Factors contributing to the recognition of anxiety and depression in general practice

Development and psychometric evaluation of a questionnaire for the assessment of depression in primary care: a cross-sectional study

OBJECTIVES

To develop a new questionnaire for the diagnostic assessment of depression adapted to the primary care setting by combining psychiatric criteria and heuristics of general practitioners (GPs). Psychometric evaluation of the new questionnaire and first validity evidence.

DESIGN

The questionnaire was developed using cognitive interviews with think-aloud technique. Factorial validity was then examined in a cross-sectional study.

SETTING

Primary care. Five general practices in Bavaria, Germany.

PARTICIPANTS

15 GPs, 4 psychiatrists/psychotherapists and 13 patients participated in cognitive expert interviews. A primary care sample of N=277 consecutive patients participated in the cross-sectional study.

METHODS

After consultation with experts and literature research, the questionnaire contained a self-rating part for patients and an external part for GPs. Items were then iteratively optimised using cognitive interviews. Factorial validity was examined. To estimate internal consistency, Cronbach's α was calculated. Validity was assessed by correlating the new questionnaire and the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

The preliminary version of the two-part 'Questionnaire for the assessment of DEpression SYmptoms in Primary Care' (DESY-PC) comprised 52 items for patients (DESY-PAT-1: questions about patient's environment; DESY-PAT-2: questions about depression-specific symptoms) and 21 items for GPs (DESY-GP). The analysis of the DESY-PAT-1 revealed a one-factor solution ('environmental factors') with Cronbach's α of 0.55. The items of the DESY-PAT-2 were assigned to three factors, 'depressive cognitions', 'suicidality' and 'symptoms of fatigue', with Cronbach's α of 0.86, 0.79 and 0.85, respectively. Factorial analysis revealed two factors for the DESY-GP: 'depression symptoms' and 'medical history/external factors'. Cronbach's α was 0.90 and 0.59, respectively. After factorial analysis, the DESY-PAT was reduced to 28 items, and the DESY-GP was reduced to 15 items. Correlations of the DESY-PC with the PHQ-9 were high and significant, indicating convergent validity.

CONCLUSIONS

The new questionnaire represents an innovative extension of depression questionnaires and could be particularly suitable for general practices.

Physiotherapists often encounter clients disclosing suicidal thoughts and behaviors: a cross-sectional survey of Australian physiotherapists

BACKGROUND

All health professionals have a role in suicide prevention, although little is known about physiotherapists' contact with clients experiencing suicidal thoughts and behaviors.

OBJECTIVE

The aims of this study were to investigate physiotherapists' self-reported frequency of contact with clients who disclose suicidal thoughts and behaviors and to identify potential factors associated with frequency of contact.

METHODS

Three-hundred and thirty-eight Australian physiotherapists were surveyed using an online questionnaire, with an estimated response rate of 6.1%. Data were analyzed using descriptive analysis and logistic regression.

RESULTS

Over half the respondents (52.1%) reported encountering clients at least once a year who disclosed suicidal thoughts, and nearly half (49.4%) reported having received at least one disclosure of a suicide plan at some point in their career. Among those working in the public sector, 67.5% of respondents reported having received a disclosure of a suicide plan, and almost all physiotherapists working in pain management reported having received such a disclosure (93.8%). The binary logistic regression model explained approximately 39.7% of the variance in whether a physiotherapist had a client disclose a plan for suicide at some point in their career or not.

CONCLUSION

The results highlight that all physiotherapists should receive training in suicide prevention.

Improving mental health care in depression: A call for action

Depressive disorders have one of the highest disability-adjusted life years (DALYs) of all medical conditions, which led the European Psychiatric Association to propose a policy paper, pinpointing their unmet health care and research needs. The first part focuses on what can be currently done to improve the care of patients with depression, and then discuss future trends for research and healthcare. Through the narration of clinical cases, the different points are illustrated. The necessary political framework is formulated, to implement such changes to fundamentally improve psychiatric care. The group of European Psychiatrist Association (EPA) experts insist on the need for (1) increased awareness of mental illness in primary care settings, (2) the development of novel (biological) markers, (3) the rapid implementation of machine learning (supporting diagnostics, prognostics, and therapeutics), (4) the generalized use of electronic devices and apps into everyday treatment, (5) the development of the new generation of treatment options, such as plasticity-promoting agents, and (6) the importance of comprehensive recovery approach. At a political level, the group also proposed four priorities, the need to (1) increase the use of open science, (2) implement reasonable data protection laws, (3) establish ethical electronic health records, and (4) enable better healthcare research and saving resources.

Psychometric evaluation and Rasch analyses of the German Overall Anxiety Severity and Impairment Scale (OASIS-D)

The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that captures symptoms of anxiety and associated functional impairments. This study evaluates a German version (OASIS-D) that was administered to a convenience sample of 1398 primary care patients of whom 419 were diagnosed with panic disorder with/without agoraphobia. Psychometric properties were analyzed using classical test theory as well as probabilistic test theory. Factor analyses suggested a unitary (latent) factor structure. The internal consistency was good to excellent. Convergent as well as discriminant validity with other self-report measures was found. A sum score (range 0-20) of ≥ 8 emerged as optimal cut-score for screening purposes. A difference score of ≥ 5 was indicative of reliable individual change. A Rasch analysis of local item independence suggested response dependency between the first two items. Rasch analyses of measurement invariance detected noninvariant subgroups associated with age and gender. Analyses of validity and optimal cut-off score were solely based on self-report measures, which may have introduced method effects. In sum, the findings support the transcultural validity of the OASIS and indicate its applicability to naturalistic primary care settings. Caution is warranted when using the scale to compare groups that differ in age or gender.

Combining the GP's assessment and the PHQ-9 questionnaire leads to more reliable and clinically relevant diagnoses in primary care

Background

Screening questionnaires are not sufficient to improve diagnostic quality of depression in primary care. The additional consideration of the general practitioner’s (GP’s) assessment could improve the accuracy of depression diagnosis. The aim of this study was to examine whether the GP rating supports a reliable depression diagnosis indicated by the PHQ-9 over a period of three months.

Methods

We performed a secondary data analysis from a previous study. PHQ-9 scores of primary care patients were collected at the time of recruitment (t1) and during a follow-up 3 months later (t2). At t1 GPs independently made a subjective assessment whether they considered the patient depressive (yes/no). Two corresponding groups with concordant and discordant PHQ-9 and GP ratings at t1 were defined. Reliability of the PHQ-9 results at t1 and t2 was assessed within these groups and within the entire sample by Cohen’s Kappa, Pearson’s correlation coefficient and Bland-Altman plots.

Results

364 consecutive patients from 12 practices in the region of Upper Bavaria/Germany participated in this longitudinal study. 279 patients (76.6%) sent back the questionnaire at t2. Concordance of GP rating and PHQ-9 at t1 led to higher replicability of PHQ-9 results between t1 and t2. The reliability of PHQ-9 was higher in the concordant subgroup (κ = 0.507) compared to the discordant subgroup (κ = 0.211) (p = 0.064). The Bland-Altman Plot showed that the deviation of PHQ-9 scores at t1 and t2 decreased by about 15% in the concordant subgroup. Pearson’s correlation coefficient between PHQ-9 scores at t1 and t2 increased significantly if the GP rating was concordant with the PHQ-9 at t1 (r = 0.671) compared to the discordant subgroup (r = 0.462) (p = 0.044).

Conclusions

The combination of PHQ-9 and GP rating might improve diagnostic decision making regarding depression in general practices. PHQ-9 positive results might be more reliable and accurate, when a concordant GP rating is considered.

Integrating Neuropsychology into Interprofessional Geriatrics Clinics

Interprofessional healthcare teams are increasingly viewed as a clinical approach to meet the complex medical, psychological, and psychosocial needs of older adult patients. Despite the fact that older adults are at risk for cognitive difficulties, neuropsychologists are not routinely included on Geriatrics consult teams. The primary aim of this paper is to highlight the utility of neuropsychology within an interprofessional Geriatrics consult clinic. To address this aim, we describe specific benefits to patient care that may be associated with the inclusion of neuropsychologists on Geriatrics consult teams, including differential diagnosis, enhanced patient care, and reduced barriers to care. We provide a description of the integration of neuropsychology within a Veterans Health Administration (VA) interprofessional Geriatrics consult clinic team in order to illustrate the implementation of this model.

Anxiety in the Medically Ill: A Systematic Review of the Literature

BACKGROUND

Although anxiety is highly represented in the medically ill and its occurrence has relevant clinical implications, it often remains undetected and not properly treated. This systematic review aimed to report on anxiety, either symptom or disorder, in patients who suffer from a medical illness.

METHODS

English-language papers reporting on anxiety in medically ill adults were evaluated. PubMed, PsycINFO, Web of Science, and Cochrane databases were systematically searched from inception to June 2021. Search term was "anxiety" combined using the Boolean "AND" operator with "medically ill/chronic illness/illness/disorder/disease." Risk of bias was assessed via the Joanna Briggs Institute (JBI) Critical Appraisal Tools-Checklist for Prevalence Studies. The PRISMA guidelines were followed.

RESULTS

Of 100,848 citations reviewed, 329 studies met inclusion criteria. Moderate or severe anxious symptoms were common among patients with cardiovascular, respiratory, central nervous system, gastrointestinal, genitourinary, endocrine, musculoskeletal system or connective tissue, dermatological diseases, cancer, AIDS and COVID-19 infections. The most common anxiety disorder was generalized anxiety disorder, observed among patients with cardiovascular, respiratory, central nervous system, dermatologic diseases, cancer, primary aldosteronism, amenorrhea, and COVID-19 infection. Panic disorder was described for cardiovascular, respiratory, dermatology diseases. Social anxiety was found for cardiovascular, respiratory, rheumatoid diseases. Specific phobias were relatively common in irritable bowel syndrome, gastroesophageal reflux, end-stage renal disease.

CONCLUSION

Anxiety is a major challenge in medical settings. Recognition and proper assessment of anxiety in patients who suffer from a medical illness is necessary for an appropriate management. Future reviews are warranted in order also to clarify the causal and temporal relationship between anxiety and organic illness.

Prevalence, predictors, and prognoses of prestroke neuropsychiatric symptoms at 3 months poststroke

OBJECTIVES

Prior neuropsychiatric disturbances are risk factors for stroke. There is a knowledge gap on the predictors of prestroke psychopathology, as well as their association with stroke outcomes in survivors living in low- and middle-income countries (LMICs). We estimated prevalence, predictors, and association of prestroke neuropsychiatric symptoms with poststroke depression (PSD), disability, and mortality.

DESIGN

Prospective observation.

SETTING

Nigeria.

PARTICIPANTS

Adult ischemic and hemorrhagic stroke survivors.

MEASUREMENTS

Prestroke psychopathology were ascertained using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Outcomes were assessed using validated tools, including the Centre for Epidemiologic Studies - Depression Scale (CES-D 10) and modified Rankin scale (mRS). Independent associations were investigated using regression models with Bonferroni corrections, and presented as standardized mean differences (SMD) and odds ratios (OR) within 95% confidence intervals (CI).

RESULTS

Among 150 participants, prestroke neuropsychiatric symptoms were found in 78 (52%). In multivariate logistic regression analyses, prestroke sleep disturbance was associated with systemic hypertension (OR = 5.39, 95% CI = 1.70-17.08). Prestroke neuropsychiatric symptoms independently predicted worse motor disability scores (SMD = 0.92, 95% CI = 0.21-1.62) and greater odds of poststroke mortality (OR = 2.7, 95% CI = 1.1-7.0) at 3 months. However, prestroke depression was not significantly associated with PSD.

CONCLUSION

Prestroke sleep disturbances was associated with systemic hypertension, a key index of high cardiovascular risk profile and stroke. The findings should energize before-the-stroke identification and prioritization of limited treatment resources in LMICs to persons with sleep symptoms who have multiple, additional, risks of stroke.

Implementation of a care manager organisation and its association with antidepressant medication patterns: a register-based study of primary care centres in Sweden

OBJECTIVE

To evaluate the implementation of a care manager organisation for common mental disorders and its association with antidepressant medication patterns on primary care centre (PCC) level, compared with PCCs without this organisation. Moreover, to determine whether a care manager organisation is associated with antidepressant medication patterns that is more in accordance with treatment guidelines.

DESIGN

Register-based study on PCC level.

SETTING

Primary care in Region Västra Götaland, Sweden.

PARTICIPANTS

All PCCs in the region. PCCs were analysed in three subgroups: PCCs with a care manager organisation during 2015 and 2016 (n=68), PCCs without the organisation (n=92) and PCCs that shifted to a care manager organisation during 2016 (n=42).

OUTCOME MEASURES

Proportion of inadequate medication users, defined as number of patients >18 years with a common mental disorder diagnosis receiving care at a PCC in the region during the study period and dispensed 1-179 defined daily doses (DDD) of antidepressants of total patients with at least 1 DDD. The outcome was analysed through generalised linear regression and a linear mixed-effects model.

RESULTS

Overall, all PCCs had about 30%-34% of inadequate medication users. PCCs with a care manager organisation had significantly lower proportion of inadequate medication users in 2016 compared with PCCs without (-6.4%, p=0.02). These differences were explained by higher proportions in privately run PCCs. PCCs that shifted to a care manager organisation had a significant decrease in inadequate medication users over time (p=0.01).

CONCLUSIONS

Public PCCs had a more consistent antidepressant medication pattern compared with private PCCs that gained more by introducing a care manager organisation. It was possible to document a significant decrease in inadequate medication users, notwithstanding that PCCs in the region followed the guidelines to a comparatively high extent regardless of present care manager organisation.

Training results in increased practitioner confidence and identification of depression in people with low vision: a mixed methods study

PURPOSE

The prevalence of depression in people with low vision is high and often goes undiagnosed. There is the potential for those who provide low vision services to perform concurrent depression screening. However, prior training in depression identification and suitable referral pathways is required. The aims of this study were: (1) to assess the impact of a training programme on practitioners' confidence and behaviour in addressing depression in patients with low vision, and (2) to review the training programme and identify areas for further development.

METHODS

A convergent mixed methods approach was used. Questionnaires were completed by practitioners pre-, immediately post- and 6 months post- training (n = 40) to assess practitioner confidence in approaching depression in patients with low vision. Qualitative interviews were performed with a subset of practitioners 6 months post-training (n = 9). Additionally, routine data from the Low Vision Service Wales (LVSW) database was used to determine the change in the number of practitioners identifying depression in patients, and the change in the number of patients identified at risk of depression 6 months post-training.

RESULTS

Of the 148 practitioners who completed low vision assessments pre- and post-training, 28 (18.9%) documented risk of depression in their patients pre-training, which increased substantially to 65 (43.9%) post-training (p < 0.0001). Mixed methods analysis confirmed increased documentation of depressive symptoms by practitioners. Practitioner confidence increased following training, with 92.3% feeling more confident to approach emotional issues with patients and 92.2% intending to use the recommended screening tool to identify depression. Interviews provided insight into areas where confidence was still lacking. Quantitative questionnaires revealed that training content was considered appropriate by 91% of participants. Interviews confirmed these findings while expanding upon possibilities for programme improvement.

CONCLUSIONS

Training for depression screening was found to be time-efficient and acceptable for LVSW practitioners and shown to increase practitioner confidence in the identification of depression. Additionally, the programme changed behaviour, resulting in an increase in the identification of depression in patients with low vision. However, this is a complex topic and ongoing development is required to embed depression screening as an integral part of low vision services.

The Independent Association of Prestroke Psychiatric Symptoms and Acute Phase Delirium with Poststroke Mortality at One Year in Nigeria

BACKGROUND

Undetected acute phase delirium contributes to high poststroke mortality in sub-Saharan Africa (SSA). The present study adds to existing literature by examining the association of prestroke psychiatric symptoms with poststroke mortality at 3 and 12 months in Nigeria.

METHODS

A prospective observational study with repeated delirium assessments conducted using the Confusion Assessment Method (CAM). Delirium was characterised in participants meeting criteria in the Fifth edition of the Diagnostic and Statistical Manual of mental disorders (DSM-V) as well as in those with ≥two core delirium features. Prestroke psychiatric symptoms were ascertained using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Information on mortality was obtained by research supervisors during medical follow-up. Associations were investigated using multivariate logistic regression analyses and presented as odds ratios (O.R) within 95% confidence intervals (C.I).

RESULTS

Forty-five (30%) of 150 participants who provided data in the first week of stroke died by one-year follow-up. Those who died were more likely to have had a prestroke psychiatric symptom (64.4%, p=0.005) and delirium in the acute phase (60.0%, p=0.002). In analyses adjusting for the effect of age, education, tobacco smoking and stroke severity, prestroke psychiatric symptoms (O.R=3.3, 95% C.I=1.3,8.2; O.R=2.2, 95% C.I=1.0,4.6) and acute phase delirium (O.R=3.1, 95% C.I= 1.2,7.6; O.R=3.4, 95% C.I=1.5, 7.6) predicted mortality at 3 and 12 months poststroke, respectively.

CONCLUSION

This study found that prestroke psychiatric symptoms and acute phase delirium independently predicted post-stroke mortality at 3- and 12 months. Detection and treatment of mental health conditions in the population at increased risk of stroke may help reduce poststroke mortality in SSA.

Use of Mental Health Services for Patients Diagnosed with Major Depressive Disorders in Primary Care

Major depressive disorder (MDD) is one of the most disabling diseases worldwide, generating high use of health services. Previous studies have shown that Mental Health Services (MHS) use is associated with patient and Family Physician (FP) factors. The aim of this study was to investigate MHS use in a naturalistic sample of MDD outpatients and the factors influencing use of services in specialized psychiatric care, to know the natural mental healthcare pathway. Non-randomized clinical trial including newly depressed Primary Care (PC) patients (n = 263) with a 12-month follow-up (from 2013 to 2015). Patient sociodemographic variables were assessed along with clinical variables (mental disorder diagnosis, severity of depression or anxiety, quality of life, disability, beliefs about illness and medication). FP (n = 53) variables were also evaluated. A multilevel logistic regression analysis was performed to assess factors associated with public or private MHS use. Subjects were clustered by FP. Having previously used MHS was associated with the use of MHS. The use of public MHS was associated with worse perception of quality of life. No other sociodemographic, clinical, nor FP variables were associated with the use of MHS. Patient self-perception is a factor that influences the use of services, in addition to having used them before. This is in line with Value-Based Healthcare, which propose to put the focus on the patient, who is the one who must define which health outcomes are relevant to him.

The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial

While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.