Consultation for physical illnesses by patients diagnosed and treated for psychiatric disorders by a general practitioner: 20 year follow up study

Focus on Extracellular Vesicles: Physiological Role and Signalling Properties of Extracellular Membrane Vesicles

Extracellular vesicles (EVs) are a heterogeneous population of secreted membrane vesicles, with distinct biogenesis routes, biophysical properties and different functions both in physiological conditions and in disease. The release of EVs is a widespread biological process, which is conserved across species. In recent years, numerous studies have demonstrated that several bioactive molecules are trafficked with(in) EVs, such as microRNAs, mRNAs, proteins and lipids. The understanding of their final impact on the biology of specific target cells remains matter of intense debate in the field. Also, EVs have attracted great interest as potential novel cell-free therapeutics. Here we describe the proposed physiological and pathological functions of EVs, with a particular focus on their molecular content. Also, we discuss the advances in the knowledge of the mechanisms regulating the secretion of EV-associated molecules and the specific pathways activated upon interaction with the target cell, highlighting the role of EVs in the context of the immune system and as mediators of the intercellular signalling in the brain.

What factors influence long-term antidepressant use in primary care? Findings from the Australian diamond cohort study

BACKGROUND

Antidepressants are one of the most commonly prescribed drugs in primary care. The rise in use is mostly due to an increasing number of long-term users of antidepressants (LTU AD). Little is known about the factors driving increased long-term use. We examined the socio-demographic, clinical factors and health service use characteristics associated with LTU AD to extend our understanding of the factors that may be driving the increase in antidepressant use.

METHODS

Cross-sectional analysis of 789 participants with probable depression (CES-D≥16) recruited from 30 randomly selected Australian general practices to take part in a ten-year cohort study about depression were surveyed about their antidepressant use.

RESULTS

165 (21.0%) participants reported <2 years of antidepressant use and 145 (18.4%) reported ≥2 years of antidepressant use. After adjusting for depression severity, LTU AD was associated with: single (OR 1.56, 95%CI 1.05-2.32) or recurrent episode of depression (3.44, 2.06-5.74); using SSRIs (3.85, 2.03-7.33), sedatives (2.04, 1.29-3.22), or antipsychotics (4.51, 1.67-12.17); functional limitations due to long-term illness (2.81, 1.55-5.08), poor/fair self-rated health (1.57, 1.14-2.15), inability to work (2.49, 1.37-4.53), benefits as main source of income (2.15, 1.33-3.49), GP visits longer than 20min (1.79, 1.17-2.73); rating GP visits as moderately to extremely helpful (2.71, 1.79-4.11), and more self-help practices (1.16, 1.09-1.23).

LIMITATIONS

All measures were self-report. Sample may not be representative of culturally different or adolescent populations. Cross-sectional design raises possibility of "confounding by indication".

CONCLUSIONS

Long-term antidepressant use is relatively common in primary care. It occurs within the context of complex mental, physical and social morbidities. Whilst most long-term use is associated with a history of recurrent depression there remains a significant opportunity for treatment re-evaluation and timely discontinuation.

Lo studio internazionale multicentrico dell'Organizzazione Mondiale della Sanità sui disturbi psichici nella medicina generale: risultati relativi all'area di Verona

Objectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.

Deprivation, psychological distress, and consultation length in general practice

BACKGROUND

Recent research has shown the benefits of longer consultations in general practice. Approximately 40% of patients presenting to general practitioners (GPs) are psychologically distressed. Studies have shown that psychological morbidity increases with increasing socioeconomic deprivation. The combined effects of psychological morbidity and socioeconomic deprivation on consultation length are unknown. In addition, though it is known that doctors correctly identify half their distressed patients as such, the effect of consultation length on identification is unknown.

AIM

To examine factors associated with presentation and recognition of psychological distress in GPs' surgeries and the interaction of these factors with consultation length.

DESIGN OF STUDY

A cross-sectional study.

SETTING

Nine general practices in the West of Scotland, involving 1075 consultations of 21 full-time GPs.

METHOD

The main outcome measures were patient psychological distress (measured by General Health Questionnaire-12), doctors' identification of psychological distress, consultation length, and Carstairs deprivation category scores.

RESULTS

The mean consultation length was 8.71 minutes (SD = 4.40) and the prevalence of positive GHQ scores was 44.7%. Increasing GHQ (greater psychological distress) and lower deprivation category scores (greater affluence) were associated with longer consultations. Positive GHQ scoring increased with greater socioeconomic deprivation and also peaked in the 30 to 39 years age group. Recognition of psychological distress was greater in longer consultations (50% increase in consultation length associated with 32% increase in recognition).

CONCLUSION

Increasing socioeconomic deprivation is associated with higher prevalence of psychological distress and shorter consultations. This provides further evidence to support Tudor Hart's 'inverse care law' and has implications for the resourcing of primary care in deprived areas.

Somatic disease and psychological disorder

The association between physical and psychological disorders has been demonstrated repeatedly. There are a number of explanations for this association, each of them pointing to specific diseases and operationalizations of mental distress. In this article, the relationship between various somatic diseases and a number of indices for psychological distress was investigated. Within one study population, patients with different somatic diseases were identified, and their experience with mental distress, their requests for help from their GP during consultations, and their GPs' diagnoses were registered and compared with the total study population: It appears that relationships could be demonstrated between experience of distress and presentation of psychological symptoms during consultations, on the one hand, and common physical disorders, on the other. Patients with neurological diseases (Parkinson's, epilepsy, multiple sclerosis) and gastric ulcers showed the same relationships, but were also more frequently diagnosed by the GP as having psychological disorders. Patients with a number of other serious somatic diseases, such as diabetes, cancer, and arthritis, did not distinguish themselves in a positive way on one of indices for psychological distress.

Detecting psychological distress: can general practitioners improve their own performance?

BACKGROUND

Many studies have suggested that general practitioners fail to detect a substantial minority of their patients who are psychologically distressed, and there is concern about the possible sequelae of this. Individual patients may suffer unresolved problems, and there are potential costs to the health service in consequent recurrent consultations, inappropriate referrals or treatment. Educational interventions based on small groups led by facilitators have been shown to alter the consultation behaviours of general practitioners that are known to be related to accurate detection of psychological distress.

AIM

This controlled study aimed to show that, by utilizing a brief self-directed educational intervention focusing on detection of psychological distress, general practitioners can improve their performance significantly. For this purpose, a new educational intervention was designed: the second aim of the study was thus to assess the effectiveness of this specific intervention.

METHOD

An educational intervention was designed which focused on skills relevant to detecting psychological distress, using the principles of reflection on general practitioner performance and consultation skill work. It was designed to be used by individual general practitioners without outside support, using a combination of written background material, feedback on performance and analysis of video material. The effectiveness of the intervention was tested by comparing a trial and control cohort of general practitioners, using detection rates as an outcome measure.

RESULTS

The detection rate of the general practitioners who underwent the intervention improved significantly compared with their performance before intervention and with that of the control group.

CONCLUSION

General practitioners can improve their ability to detect psychological distress in their patients utilizing this self-directed educational approach.

Antidepressant-treated patients in ambulatory care long-term use of non-psychotropic and psychotropic drugs

BACKGROUND

Despite the problems involved in treating depression and concomitant medical disease, there are virtually no longitudinal studies on drug utilisation among depressed patients.

METHOD

Use of prescription drugs among all first-time users of antidepressants in a defined population five years before and six years after the index (first) treatment was compared to a referent group without antidepressant treatment. The generalised estimating equations (GEE) method was used for analysis.

RESULTS

The antidepressant-treated group used considerably more non-psychotropic drugs during the whole study period than the referent group. They also used more psychotropic drugs, a use which increased in connection with the initiation of antidepressant treatment, and stayed high for a further five years.

CONCLUSIONS

The high use of prescription drugs indicated widespread somatic and psychiatric health problems during the whole study period. Antidepressant-treated patients are at risk for drug interactions and adverse effects, and would benefit from a closer collaboration between psychiatry and medicine.

HIV-1 infection at two public psychiatric hospitals in New York City

Seroprevalence for HIV-1 was anonymously evaluated between November 1989 and July 1991 among severely mentally ill patients at two public psychiatric hospitals in New York City. The study population consisted of new admissions and long-stay patients aged 18-59. Of 1116 eligible patients, usable samples were obtained from routine blood drawings on 971 (87%). Seroprevalence was comparable among men (5.2%) and women (5.3%). Age did not predict seropositivity. Men with a recorded history of homosexual behaviour or injection drug use were, respectively, 1.8 and 2.0 times more likely to be seropositive than men without these histories. Women with a recorded history of injection drug use were 4.0 times more likely to be seropositive than women without such a history. Ethnicity was not predictive for men, but Black women were 2.4 times more likely to be HIV-1 positive than non-Black women. Severely mentally ill inpatients had a substantial rate of HIV-1 seropositivity, indicating a need for additional testing, education and counselling efforts for this population.

Life events, social problems and physical health status as predictors of emotional distress in men and women in a community setting

The main aim of this study was to construct logistic models of emotional distress (defined as a GHQ-30 score of 6 or greater) in a community sample of 226 men and 225 women. The independent variables included were: sociodemographic characteristics, physical health status, social problems and undesirable life events. Univariate comparisons showed that in both sexes undesirable life events and social problems were associated with emotional distress; in men the presence of physical symptoms and widowed, separated or divorced status also showed such an association. Separate logistic regression models for men and women confirmed the importance of undesirable life events and social problems as predictors for emotional distress. In women there was also a significant interaction effect between the two variables on emotional distress. Sociodemographic characteristics and physical health status did not exert a statistically significant effect in these models.

The General Practice Research Unit at the Institute of Psychiatry

The General Practice Research Unit (GPRU) was established at the Institute of Psychiatry in the late 1950s, under the honorary directorship of Professor Michael Shepherd. For 30 years it has been staffed by medically qualified workers and social scientists supported, at various times, by the Nuffield Foundation, the Mental Health Research Fund, and the Department of Health and Social Security, as well as by university monies.

Referrals from general practitioners to psychiatrists and paramedical mental health professionals

The literature on referral of patients by GPs to psychiatrists and mental health specialists is examined. Referrals to psychiatrists account for 3% of all those made by GPs, but the individual rates vary widely. The proportion of patients referred to psychiatrists and paramedical mental health workers in general practice is unknown, but probably substantial.