Delivering stepped care for depression in general practice: results of a survey amongst general practitioners in the Netherlands

Clinical factors, C-reactive protein point of care test and chest X-ray in patients with pneumonia: A survey in primary care

Background: In patients with an acute lower respiratory tract infection (LRTI), general practitioners (GPs) often find it challenging to decide to prescribe antibiotics or not. C-reactive protein (CRP) point of care test (POCT), and chest X-ray are diagnostic tests that can optimize the treatment decision. However, their usefulness in clinical practice is unknown.

Objectives: To determine the proportion of Dutch GPs using CRP and chest X-ray in patients with an acute LRTI. To determine whether clinical factors and C-reactive protein point of care test affect the behaviour in requesting chest X-rays.

Methods: In 2014, a questionnaire was sent to a random sample of 900 Dutch GPs. Outcome parameters are the use of CRP and chest X-ray, the percentage of GPs who guide their decision in requesting chest X-rays by CRP testing and the GP’s expectation regarding presence or absence of pneumonia. In addition, considerations for requesting chest X-rays were assessed.

Results: Two hundred and fifty-five completed questionnaires (29%) were returned. In 2014, 54% of the responding GPs used the CRP test. These GPs tend to use fewer chest X-rays (p = 0.07). GPs overestimate the chance that pneumonia will be present on the radiograph. Seventy percent consider the possibility of abnormalities other than pneumonia as the main reason for requesting a chest X-ray.

Conclusion: In patients with an acute lower respiratory tract infection, GPs report that CRP results affect their behaviour regarding the request of a chest X-ray in patients with lower respiratory tract infection and therefore research is needed to substantiate the use of these diagnostic tools for this purpose.

Antidepressant prescriptions and mental health nurses: an observational study in Dutch general practice from 2011 to 2015

PURPOSE

The purpose of this study was to investigate developments in antidepressant prescriptions by Dutch general practitioners, alongside the national introduction of mental health nurses. Antidepressant prescriptions are very common in general practice, but are often not in line with recommendations. The recent introduction of mental health nurses may have decreased antidepressant prescriptions, as general practitioners (GPs) have greater potential to offer psychological treatment as a first choice option instead of medication.

MATERIAL AND METHODS

Anonymised data from the medical records of general practices participating in the NIVEL Primary Care Database in 2011-2015 were analysed in an observational study. We used multilevel logistic regression analyses to determine whether total antidepressant prescriptions and antidepressants prescribed within one week of diagnosing anxiety or depression decreased in the period 2011-2015. We analysed whether changes in antidepressant prescriptions were associated with the employment or consultation of mental health nurses.

RESULTS

Antidepressants were prescribed in 30.3% of all anxiety or depression episodes; about half were prescribed within the first week. Antidepressants prescriptions for anxiety or depression increased slightly in the period 2011-2015. The employment of mental health nurses was not associated with a decreased number of prescriptions of antidepressants. Patients who had at least one mental health nurse consultation had fewer immediate prescriptions of antidepressants, but not fewer antidepressants in general.

CONCLUSIONS

Antidepressant prescriptions are still common in general practice. So far, the introduction of mental health nurses has not decreased antidepressant prescriptions, but it may have a postponing effect.

PsyScan e-tool to support diagnosis and management of psychological problems in general practice: a randomised controlled trial

BACKGROUND

GPs are crucial in adequately diagnosing and initiating appropriate management for patients with psychological problems, but face many challenges and require support.

AIM

To determine the effects of the e-tool PsyScan.

DESIGN AND SETTING

A randomised controlled trial with a 1-year follow-up, comparing care using PsyScan with usual care for psychological problems, was undertaken in 10 multidisciplinary primary healthcare centres in Eindhoven, the Netherlands.

METHOD

Between consultations with their GP, participants in the intervention group could complete PsyScan. The e-tool consists of a distress screener and Four-Dimensional Symptom Questionnaire to differentiate between stress, depression, anxiety, and somatisation symptoms, and to explore symptom severity. PsyScan generated diagnostic and therapeutic advice for GPs and participants that was automatically transferred to each patient's electronic medical record. The primary outcome was the proportion of participants that achieved a successful treatment result; namely, a decrease of ≥50% on the Symptom Checklist-90-Revised, after 1 year.

RESULTS

There were 176 participants in the intervention group and 160 in the control group. After multiple imputation, the participants in the intervention group had higher chances of achieving a successful treatment result compared with those in the control group (odds ratio [OR] 2.7, 95% confidence interval [CI] = 1.5 to 4.8, P = 0.002). Quality of life was higher in the intervention group at 12 months (mean difference in EuroQol 5 Dimensions 5 Levels index values was 0.076, 95% CI = 0.015 to 0.136, P = 0.01). The mean 1-year costs per participant were similar (€13 622 in intervention group, €12 487 in control group [β = -0.03, P = 0.71, R² = 0.05]).

CONCLUSION

PsyScan generated clinically relevant and statistically significant effects, and could be useful in offering effective individualised care to patients.

Potential for substitution of mental health care towards family practices: an observational study

BACKGROUND

Substitution is the shift of care from specialized health care to less expensive and more accessible primary health care. It seems promising for restraining rising mental health care costs. The goal of this study was to investigate a potential for substitution of patients with psychological or social problems, but without severe psychiatric disorders, from Dutch specialized mental health care to primary care, especially family practices.

METHODS

We extracted anonymized data from two national databases representing primary and specialized care in 2012. We calculated the number of patients with and without psychiatric disorder per 1,000 citizens in three major settings: family practices, primary care psychologists, and specialized care. Family physicians recorded psychopathology using the International Classification of Primary Care, while psychologists and specialists used the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

RESULTS

Considerable numbers of patients without a diagnosed DSM-IV psychiatric disorder were treated by primary care psychologists (32.8%) or in specialized care (20.8%). Over half of the patients referred by family physicians to mental health care did not have a psychiatric disorder.

CONCLUSION

A recent reform of Dutch mental health care, including new referral criteria, will likely increase the number of patients with psychological or social problems that family physicians have to treat or support. Enabling and improving diagnostic assessment and treatment in family practices seems essential for substitution of mental health care.

The concurrent validity of a new eDiagnostic system for mental disorders in primary care

BACKGROUND

An eDiagnostic system was implemented to classify mental disorders, to support general practitioners.

OBJECTIVE

Assessing the validity of the system, compared to the psychologists' judgment.

METHODS

Concurrent validity, using routinely collected data of 675 primary care patients with a suspicion of a mental disorder in the Netherlands. Four psychologists classified the patients according to the DSM-IV. Hundred records were randomly selected to investigate the inter-rater reliability among psychologists. To investigate the concurrent validity of the system the sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs) and Cohen's κ-values (κ-values) were calculated.

RESULTS

Inter-rater agreement between psychologists were fair to good or excellent. The system could correctly estimate the echelon (sensitivity range: 0.85-0.95, specificity range: 0.88-0.98) and correctly identify most Axis I classifications (sensitivity: 0.46-1.00, specificity: 0.75-0.99), except for Asperger's, sexual and adjustment disorders (sensitivity: 0.10-0.24, specificity: 0.97-0.99). It could determine the absence of a personality disorder (sensitivity: 0.81, specificity: 0.84, PPV: 0.77, NPV: 0.87 and κ-value: 0.65). The sensitivities and specificities for most specific personality disorders were good, but the PPVs for several specific Axis II classifications were low (PPV range: 0.06-0.77). The system was inaccurate in identifying the global assessment of functioning of patients (e.g. κ-values varied from 0.17-0.46).

CONCLUSIONS

Generally, the system can be seen as a valid instrument for most DSM-IV classifications in primary care patients. It could assist healthcare professionals in the assessment and classification of mental disorders. Future research should include comparison to an independently administered structured clinical interview.

Feasibility of an online well-being intervention for people with spinal cord injury: a pilot study

STUDY DESIGN

Pre-test and post-test designs with 14 participants. Measurements were taken at baseline (T1), immediately after the intervention (T2) and at 3-month follow-up (T3).

OBJECTIVES

Psyfit is an online self-help program designed to enhance well-being in persons with depressed mood. We examined the feasibility of Psyfit in people with spinal cord injury (SCI).

SETTING

Community, the Netherlands.

METHODS

Participants chose two of the six Psyfit modules. The researcher maintained telephone contact with the participants. Feasibility was inferred from the completion rate of the modules and feedback from the participants. Outcome measures were the Mental Health Inventory-5, the Center for Epidemiological Studies Depression scale and the Warwick-Edinburgh Mental Well-Being Scale.

RESULTS

Overall, 75% of the first module and 39% of the second module were completed. Seven participants were considered as study completers and were included in the evaluation. They evaluated Psyfit as a useful program and helpful for persons with SCI. Several technical problems were reported that mainly concerned browser compatibility. An increase in mental health and nonsignificant change of well-being were found at the end of the intervention period, but these were not maintained at follow-up.

CONCLUSION

Psyfit seems a potentially feasible program. However, adaptation to the SCI population and further study with a controlled design and utilizing a larger sample size are necessary before it can be recommended as part of SCI rehabilitation.

Stepped care for depression is easy to recommend, but harder to implement: results of an explorative study within primary care in the Netherlands

Background

Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care.

Methods

Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire.

Results

Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals was considered an important factor for improvement by nearly all GPs.

Conclusions

The management of depression in primary care seems in line with stepped care principles, although it can be improved by applying more elements of a stepped care approach. Collaboration between GPs and mental health care providers in primary care and secondary care should be enhanced.