Mental illness in primary care: a narrative review of patient, GP and population factors that affect prescribing rates

Implementing digital mental health interventions at scale: one-year evaluation of a national digital CBT service in Ireland

BACKGROUND

In recent years, exponential growth in digital innovations and internet access has provided opportunities to deliver health services at a much greater scale than previously possible. Evidence-based technology-enabled interventions can provide cost-effective, accessible, and resource-efficient solutions for addressing mental health issues. This study evaluated the first year of a supported digital cognitive behavioral therapy (CBT) service provided by the national health service in Ireland, which has been accessible to individuals who receive a referral from one of five referring groups: General Practitioners, Primary Care Psychology, Counselling Primary Care, Community Mental Health, and Jigsaw (a nationwide youth mental health service).

METHODS

A retrospective, observational study examining data from the service between April 2021 to April 2022 was conducted. Descriptive statistics on referrals, account activations, user demographics, program usage, and user satisfaction were extracted, and pre-to-post clinical outcomes for depression measured by the Patient Health Questionnaire-9 and for anxiety measured by the Generalised Anxiety Disorder-7 were analysed using linear mixed effect models.

RESULTS

There were 5,298 referrals and 3,236 (61%) account activations within the year. Most users were female (72.9%) and aged between 18 and 44 years (75.4%). The CBT programs were associated with significant reductions in both depression (β = 3.34, 95% CI [3.03, 3.65], p < 0.001) and anxiety (β = 3.64, 95% CI [3.36, 3.93], p < 0.001), with large effect sizes (Cohen's d > 0.8). Time spent using the programs was also found to be a predictor of the variability in these clinical outcomes (p < 0.001), and accounting for this resulted in significantly better model fits (p < 0.001). User satisfaction ratings were also very high, exceeding 94%.

CONCLUSIONS

Efforts to improve the representation of male and older adult users are warranted. However, overall, the results demonstrate how digital CBT can be provided at scale and lead to symptom reductions with large effect sizes for patients seeking help for depression and anxiety. The findings substantiate the continued use and expansion of this service in Ireland and the more widespread implementation of similar services in other international public healthcare settings.

Prepandemic psychotropic drug status in Portugal: a nationwide pharmacoepidemiological profile

The prescription of psychotropic drugs has been rising in Europe over the last decade. This study provides a comprehensive profile of prepandemic consumption patterns of antidepressant, antipsychotic, and anxiolytic drugs in Portugal considering full nationwide psychotropic drug prescription and dispensing records (2016-2019) against several criteria, including active ingredient, sociodemographics, medical specialty, and incurred costs. An increase of 29.6% and 34.7% in the consumption of antipsychotics and antidepressants between 2016 and 2019 is highlighted, accompanied by an increase of 37M Eur in total expenditure (> 20M Eur in public copay) for these classes of drugs. Disparities in sociodemographic and geographical incidence are identified. Amongst other pivotal results, 64% of psychotropic drug prescriptions are undertaken by general practitioners, while only 21% undertaken by neurological and psychiatric specialties. Nationwide patterns of psychotropic drug prescription further reveal notable trends and determinants, establishing a reference point for cross-regional studies and being currently assessed at a national level to establish psychosocial initiatives and guidelines for medical practice and training.

Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework

OBJECTIVES

This study aimed to (1) examine barriers and enablers to General Practitioners' (GP) use of National Institute for Health and Care Excellence (NICE) guidelines for self-harm and (2) recommend potential intervention strategies to improve implementation of them in primary care.

DESIGN

Qualitative interview study.

METHODS

Twenty-one telephone interviews, semi-structured around the capabilities, opportunities and motivations model of behaviour change (COM-B), were conducted with GPs in the United Kingdom. The Theoretical Domains Framework was employed as an analytical framework. Using the Behaviour Change Wheel, Behaviour Change Techniques (BCTs), intervention functions and exemplar interventions were identified.

RESULTS

GPs valued additional knowledge about self-harm risk assessments (knowledge), and communication skills were considered to be fundamental to high-pressure consultations (cognitive and interpersonal skills). GPs did not engage with the guidelines due to concerns that they would be a distraction from patient cues about risk during consultations (memory, attention and decision processes), and perceptions that following the guidance is difficult due to time pressures and lack of access to mental health referrals (environmental context and resources). Clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral, drives GPs to rely on their professional judgement over the guidance (beliefs about capabilities).

CONCLUSIONS

Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self-harm. Five intervention functions and ten BCT groups were identified as potential avenues for intervention design.

Mental Health among Spanish Adults with Diabetes: Findings from a Population-Based Case-Controlled Study

Background: The purpose of this study was to assess and compare the prevalence of self-reported mental disorders, psychological distress, and psychotropic drug consumption among people with diabetes mellitus (DM) and matched non-DM controls. Methods: A case–controlled study using data from the Spanish National Health Interview Survey was conducted in 2017. We identified 2116 DM adults (aged ≥35 years). Non-DM controls were matched 1:1 by age, sex, and province of residence. Results: Prevalence of mental disorders (25.0% vs. 19.2%; p < 0.001), psychological distress (29% vs. 19.5%; p < 0.001), and consumption of psychiatric medications (29.7% vs. 23.5%; p < 0.001) among DM cases were higher than those among matched non-DM controls. The DM patient variables associated with experiencing a mental disorder, psychological distress, and consumption of psychiatric medications were: being a woman, worse self-rated health, and a visit to a psychologist within the last year. Older age (≥80 years) was associated with a lower probability of reporting mental disorders and psychological distress among DM cases. Not practicing physical exercise was significantly associated with experiencing psychological distress. Conclusions: Adults with DM included in our investigation have a significantly higher prevalence of mental disorders, psychological distress, and consumption of psychiatric medications than non-DM controls. It is necessary to implement screening strategies and psychological interventions to improve the mental health of DM patients in Spain, focusing especially on women and those aged 35 to 59 years.

Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice

OBJECTIVES

Despite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing.

DESIGN

Semistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken.

PARTICIPANTS

General practice prescribers: general practitioners (GPs), PBPs, nurses.Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing.

SETTING

General practices and NHS organisations in England.

RESULTS

Interviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers' professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice.

CONCLUSION

Prescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.