap depresi di Italia.

Metode

Translasi

Versi Italia dari DAQ diproduksi. The 'maju-mundur' prosedur diterapkan untuk
menerjemahkan kuesioner dari Inggris ke Italia. Dua penerjemah profesional
independen menghasilkan dua maju-terjemahan, dan setelah pertemuan, disepakati
pada versi umum. Kemudian, versi Italia ini direvisi oleh psikolog (F.C.) dan
psikiater (M.M.) untuk mengatasi terminologi ilmiah dan kesetaraan konseptual.
dihasilkan versi maju-terjemahan kemudian 'mundur diterjemahkan', dua
penerjemah Inggris-Italia profesional bekerja secara independen untuk
menghasilkan dua versi bahasa Inggris. Italia dan dua versi bahasa Inggris dikirim
ke Layanan Kesehatan Departemen Riset (M.H.) untuk review seluruh prosedur.
Akhirnya, versi Italia DAQ itu diuji coba di sampel 30 PCPs dan hasilnya ditinjau
oleh tim riset dan PCP.

Sampel dan pengumpulan data

Versi Italia akhir DAQ yang diberikan untuk sampel yang representatif dari PCPs
bekerja di wilayah Emilia-Romagna Italia Utara. Kuesioner diberikan selama
kursus penyegaran pada masalah kejiwaan atau pertemuan lokal yang

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diselenggarakan di 'G. Leggieri Program 'pada kolaborasi antara perawatan primer
dan kesehatan mental untuk pengelolaan gangguan mental (Berardi et al. 1996).
Kursus dan pertemuan diadakan di berbagai kota (Bologna, Castelfranco Emilia,
Forl, Reggio Emilia, Rimini) di tahun 2006-2010. The PCPs diberitahu bahwa
kuesioner benar-benar anonim. Data sosio-demografis (seperti usia dan jenis
kelamin) dan informasi tentang praktek klinis yang PCPs '(tahun praktek dalam
perawatan primer, lokasi kantor PCP ini, solo-praktek atau obat kelompok)
dikumpulkan melalui ad hoc kuesioner tertutup dengan instrumen .

Analisis statistik

SPSS 15.0 for Windows (Paket Statistik untuk software Ilmu Sosial, Chicago, IL)
dan Mplus 3.0 (Muthn & Muthn, 1998-2004) digunakan untuk analisis data.
statistik deskriptif, termasuk proporsi, nilai rata-rata dan standar deviasi, yang
digunakan untuk menyajikan data demografi dan DAQ item. Asumsi normalitas
dari data diperiksa dengan memeriksa tes numerik normalitas, skewness dan
kurtosis. Secara umum dengan penulis lain (.. Ross et al 1999; Haddad et al 2007),
item DAQ dibagi ke dalam kategori berikut - tidak setuju (0-33 mm), netral (34-66)
dan setuju (67-100) - untuk kemudahan menyajikan temuan.

Sejak penelitian sebelumnya pada DAQ telah menunjukkan solusi faktor lemah
terpercaya, kami memutuskan untuk melakukan dua analisis: eksplorasi dan
konfirmasi analisis faktor (EFA dan CFA).

EFA dan CFA dilakukan dengan Mplus 3.0 (Muthn & Muthn, 1998-2004).
Karena variabel diubah menjadi variabel trichotomic, kuadrat terkecil tertimbang
estimasi (sarana-disesuaikan WLSM) digunakan. Model statistik fit analisis faktor
konfirmatori adalah: [chi] 2 / df <5,00 menunjukkan cocok (Marsh & Hocevar,
1985); CFI / TLI> 0,90 yang menunjukkan fit yang memadai (Tucker & Lewis,
1973; Bentler, 1990; Byrne, 2001; Kline, 2005); RMSEA <0,08 untuk memadai fit
(Browne & Cudeck, 1992; Byrne, 2001; Kline, 2005). Jumlah faktor untuk
mengekstrak dengan EFA, ditentukan dengan mempertimbangkan dua kriteria:
RMSEA <0,06 dan interpretability faktor.

Faktor-faktor tersebut kemudian dibandingkan antara kelompok berdasarkan jenis

kelamin, durasi praktek klinis (lebih besar dari atau kurang dari 15 tahun), lokasi
kantor PCP ini (daerah pusat, daerah pinggiran kota dan pedesaan / pegunungan)
dan jenis klinik (solo praktek v. Kelompok obat). Antara kelompok perbandingan
diuji dengan uji Student t dan analisis satu arah varians (perbedaan paling signifikan
(LSD) post hoc test), dan nilai-nilai p kurang dari atau sama dengan 0,05 dianggap
signifikan secara statistik. pemodelan persamaan struktural juga digunakan untuk
menguji perbedaan signifikan secara statistik ditemukan di kelompok PCP.

Hasil

Karakteristik sampel dan barang DAQ

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Sebanyak 655 PCPs berpartisipasi dalam studi. Dua pertiga (67,9%) dari peserta
adalah laki-laki; usia rata-rata adalah 53,3 5,3 (rentang: 29-78), dan durasi rata-
rata bekerja di praktek klinis perawatan primer adalah 21,8 8,3 tahun (kisaran: 1-
47). Lebih dari setengah (57,3%) dari PCPs bekerja dalam praktek solo dan 70,5%
dari mereka telah menghadiri setidaknya dua pertemuan atau konferensi pada topik
kejiwaan dalam 2 tahun sebelumnya (2,5 1,7 kursus; kisaran: 1-15). The PCPs
tanggapan terhadap item DAQ individu dinyatakan sebagai mean dan deviasi
standar diringkas dalam Tabel 1.

Table 1.

PCPs' responses to DAQ: mean and standard deviation (sd)

N DAQ item Mean Sd

13 Working with depressed patients is heavy going 86.8 12.9

1 During the last 5 years, I have seen an increase in the number 75.8 18.8
of patients with depressive symptoms

18 AD usually produce a satisfactory result in the treatment of 72.5 18.8

depressed patients in GP

19 Psychotherapy for depressed patients should be left to a 71.9 27.6

specialist

4 An underlying biochemical abnormality is at the basis of 61.8 25.7

severe cases of depression

2 The majority of depression in general practice originates from 58.0 23.0

patients' recent misfortunes.

20 If psychotherapy were freely available, this would be more 56.5 26.6

beneficial than AD, for most depressed patients

12 The practice nurse could be a useful person to support 54.2 28.5

depressed patients

5 It is difficult to differentiate patients with unhappiness or a 49.3 25.4

clinical depressed disorder that need treatment

8 Depressed patients are more likely to have experienced 47.7 27.5

deprivation in early life than other people

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 N DAQ item Mean Sd

9 I feel comfortable in dealing with depressed 47.3 25.6

patients' needs

15 It is rewarding to spend time looking after 46.2 28.2

depressed patients

6 It is possible to distinguish two main group of 45.5 27.5

depression: psychological/biochemical

3 Most depressive disorders seen in general practice 39.8 24.1

improve without medication

16 Psychotherapy tends to be unsuccessful with 39.2 28.3

depressed patients

7 Becoming depressed is a way that people with poor 37.8 29.6

stamina deal with difficulties

11 Becoming depressed is a natural part of being old 35.8 26.3

17 If depressed patients need AD, they are better off 35.6 27.9
with a psychiatrist than with a GP

10 Depression reflects a characteristic response in 33.4 25.0

patients, which is not amenable to change

14 There is little to be offered to those depressed 33.2 26.0

patients who do not respond to what GPs do

Kisaran jawaban 'pergi dari 100 mengungkapkan total kesepakatan dengan 0

menunjukkan tidak ada kesepakatan sama sekali. Kami juga dibedakan tiga kategori
perjanjian: 0-33 ada kesepakatan; 34-66 posisi netral dan 67-100 total kesepakatan.

EFA

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Data respon hilang ditangani oleh pasangan-bijaksana penghapusan. Pertama, kami
mengamati distribusi frekuensi tanggapan untuk item DAQ individu. Pernyataan
'bekerja dengan pasien depresi yang berat akan' (item 13) menarik kesepakatan
yang paling besar (92,7%), jadi kami memutuskan untuk mengecualikan item ini
dari EFA karena tidak menghasilkan varians dalam penelitian kami. Sisanya 19
DAQ respon item sebagai nilai-nilai dalam mm antara 0 dan 100 menjadi sasaran
EFA.

Kesesuaian data untuk analisis faktor dinilai. Nilai Kaiser-Meyer-Olkin adalah

0,662, melebihi nilai yang direkomendasikan dari 0,6 (Kaiser, 1974) dan uji Bartlett
untuk kebulatan (Bartlett, 1954) mencapai signifikansi statistik (p <0,001),
mendukung factorability dari matriks korelasi.

Karena keberadaan data yg dibagi atas tiga, EFA dilakukan dengan Mplus 3.0 yang
memungkinkan analisis variabel ordinal. model tiga faktor yang disediakan
memadai (RMSEA <0,06 dan baik faktor interpretability). Model ini kemudian
diuji dengan CFA, dan mengakibatkan cocok miskin. indeks modifikasi dan Hooper
et al. (2008) pedoman, yang menyarankan menjatuhkan item dengan R nilai lebih
rendah dari 0,40, digunakan untuk meningkatkan fit model struktural ini. Model
revisi menunjukkan indeks diterima fit (RMSEA = 0,039 CFI / TLI 0,943 / 0.920
[chi] 2 / df = 1.88). Tiga faktor yang melibatkan sepuluh item DAQ muncul dari
analisis (Tabel 2).

able 2.

Three-factor model of the DAQ (19 items)

Component

Item Synthesis DAQ items Professiona Negati Biological

l ve stance
confidence viewpo
int

1 During the last 5 years, I have seen an increase in 0.088 0.157 0.324
the number of patients with depressive symptoms

2 The majority of depression in general practice -0.146 0.403 0.291

originates from patients' recent misfortunes.

3 Most depressive disorders seen in general -0.153 0.246 -0.029

practice improve without medication

4 An underlying biochemical abnormality is at the -0.125 -0.109 0.447

basis of severe cases of depression

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 5 It is difficult to differentiate patients with 0.019 0.464 0.005
unhappiness or a clinical depressed disorder that
need treatment

6 It is possible to distinguish two main group of 0.047 0.299 0.276

depression: psychological/biochemical

7 Becoming depressed is a way that people with 0.011 0.607 0.045

poor stamina deal with difficulties

8 Depressed patients are more likely to have -0.080 0.256 0.170

experienced deprivation in early life than other
people

9 I feel comfortable in dealing with depressed -0.780 0.071 -0.042

patients' needs

10 Depression reflects a characteristic response in -0.259 0.671 -0.131

patients, which is not amenable to change

11 Becoming depressed is a natural part of being old -0.022 0.426 -0.039

12 The practice nurse could be a useful person to 0.077 0.040 0.056

support depressed patients

14 There is little to be offered to those depressed 0.017 0.420 -0.194

patients who do not respond to what GPs do

15 It is rewarding to spend time looking after -0.522 0.034 0.039

depressed patients

16 Psychotherapy tends to be unsuccessful with 0.157 0.155 -0.005

depressed patients

17 If depressed patients need AD, they are better off 0.287 0.273 -0.009
with a psychiatrist than with a GP

18 AD usually produce a satisfactory result in the -0.121 -0.192 0.458

treatment of depressed patients in GP

19 Psychotherapy for depressed patients should be 0.358 0.025 0.260

left to a specialist

20 If psychotherapy were freely available, this 0.044 0.343 0.003

would be more beneficial than AD, for most
depressed patients

nilai-nilai yang berani mengidentifikasi sepuluh item dan faktor-faktor relatif

mereka terlibat dalam.

Komponen 1. Profesional kepercayaan (item 9 dan 15). Agreement (nilai yang

tinggi), mengungkapkan kemudahan profesional dalam pengelolaan pasien depresi.

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Secara khusus, barang-barang ini menunjukkan kenyamanan dalam menangani
kebutuhan dan PCPs 'pasien depresi kepuasan dalam waktu yang dihabiskan
merawat pasien tersebut. Tanggapan PCPs 'menghasilkan nilai rata-rata total 46,6
( 22,6) menunjukkan posisi netral.

Komponen 2. sudut pandang negatif (item 2, 5, 7, 10, 11 dan 14). nilai yang tinggi
menunjukkan perjanjian dengan pandangan deterministik dan stigma depresi,
mengungkapkan sedikit kesempatan perbaikan meskipun pengobatan. Nilai rata-
rata total 41,1 ( 14,8), menunjukkan sekali lagi posisi netral di antara PCPs dalam
sampel ini.

Komponen 3. sikap Biologi (item 4 dan 18). nilai yang tinggi menunjukkan
perjanjian dengan pandangan biokimia depresi dan dengan efektivitas antidepresan
sebagai pengobatan. skor mean PCPs 'dari 67,2 ( 14,5), menunjukkan dukungan
dari perspektif ini.

pemodelan persamaan struktural kemudian dilakukan untuk menguji hubungan

kepercayaan dan sikap terhadap depresi PCPs ', dengan psikoterapi (Gambar 1.):
[chi] 2 / df = 1.70 CFI / TLI 0,946 / 0,926 RMSEA 0,035 SRMR 0.050.

Ara. 1.

model persamaan struktural untuk mengeksplorasi pengaruh usia opini PCPs dan
PCPs 'dan sikap terhadap depresi pada psikoterapi. (Sebuah versi warna angka ini
tersedia online di http://journals.cambridge.org/eps)

Perbandingan antara PCP sub-kelompok

Tidak ada perbedaan dalam faktor DAQ ditemukan ketika kita dibandingkan
sampel dengan tahun praktek klinis (lebih besar dari atau kurang dari 15 tahun),
dengan lokasi kantor PCPs '(daerah pusat, daerah pinggiran kota dan pedesaan /
pegunungan) maupun oleh jenis klinik (praktek solo atau obat-obatan kelompok).
Perbandingan dengan gender PCP menunjukkan perbedaan yang signifikan secara
statistik pada dua (Faktor 1 dan 2) dari tiga faktor. Namun, efek ini menghilang
ketika usia termasuk dalam analisis. usia dokter 'dikaitkan dengan keyakinan
profesional (Factor 1) dan sikap biologis (Factor 3) (Gambar. 1). The PCPs tua
cenderung merasa lebih percaya diri dalam menangani pasien depresi (Factor 1),
harus lebih berorientasi biologis (Factor 3) dan, koheren, untuk mengadakan sikap
negatif terhadap efektivitas psikoterapi dalam pengobatan depresi (Barang 16 ).

Diskusi

Tujuan pertama dari penelitian ini adalah untuk memvalidasi versi Italia dari DAQ
dan untuk menilai struktur faktorial dalam sampel PCPs Italia. evaluasi awal dari
sifat psikometrik DAQ melaporkan temuan yang tidak konsisten (Haddad et al.
2005), memberikan informasi lengkap tentang struktur faktor (Richards et al. 2004),

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dan mengidentifikasi koefisien alpha Cronbach bawah diterima minimal <0,65
(Haddad et al. 2007 ). Dalam rangka untuk mencoba untuk mengatasi kesulitan
psikometri ditemukan dalam studi sebelumnya, kami mengadopsi pendekatan
psikometri yang lebih ketat. Melalui EFA dan CFA, bersama-sama dengan indeks
modifikasi dan penerapan Hooper et al. (2008) pedoman untuk meningkatkan fit
model struktural ini, tiga faktor-solusi, 'kepercayaan profesional', 'pandangan
negatif' dan 'sikap biologis ', dengan sifat psikometrik yang memadai diperoleh.
solusi ini, dan khususnya dua faktor pertama, tampak mirip dengan literatur
sebelumnya (Ross et al, 1999;. Richards et al 2004;. Haddad et al 2011.). kesamaan
ini memberikan indikasi kesetaraan DAQ Italia untuk satu Inggris serta validitas
konstruk nya.

Tujuan kedua dari penelitian ini adalah untuk menilai sikap PCP terhadap depresi.
Untuk pengetahuan kita ini adalah penyelidikan pertama di Italia menggunakan
sampel besar dan instrumen yang relevan. Berkenaan dengan pendapat PCPs
'terhadap depresi, mayoritas sampel kami mencatat bahwa bekerja dengan pasien
depresi adalah berlangsung berat (DAQ barang 13), dan bahwa selama 5 tahun
terakhir jumlah pasien depresi mereka melihat telah meningkat (item DAQ 1).
tanggapan ini memberikan indikasi yang jelas bahwa PCPs menganggap depresi
sebagai isu penting untuk praktek klinis sehari-hari mereka. Sebagian besar sampel
merasa bahwa obat antidepresi pengobatan yang efektif (DAQ barang 18) dan
dianggap pengobatan psychopharmacological sebagai tugas PCP ini (DAQ barang
17); sebaliknya, PCPs percaya bahwa psikoterapi harus diserahkan kepada spesialis
(DAQ barang 19). tanggapan ini untuk item DAQ individu, bersama-sama dengan
perjanjian tinggi dari PCPs pada faktor 3 'sikap biologis', menunjukkan orientasi
umum terhadap aspek biokimia depresi dan manajemen.

Secara keseluruhan, PCPs tampaknya tidak memegang pandangan stigma depresi

atau perspektif negatif pada respon terhadap pengobatan, dan posisi ini
dikonfirmasi oleh total skor rata-rata pada faktor 'pandangan negatif'. Bahkan,
meskipun nilai dianggap 'netral', jauh lebih dekat ke kutub perselisihan
menunjukkan kecenderungan perbedaan dari pandangan negatif. The 'kepercayaan
profesional' faktor berarti skor netral, dan itu ditemukan memiliki perbedaan yang
mencolok pada membandingkan data ini dengan orang-orang yang dikumpulkan
dari kolam besar dokter bekerja di UK (Haddad et al. 2011). Secara khusus, British
dokter melaporkan bahwa mereka merasa lebih nyaman dalam berurusan dengan
depresi (63,1 v. 47.3, [Delta] = 15,8), dan menganggapnya bermanfaat untuk
merawat pasien depresi (62,5 v. 46,2, [Delta] = 16,3) . Selain itu, dokter Inggris
anggap bekerja dengan pasien depresi kurang menuntut daripada rekan-rekan
mereka Italia (64,0 v. 86.6, [Delta] = 22,6). Sebuah penjelasan yang mungkin untuk
perbedaan ini dapat ditemukan dalam organisasi yang berbeda dari perawatan
primer dan spesialis di Inggris dan Italia (Haddad et al. 2011). Di Inggris, perawatan
primer dikembangkan dengan baik dan itu dianggap sebagai pengaturan pusat untuk
manajemen depresi, mempengaruhi kepercayaan PCPs 'dalam menangani pasien
depresi. Sebaliknya, perawatan primer di Italia kurang terlibat dalam pengelolaan
gangguan mental. Pelatihan dari PCPs dan praktek klinis mereka sehari-hari

10
terutama difokuskan pada penyakit fisik (penyakit kardiovaskular, diabetes, dll).
Aspek penting lainnya untuk dipertimbangkan adalah bahwa Komunitas Pusat
Kesehatan Mental (CMHCs) di Italia adalah struktur tingkat dasar, dapat diakses
secara bebas kepada warga tanpa referral PCP. organisasi ini menunjukkan bahwa
PCPs cenderung untuk mengelola gangguan depresi, dan ini dapat mempengaruhi
kepercayaan mereka di daerah ini praktek. Baru-baru ini, departemen perawatan
primer dan berkolaborasi program antara perawatan primer dan kesehatan mental
telah dilaksanakan (Rucci et al. 2012). Penelitian lebih lanjut dapat mengevaluasi
apakah kolaborasi ini akan mempengaruhi sikap PCPs 'dalam mengelola gangguan
mental yang umum.

Ketika kami menguji pengaruh usia PCPs pada sikap mereka terhadap depresi, kami
menemukan bahwa PCPs tua cenderung merasa lebih percaya diri dalam
menangani pasien depresi dan harus lebih berorientasi biologis. kepercayaan dokter
tua 'yang lebih tinggi dalam menangani pasien depresi dapat dijelaskan oleh lebih
banyak kesempatan mereka telah beberapa tahun mereka praktek untuk mengikuti
pelatihan kesehatan mental tertentu, dan oleh perbedaan dalam jumlah kontak
dengan pasien depresi mereka dibandingkan dengan rekan-rekan mereka yang lebih
muda. Selain itu, seperti yang disarankan dalam studi sebelumnya (Haddad et al.
2011), yang PCPs muda mungkin lebih akrab dengan bukti kontemporer dan
pedoman untuk pengobatan depresi, yang dapat menjelaskan kepercayaan mereka
lebih besar dalam manfaat psikoterapi dan kecenderungan lebih rendah untuk
berorientasi biologis dibandingkan dengan rekan-rekan mereka yang lebih tua.
Perbedaan ini menurut usia PCPs 'mungkin dipertimbangkan dalam perencanaan
pelatihan kesehatan mental disesuaikan dengan kebutuhan spesifik dari peserta.

Ketika kita mempertimbangkan kelompok secara keseluruhan, temuan kami juga

menunjukkan bahwa pendapat PCPs 'tentang pengobatan psikoterapi secara
bermakna dikaitkan dengan tiga faktor yang diidentifikasi. Secara khusus, mereka
PCPs yang lebih biologis berorientasi (sikap biologis) tampaknya memiliki persepsi
terbatas efektivitas psikoterapi, sedangkan PCPs yang tidak merasa percaya diri
dalam menangani pasien depresi (Factor 1), dan orang-orang yang mengadakan
negatif sikap terhadap depresi (Factor 2), memiliki pandangan yang lebih positif
psikoterapi sebagai pengobatan berguna untuk depresi. Sebuah penjelasan yang
mungkin untuk temuan ini mungkin bahwa kurangnya kepercayaan dalam
menangani pasien depresi dapat mewakili penghalang dalam mengelola depresi
dalam perawatan primer (Goldman et al, 1999;. Leiferman et al 2010.). Namun
demikian, PCPs mungkin percaya bahwa pasien ini mungkin mendapat manfaat
dari psikoterapi yang disediakan oleh spesialis. Demikian pula, PCPs yang
menganggap depresi sebagai kelemahan karakter mungkin berpikir bahwa
psikoterapi dapat berguna. Temuan ini konsisten dengan tanggapan ke item 19, di
mana mayoritas PCPs menunjukkan bahwa psikoterapi harus diserahkan kepada
spesialis.

keterbatasan studi

11
Keterbatasan penelitian ini berkaitan dengan wilayah Italia di mana ia dilakukan.
Meskipun kelompok besar dan perwakilan dari peserta PCP, Emilia-Romagna
merupakan salah satu wilayah yang paling maju dan makmur di Eropa, dan telah
terstruktur program kolaborasi dan integrasi antara perawatan primer dan kesehatan
mental untuk pengelolaan gangguan kesehatan mental. Oleh karena itu, hasilnya
mungkin tidak berlaku untuk wilayah Italia lainnya. Selain itu, para peserta
penelitian direkrut dari perawatan primer kursus penyegaran kesehatan mental,
sehingga kemungkinan bahwa mereka tertarik psikiatri dan mungkin telah
mengadakan sikap yang lebih positif terhadap depresi dibandingkan PCPs lainnya.

kesimpulan

DAQ diaktifkan penilaian sikap PCP dan opini tentang depresi, yang memainkan
peran penting dalam hubungan dokter-pasien dan dalam proses penilaian dan
pengobatan. Persepsi PCPs 'bekerja dengan depresi berat akan sering menjadi lebih
umum dalam praktek klinis mereka, menyoroti pentingnya mempertimbangkan
kepercayaan mereka, sikap dan pendapat untuk memahami kebutuhan yang
mungkin untuk dukungan untuk membantu manajemen mereka gangguan ini.
Selain itu, PCPs 'pertimbangan depresi sebagai gangguan yang dapat diobati dan
setuju untuk mengubah menunjukkan nilai kemungkinan dari pelatihan lebih lanjut
tentang pengobatan depresi untuk membantu PCPs' kepercayaan dalam bidang
yang penting dari praktek. Versi Italia dari DAQ tampaknya menjadi alat yang
berguna untuk tujuan ini.

Ucapan Terima Kasih

Kami berterima kasih kepada Luigi Rocco Chiri Ph.D., untuk komentar dan saran
atas kertas ini.

Deklarasi Minat

Para penulis melaporkan tidak ada konflik kepentingan dalam kaitannya dengan
makalah ini. Studi ini tidak menerima dukungan keuangan eksternal.

Instrumen ini tersedia secara bebas di permintaan untuk penulis.

12
Lampiran Naskah Asli

Adaptation and psychometric evaluation of the

Italian version of the depression attitude
questionnaire (DAQ)
Sighinolfi, C; Norcini Pala, A; Casini, FAuthor Information ; Haddad, M; Berardi,
DAuthor Information ; et al. Epidemiology and Psychiatric Sciences 22.1 (Mar
2013): 93-100.

1. Full text

2. Full text - PDF

3. Abstract/Details

4. References 31

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Abstract
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Aims. To validate the Italian version of the 'depression attitude questionnaire' (DAQ),
to assess its psychometric properties and to evaluate the primary care physicians'
(PCPs) opinion and attitude towards depression. Methods. An Italian version of the
DAQ was created and then administered to a representative sample of PCPs working
in the Emilia-Romagna region. Results. The findings derived from the Italian version
of the DAQ indicated a three-factor solution (professional confidence, negative
viewpoint and biological stance), broadly similar to previous studies and with
acceptable fit indices. Our results showed that the PCPs consider depression as an
increasingly important issue for their daily clinical practice. A large majority of them
believed in the effectiveness of antidepressants and considered
psychopharmacological treatment as appropriate for the PCPs to undertake.
However, most PCP respondents thought that psychotherapy should be left to the
specialists. Our findings suggest a prevalent orientation to the biochemical aspects of
depression and the use of antidepressant treatment. Conclusions. The PCPs' attitude

13
 and opinion towards depression is an important aspect of their understanding and
response to this common and disabling condition. The Italian version of the DAQ
appears to be an appropriate and useful instrument to assist the understanding of the
PCPs' views and potential need for further professional development.[PUBLICATION
ABSTRACT]

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Instruments

Introduction

Depression is a widespread and disabling condition managed mainly by primary care

physicians (PCPs). The recent PREDICT study, conducted in primary care in six
European countries, found 6-month prevalence rates of major depression ranging
from 6.5 to 18.4% in women and 4.4 to 12.7% in men (King et al. 2008). However,
the management of depression in primary care has often been considered
unsatisfactory due to the under-recognition of cases (Barbui & Tansella, 2006;
Balestrieri et al. 2007), and inadequate provision of either psychopharmacological or
psychosocial treatment (Hirschfeld et al. 1997; Lecrubier 2007). These problems
might be related to limited time to evaluate and treat depression, poor professional
education about psychiatry, insufficient training in communication and interpersonal
skills, and the clinician's attitude towards mental illness, as well as the patients'
reluctance to present and disclose emotional difficulties - which may be related to the
stigma associated with mental health problems.

The PCPs' opinions and attitudes to depression are likely to be important to their
identification and subsequent treatment of this condition, as well as to the
development of the physician-patient relationship. A number of studies that have
investigated clinicians' attitude to depression have used ad hoc questionnaires
constructed by the researchers (Orrell et al. 1995; McCall et al. 2002; Richardset
al. 2004) and used only in the project for which they were developed. Problematically,
this approach does not enable comparisons between different groups and settings, or
across time. The instrument that is most widely reported in the literature is the

14
'depression attitude questionnaire' (DAQ), which was developed in the UK (Botega et
al. 1992) and has been used in a variety of different settings and clinical disciplines.

Previous studies on DAQ's psychometric properties

The DAQ is a self-completion instrument comprising 20 statements about depression

concerning aetiology, course, treatment options, and roles of the PCP, mental health
specialist and nurse; answers to each item are marked on a visual analogue scale,
where 'strongly disagree' is marked at 0 mm and 'strongly agree' at 100 mm. The
DAQ was created to evaluate the PCPs' attitude to depression and was initially
tested on a sample of 72 PCPs drawn randomly from the UK Medical Research
Council general practice research framework (Botega et al. 1992). Initial factor
analysis based on this sample resulted in a four principal components solution,
accounting for 43% of the variance, comprising: 'antidepressant/psychotherapy' that
identified the PCP's attitude towards treatment; 'professional unease' indicating the
PCP's comfort in dealing with depressed patients; 'inevitable course of depression'
showing the PCP's pessimistic attitude towards depression and 'identification of
depression' that indicated the physician's confidence in discriminating depression
from unhappiness. A subsequent analysis indicated that the PCPs could be clustered
into three different groups on the basis of their attitudes. Group A had a sympathetic
and supportive approach towards depression and was less likely to prescribe
antidepressants; group B viewed depression as an organic illness best responding to
antidepressants; group C considered taking care of depressive patients as very
demanding and unrewarding (Botega & Silveira, 1996).

Ross et al. (1999) used the DAQ to assess the relationship between attitude and
clinical practice among 407 PCPs in Glasgow using depression vignettes, and
identified an alternative three-factor solution: 'inevitable course of depression',
'professional confidence' and 'social model of depression'. These factors appeared to
be associated with the clinical behaviour. For example, the PCPs with higher scores
on 'inevitable course of depression' were less likely to discuss a non-physical cause
of symptoms including social factors and life events, while those with higher 'social
model of depression' scores were less likely to prescribe psychiatric drugs.
Richards et al.(2004) used the DAQ in a survey of 420 PCPs in Australia. They found
a four-factor solution accounting for about 42% of the variance: 'General Practitioner
(GP) helpless', 'GP effort', 'psychosocial orientation' and 'biological orientation'. In this

15
study, the PCPs with less knowledge and confidence in the management of
depressed patients were more likely to refer them to a psychiatrist. In addition to the
studies of physicians, the DAQ has also been used with nurse samples (Payne et
al. 2002; Haddad et al. 2007, 2010). Consistently, these studies showed three- or
four-factor solutions quite similar to those found with the PCPs.

Recently, a pooled analysis (Haddad et al. 2011) of existing DAQ data obtained from
12 studies (1543 GPs; 984 nurses) tried to resolve the psychometric inconsistencies
evident in previous studies, with a more adequate sample size. The findings showed
that several items were redundant and indicated a probable two-factor structure with
internal consistency values of 0.59 ('confidence in professional role') and of 0.61
('positive view of depression and its management'); the Cronbach's alpha value for
the overall scale (restricted to 9 items) was 0.64.

The aims of this study are to validate the Italian version of the DAQ, to assess its
psychometric properties and to use this instrument to investigate the PCPs' attitude
towards depression in Italy.

Methods

Translation

An Italian version of the DAQ was produced. The 'forward-backward' procedure was
applied to translate the questionnaire from English to Italian. Two professional
translators independently produced two forward-translations, and after a meeting,
agreed on a common version. Then, this Italian version was revised by a
psychologist (F.C.) and a psychiatrist (M.M.) to address the scientific terminology and
conceptual equivalence. The resulting forward-translation version was then
'backward translated', two professional English-Italian translators worked
independently to produce two English versions. The Italian and the two English
versions were sent to the Health Services Research Department (M.H.) for a review
of the entire procedure. Finally, the Italian version of the DAQ was pilot tested in a
sample of 30 PCPs and the results were reviewed by the research team and a PCP.

Sample and data collection

16
The final Italian version of the DAQ was administered to a representative sample of
PCPs working in the Emilia-Romagna region of Northern Italy. The questionnaire was
administered during refresher courses on psychiatric issues or local meetings
organized in the 'G. Leggieri Programme' on collaboration between primary care and
mental health for the management of mental disorders (Berardi et al. 1996). Courses
and meetings were held in different cities (Bologna, Castelfranco Emilia, Forl,
Reggio Emilia, Rimini) in the years 2006-2010. The PCPs were informed that the
questionnaire was completely anonymous. Socio-demographic data (such as age
and gender) and information about the PCPs' clinical practice (years of practice in
primary care, the PCP's office location, solo-practice or group medicine) were
collected through an ad hoc questionnaire enclosed with the instrument.

Statistical analysis

SPSS 15.0 for Windows (Statistical Package for Social Sciences software, Chicago,
IL) and Mplus 3.0 (Muthn & Muthn, 1998-2004) were used for data analysis.
Descriptive statistics, including proportions, mean values and standard deviations,
were used to present demographic data and DAQ items. Assumptions of normality of
the data were checked by examining the numerical test of normality, skewness and
kurtosis. In common with other authors (Ross et al. 1999; Haddad et al. 2007), the
DAQ items were divided into the following categories - disagree (0-33 mm), neutral
(34-66) and agree (67-100) - for ease of presenting findings.

Since previous studies on the DAQ have shown weakly reliable factor solutions, we
decided to perform two analyses: exploratory and confirmatory factors analysis (EFA
and CFA).

EFA and CFA were performed with Mplus 3.0 (Muthn & Muthn, 1998-2004). Since
the variables were transformed into trichotomic variables, the weighted least squares
estimation (means-adjusted WLSM) was used. The model fit statistics of confirmatory
factor analysis were: [chi] 2/df <5.00 indicating a good fit (Marsh & Hocevar, 1985);
CFI/TLI >0.90 indicating an adequate fit (Tucker & Lewis, 1973; Bentler, 1990; Byrne,
2001; Kline, 2005); RMSEA <0.08 for adequate fit (Browne & Cudeck, 1992; Byrne,
2001; Kline, 2005). The number of factors to extract with the EFA, was determined by
considering two criteria: the RMSEA <0.06 and the interpretability of the factors.

17
 The factors were then compared between group by gender, duration of clinical
practice (greater than or less than 15 years), the PCP's office location (central areas,
suburban areas and rural/mountain areas) and type of clinic (solo practice v. group
medicine). Between-group comparisons were tested by the Student's t test and one-
way analysis of variance (least significant difference (LSD) post hoctest),
and p values less than or equal to 0.05 were considered statistically significant.
Structural equation modelling was also used to test statistically significant differences
found in the PCP groups.

Results

Characteristics of the sample and DAQ item

A total of 655 PCPs participated in the study. Two-third (67.9%) of the participants
were male; the mean age was 53.3 5.3 (range: 29-78), and the average duration of
work in primary care clinical practice was 21.8 8.3 years (range: 1-47). Over half
(57.3%) of the PCPs worked in solo practice and 70.5% of them had attended at
least two meetings or conferences on psychiatric topics in the previous 2 years (2.5
1.7 courses; range: 1-15). The PCPs responses to individual DAQ items expressed
as mean and standard deviation are summarized in Table 1.

Table 1.

PCPs' responses to DAQ: mean and standard deviation (sd)

N DAQ item Mean Sd

13 Working with depressed patients is heavy going 86.8 12.9

1 During the last 5 years, I have seen an increase in the number of patients 75.8 18.8
with depressive symptoms

18 AD usually produce a satisfactory result in the treatment of depressed 72.5 18.8

patients in GP

19 Psychotherapy for depressed patients should be left to a specialist 71.9 27.6

18
4 An underlying biochemical abnormality is at the basis of severe cases of 61.8 25.7
depression

2 The majority of depression in general practice originates from patients' 58.0 23.0
recent misfortunes.

20 If psychotherapy were freely available, this would be more beneficial 56.5 26.6
than AD, for most depressed patients

12 The practice nurse could be a useful person to support depressed patients 54.2 28.5

5 It is difficult to differentiate patients with unhappiness or a clinical 49.3 25.4

depressed disorder that need treatment

8 Depressed patients are more likely to have experienced deprivation in 47.7 27.5
early life than other people

9 I feel comfortable in dealing with depressed patients' needs 47.3 25.6

15 It is rewarding to spend time looking after depressed patients 46.2 28.2

6 It is possible to distinguish two main group of depression: 45.5 27.5

psychological/biochemical

3 Most depressive disorders seen in general practice improve without 39.8 24.1
medication

16 Psychotherapy tends to be unsuccessful with depressed patients 39.2 28.3

7 Becoming depressed is a way that people with poor stamina deal with 37.8 29.6
difficulties

11 Becoming depressed is a natural part of being old 35.8 26.3

19
17 If depressed patients need AD, they are better off with a psychiatrist than 35.6 27.9
with a GP

10 Depression reflects a characteristic response in patients, which is not 33.4 25.0

amenable to change

14 There is little to be offered to those depressed patients who do not 33.2 26.0
respond to what GPs do

Answers' range goes from 100 expressing total agreement to 0 indicating no

agreement at all. We also distinguished three categories of agreement: 0-33 no
agreement; 34-66 neutral position and 67-100 total agreement.

EFA

The missing response data were handled by pair-wise deletion. Firstly, we observed
the frequency distribution of responses to individual DAQ items. The statement
'working with depressed patients is heavy going' (item 13) attracted the most
substantial agreement (92.7%), so we decided to exclude this item from EFA
because it did not produce variance in our study. The remaining 19 DAQ item
responses as values in mm between 0 and 100 were subjected to EFA.

The suitability of data for factor analysis was assessed. The Kaiser-Meyer-Olkin
value was 0.662, exceeding the recommended value of 0.6 (Kaiser, 1974) and
Bartlett's test of sphericity (Bartlett, 1954) reached statistical significance (p < 0.001),
supporting the factorability of the correlation matrix.

Due to the presence of trichotomous data, the EFA was performed with Mplus 3.0
which allows ordinal variables analysis. The three-factor model provided was
adequate (RMSEA <0.06 and good factor interpretability). The model was then tested
with CFA, and resulted in a poor fit. Modification indices and the Hooper et al.'s
(2008) guidelines, which suggest dropping items with R values lower than 0.40, were
used to improve the structural model's fit. The revised model showed acceptable
indices of fit (RMSEA = 0.039 CFI/TLI 0.943/0.920 [chi]2/df = 1.88). Three factors
involving ten of the DAQ items emerged from the analysis (Table 2).

Table 2.

20
 Three-factor model of the DAQ (19 items)

Component

Item Synthesis DAQ items Professional Negative Biological

confidence viewpoint stance

1 During the last 5 years, I have seen an 0.088 0.157 0.324

increase in the number of patients with
depressive symptoms

2 The majority of depression in general -0.146 0.403 0.291

practice originates from patients'
recent misfortunes.

3 Most depressive disorders seen in -0.153 0.246 -0.029

general practice improve without
medication

4 An underlying biochemical -0.125 -0.109 0.447

abnormality is at the basis of severe
cases of depression

5 It is difficult to differentiate patients 0.019 0.464 0.005

with unhappiness or a clinical
depressed disorder that need treatment

6 It is possible to distinguish two main 0.047 0.299 0.276

group of depression:
psychological/biochemical

7 Becoming depressed is a way that 0.011 0.607 0.045

people with poor stamina deal with
difficulties

21
8 Depressed patients are more likely to -0.080 0.256 0.170
have experienced deprivation in early
life than other people

9 I feel comfortable in dealing with -0.780 0.071 -0.042

depressed patients' needs

10 Depression reflects a characteristic -0.259 0.671 -0.131

response in patients, which is not
amenable to change

11 Becoming depressed is a natural part -0.022 0.426 -0.039

of being old

12 The practice nurse could be a useful 0.077 0.040 0.056

person to support depressed patients

14 There is little to be offered to those 0.017 0.420 -0.194

depressed patients who do not respond
to what GPs do

15 It is rewarding to spend time looking -0.522 0.034 0.039

after depressed patients

16 Psychotherapy tends to be 0.157 0.155 -0.005

unsuccessful with depressed patients

17 If depressed patients need AD, they 0.287 0.273 -0.009

are better off with a psychiatrist than
with a GP

18 AD usually produce a satisfactory -0.121 -0.192 0.458

result in the treatment of depressed
patients in GP

22
19 Psychotherapy for depressed patients 0.358 0.025 0.260
should be left to a specialist

20 If psychotherapy were freely available, 0.044 0.343 0.003

this would be more beneficial than
AD, for most depressed patients

Bold values identify the ten items and the relative factors they are involved in.

Component 1. Professional confidence (items 9 and 15). Agreement (high scores),

expresses professional ease in the management of depressed patients. In particular,
these items indicate comfort in dealing with depressed patients' needs and the PCPs'
satisfaction in the time spent looking after these patients. The PCPs' response
produced a total mean value of 46.6 (22.6) indicating a neutral position.

Component 2. Negative viewpoint (items 2, 5, 7, 10, 11 and 14). High scores denote
agreement with a deterministic and stigmatizing view of depression, expressing little
chance of improvement despite treatment. The total mean value of 41.1 (14.8),
indicates once again a neutral position among the PCPs in this sample.

Component 3. Biological stance (items 4 and 18). High scores indicate agreement
with a biochemical view of depression and with the effectiveness of antidepressants
as a treatment. The PCPs' mean score of 67.2 (14.5), indicates endorsement of this
perspective.

Structural equation modelling was then performed to test the association of the
PCPs' beliefs and attitude towards depression, with psychotherapy (Fig. 1): [chi]2/df =
1.70 CFI/TLI 0.946/0.926 RMSEA 0.035 SRMR 0.050.

Fig. 1.

Structural equation model to explore the influence of the age of PCPs and PCPs'
opinion and attitude towards depression on psychotherapy. (A colour version of this
figure is available online at http://journals.cambridge.org/eps)

Comparisons among PCP sub-groups

23
No differences in the DAQ factors were found when we compared the sample with
years of clinical practice (greater than or less than 15 years), by the PCPs' office
location (central areas, suburban areas and rural/mountain areas) nor by the type of
clinics (solo practice or group medicine). Comparison with the PCP's gender showed
statistically significant differences on two (Factors 1 and 2) of the three factors.
However, this effect disappeared when age was included in the analysis. The
physicians' age was associated with professional confidence (Factor 1) and biological
stance (Factor 3) (Fig. 1). The older PCPs tended to feel more confident in dealing
with the depressed patients (Factor 1), to be more biologically oriented (Factor 3)
and, coherently, to hold a negative attitude towards the effectiveness of
psychotherapy in the treatment of depression (Item 16).

Discussion

The first aim of the present study was to validate the Italian version of the DAQ and
to assess its factorial structure in a sample of Italian PCPs. Earlier evaluations of the
DAQ's psychometric properties reported inconsistent findings (Haddad et al. 2005),
provided incomplete information about factor structure (Richards et al. 2004), and
identified Cronbach's alpha coefficients below the minimum acceptable of <0.65
(Haddad et al. 2007). In order to try to overcome the psychometric difficulties found in
previous studies, we adopted a more rigorous psychometric approach. Through EFA
and CFA, together with modification indices and the application of Hooper et al.'s
(2008) guidelines to improve the structural model's fit, a three-factor-solution,
'professional confidence', 'negative viewpoint' and 'biological stance', with adequate
psychometric properties was obtained. This solution, and in particular the first two
factors, appear to be similar to the previous literature (Ross et al. 1999; Richards et
al. 2004; Haddad et al. 2011). These similarities provide indications of the
equivalence of the Italian DAQ to the English one as well as its construct validity.

The second aim of the study was to assess the PCP's attitude towards depression.
To our knowledge this is the first investigation in Italy using a large sample and a
relevant instrument. With regard to the PCPs' opinion towards depression, the
overwhelming majority of our sample noted that working with depressed patients is
heavy going (DAQ item 13), and that over the last 5 years the number of depressed
patients they saw had increased (DAQ item 1). These responses provide a clear
indication that the PCPs consider depression as an important issue for their daily

24
clinical practice. A large proportion of the sample felt that antidepressants were an
effective treatment (DAQ item 18) and considered psychopharmacological treatment
as a PCP's task (DAQ item 17); conversely, the PCPs believed that psychotherapy
should be left to the specialists (DAQ item 19). These responses to individual DAQ
items, together with the high agreement of the PCPs on factor 3 'biological stance',
suggests a prevalent orientation towards the biochemical aspects of depression and
its management.

Overall, the PCPs did not seem to hold a stigmatizing view of depression or a
negative perspective on its response to the treatment, and this position is confirmed
by the total mean score on the 'negative viewpoint' factor. In fact, although the value
is considered 'neutral', it is much closer to the disagreement pole suggesting a trend
of divergence from a negative view. The 'professional confidence' factor mean score
was neutral, and it was found to have a notable difference on comparing these data
with those collected from a large pool of GPs working in the UK (Haddad et al. 2011).
In particular, the British GPs reported that they feel more comfortable in dealing with
depression (63.1 v. 47.3, [Delta] = 15.8), and consider it rewarding to look after
depressed patients (62.5 v. 46.2, [Delta] = 16.3). Moreover, the British GPs deem
working with depressed patients less demanding than their Italian counterparts
(64.0 v. 86.6, [Delta] = 22.6). A possible explanation for these differences may be
found in the different organization of primary and specialist care in the UK and Italy
(Haddad et al. 2011). In the UK, primary care is well developed and it is regarded as
the central setting for depression management, influencing the PCPs' confidence in
dealing with depressed patients. In contrast, primary care in Italy is less involved in
the management of mental disorders. The training of the PCPs and their daily clinical
practice are mainly focused on physical illness (cardiovascular diseases, diabetes,
etc.). Another important aspect to be considered is that Community Mental Health
Centers (CMHCs) in Italy are a primary level structure, freely accessible to the
citizens without PCP referral. This organization indicates that the PCPs are less likely
to manage depressive disorders, and this may influence their confidence in this area
of practice. Recently, primary care departments and collaborating programs between
primary care and mental health have been implemented (Rucci et al. 2012). Further
studies may evaluate whether this collaboration will influence the PCPs' attitude in
managing common mental disorders.

25
When we tested the influence of the age of the PCPs on their attitude towards
depression, we found that the older PCPs tend to feel more confident in dealing with
depressed patients and to be more biologically oriented. The older physicians' higher
confidence in dealing with depressed patients may be explained by the more
opportunities they have had in their years of practice to attend specific mental-health
training, and by the difference in the number of contacts with depressed patients they
had compared with their younger colleagues. Moreover, as suggested in a previous
study (Haddad et al. 2011), the younger PCPs may be more familiar with
contemporary evidence and guidelines for depression treatment, which may explain
their greater confidence in the benefits of psychotherapy and lesser tendency to be
biologically oriented compared with their older colleagues. These differences
according to the PCPs' age might be taken into consideration in planning mental-
health training tailored to the specific needs of the participants.

When we consider the group as a whole, our findings also showed that the PCPs'
opinion about psychotherapeutic treatment was significantly associated with the three
factors identified. In particular, those PCPs who were more biologically oriented
(biological stance) seemed to have a limited perception of the effectiveness of
psychotherapy, whereas the PCPs who did not feel confident in dealing with
depressed patients (Factor 1), and those who held a negative attitude towards
depression (Factor 2), had a more positive view of psychotherapy as a useful
treatment for depression. A possible explanation for this finding might be that the lack
of confidence in dealing with depressed patients can represent a barrier in managing
depression in primary care (Goldman et al. 1999; Leiferman et al. 2010).
Nevertheless, the PCPs may believe that these patients may benefit from
psychotherapy that is provided by the specialists. Similarly, the PCPs who consider
depression as a weakness of character might think that psychotherapy can be useful.
This finding is consistent with the responses to item 19, where a majority of the PCPs
indicated that psychotherapy should be left to a specialist.

Study limitations

A limitation of this study relates to the area of Italy in which it was conducted. Despite
the large and representative group of PCP participants, Emilia-Romagna is one of the
most developed and affluent region in Europe, and has structured programmes of
collaboration and integration between primary care and mental health for the

26
management of mental-health disorders. Therefore, the results may not be applicable
to other Italian regions. In addition, the study participants were recruited from primary
care mental health refresher courses, so it is likely that they were interested in
psychiatry and may have held a more positive attitude to depression than other
PCPs.

Conclusions

The DAQ enabled the assessment of the PCP's attitude and opinion about
depression, which plays an important role in the physician-patient relationship and in
the assessment and treatment processes. The PCPs' perception of working with
depression as heavy going often becomes more common in their clinical practice,
highlights the importance of considering their confidence, attitude and opinion in
order to understand the possible needs for support to assist their management of this
disorder. Moreover, the PCPs' consideration of depression as a disorder that can be
treated and is amenable to change indicates the likely value of a further training
about depression treatment to assist the PCPs' confidence in this important area of
practice. The Italian version of the DAQ appears to be a useful instrument for this
purpose.

Acknowledgments

We thank Luigi Rocco Chiri Ph.D., for comments and suggestions on this paper.

Declaration of Interests

The authors report no conflict of interest in relation to this paper. The study did not
receive external financial support.

The instrument is freely available on request to the authors.

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AuthorAffiliation

Institute of Psychiatry, Bologna University, Bologna, Italy

Psychology Department, Milano-Bicocca University, Milan, Italy

Section of Primary Care Mental Health Service and Population Research

Department, Institute of Psychiatry at King's College London, London SE5 8AF, UK

Word count: 5289

Copyright Cambridge University Press 2012

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