A survey of hospice day services in the United Kingdom & Republic of Ireland : how did hospices offer social support to palliative care patients, pre-pandemic?

INTRODUCTION

Social support is described by patients and other stakeholders to be a valuable component of palliative day care. Less is known about the range of hospice services that have been used in practice that facilitate social support. An online survey aimed to gain an overview of all hospice day services that facilitated social support for adults outside of their own homes.

METHODS

An online survey was distributed via email to people involved in managing hospice day services. Questions were asked on hospice characteristics, including staff and volunteer roles. Respondents were asked to identify services they felt offered social support to patients. Data collection took place between August 2017 and May 2018.

RESULTS

Responses were received from 103 hospices in the UK and ROI (response rate 49.5%). Results provide an overview of hospice day and outpatient services that offer social support to patients. These are: multi-component interventions, activity groups, formal support groups, befriending, and informal social activities. Multi-component interventions, such as palliative day care, were the most commonly reported. Their stated aims tend to focus on clinical aspects, but many survey respondents considered these multicomponent interventions to be the 'most social' service at their hospice. The survey also identified a huge variety of activity groups, as well as formal therapeutic support groups. Informal 'social-only' activities were present, but less common. Over a third of all the services were described as 'drop in'. Most responding hospices did not routinely use patient reported outcome measures in their 'most social' services.

CONCLUSIONS

The survey documents hospice activity in facilitating social support to be diverse and evolving. At the time of data collection, many hospices offered multiple different services by which a patient might obtain social support outside of their own home and in the presence of other patients.

Mental health interventions and future major depression among primary care patients with subthreshold depression

BACKGROUND

Subthreshold depression is prevalent in primary care and is associated with poorer quality of life, higher health care use and increased risk of major depressive disorder (MDD). Currently, it is unclear how subthreshold depression should be managed in primary care and no studies have investigated the relationship between current models of care and the development of MDD. This study aimed to describe usual care over a six month follow-up for primary care patients with subthreshold depression and to investigate the relationship between usual care and the development of MDD.

METHODS

Data were derived from 250 participants with subthreshold depression from the diamond study, a longitudinal cohort study of primary care patients. Participants completed questionnaires at three and six months on their health care use, the interventions they received and their depression status. Interventions were categorised according to the NICE guidelines for the management of depression in adults. Generalised estimating equation (GEE) models and logistic regression were used to estimate the association between receiving an intervention and MDD over six months.

RESULTS

Four fifths (80.8%) of participants received a mental health intervention. Therapeutic listening, reassurance, pharmacotherapy and advice to exercise were most common. Subsequent MDD was predicted by history of depression, baseline depressive symptom severity and receiving a mental health intervention.

LIMITATIONS

Usual care was assessed via patient self-report.

CONCLUSIONS

Primary care physicians deliver mental health interventions to most subthreshold patients. However, it appears that current interventions are not averting MDD. Further research to identify effective interventions which are feasible in primary care is needed.

The effect of strategies of personal resilience on depression recovery in an Australian cohort: A mixed methods study

Strategies of personal resilience enable successful adaptation in adversity. Among patients experiencing depression symptoms, we explored which personal resilience strategies they find most helpful and tested the hypothesis that use of these strategies improves depression recovery. We used interview and survey data from the Diagnosis, Management and Outcomes of Depression in Primary Care 2005 cohort of patients experiencing depression symptoms in Victoria, Australia. A total of 564 participants answered a computer-assisted telephone interview question at 12 months follow-up, about what they found most helpful for their depression, stress or worries. Depressive disorder and severity were measured at annual follow-up using the Composite International Diagnostic Interview and the Patient Health Questionnaire self-rating questionnaire. Using interview responses, we categorised participants as users or not of strategies of personal resilience, specifically, drawing primarily on expanding their own inner resources or pre-existing relationships: 316 (56%) were categorised as primarily users of personal resilience strategies. Of these, 193 (61%) reported expanding inner resources, 79 (25%) drawing on relationships and 44 (14%) reported both. There was no association between drawing on relationships and depression outcome. There was evidence supporting an association between expanding inner resources and depression outcome: 25 per cent of users having major depressive disorder 1 year later compared to 38 per cent of non-users (adjusted odds ratio: 0.59, confidence interval: 0.36–0.97). This is the first study to show improved outcome for depression for those who identify as most helpful the use of personal resilience strategies. The difference in outcome is important as expanding inner resources includes a range of low intensity, yet commonly available strategies.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions

Objectives

Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role.

Design

Qualitative study in General Practice.

Setting

UK primary care.

Main outcome measures

A qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory.

Design and setting

Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory.

Participants

UK based GPs (interview and surveys); European GP trainees (focus groups).

Results

Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP.

Conclusions

We describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

Challenges of nurse delivery of psychological interventions for long-term conditions in primary care: a qualitative exploration of the case of chronic fatigue syndrome/myalgic encephalitis

BACKGROUND

The evidence base for a range of psychosocial and behavioural interventions in managing and supporting patients with long-term conditions (LTCs) is now well-established. With increasing numbers of such patients being managed in primary care, and a shortage of specialists in psychology and behavioural management to deliver interventions, therapeutic interventions are increasingly being delivered by general nurses with limited training in psychological interventions. It is unknown what issues this raises for the nurses or their patients. The purpose of the study was to examine the challenges faced by non-specialist nurses when delivering psychological interventions for an LTC (chronic fatigue syndrome/myalgic encephalomyelitis [CFS/ME]) within a primary care setting.

METHODS

A qualitative study nested within a randomised controlled trial [ISRCTN 74156610] explored the experiences and acceptability of two different psychological interventions (pragmatic rehabilitation and supportive listening) from the perspectives of nurses, their supervisors, and patients. Semi structured in-depth interviews were conducted with three nurse therapists, three supervisors, and 46 patients. An iterative approach was used to develop conceptual categories from the dataset.

RESULTS

Analyses identified four sets of challenges that were common to both interventions: (i) being a novice therapist, (ii) engaging patients in the therapeutic model, (iii) dealing with emotions, and (iv) the complexity of primary care. Each challenge had the potential to cause tension between therapist and patient. A number of strategies were developed by participants to manage the tensions.

CONCLUSIONS

Tensions existed for nurses when attempting to deliver psychological interventions for patients with CFS/ME in this primary care trial. Such tensions should be addressed before implementing psychological interventions within routine clinical practice. Similar tensions may be found for other LTCs. Our findings have implications for developing therapeutic alliances and highlight the need for regular supervision.

Embedding effective depression care: using theory for primary care organisational and systems change

BACKGROUND

Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.

METHODS

We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.

RESULTS

Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.

CONCLUSIONS

Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.

Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms

OBJECTIVE

We tested the theory that general practitioners (GPs) offer somatic intervention to patients with medically unexplained symptoms (MUS) as a defensive response to patients' dependence. We predicted that GPs most likely to respond somatically after patients indicated symptomatic or psychosocial needs had attachment style characterised by negative models of self and others.

METHOD

Twenty-five GPs identified 308 patients presenting MUS and indicated their own models of self and others. Consultations were audio recorded and coded speech-turn-by-speech-turn. We modeled the probability of GPs proposing somatic intervention on any turn as a function of their models of self and other and the number of prior turns containing symptomatic or psychosocial presentations.

RESULTS

Prior psychosocial presentations decreased the likelihood of GPs offering somatic intervention. The decrease was greatest in GPs with most positive models of self and, contrary to prediction, least positive models of others. The positive relationship between prior somatic presentations and the likelihood that GPs offered somatic intervention was unrelated to either model.

CONCLUSION

Findings are incompatible with our theory that GPs propose somatic interventions defensively. Instead, GPs may provide somatic intervention because they value patients (positive model of others) but devalue their own psychological skills (negative model of self).

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

OBJECTIVE

Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style.

METHODS

Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses.

RESULTS

Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others.

CONCLUSIONS

From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as "confrontation." Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Process evaluation for complex interventions in primary care: understanding trials using the normalization process model

BACKGROUND

The Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.

METHOD

In this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.

RESULTS

Application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.

CONCLUSION

The model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare settings.

Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention

OBJECTIVE

In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation.

METHODS

Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion).

RESULTS

Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients' and doctors' psychosocial talk. The relationship with doctors' psychosocial talk was accounted for by patients' psychosocial talk. Contrary to predictions, doctors' normalization was inversely associated with somatic intervention and physical explanations had no effect.

CONCLUSION

Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients' psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention.

Considering the case for an antidepressant drug trial involving temporary deception: a qualitative enquiry of potential participants

Background

Systematic reviews of randomised placebo controlled trials of antidepressant medication show small and decreasing differences between pharmacological and placebo arms. In part this finding may relate to methodological problems with conventional trial designs, including their assumption of additivity between drug and placebo trial arms. Balanced placebo designs, which include elements of deception, may address the additivity question, but pose substantial ethical and pragmatic problems. This study aimed to ascertain views of potential study participants of the ethics and pragmatics of various balanced placebo designs, in order to inform the design of future antidepressant drug trials.

Methods

A qualitative approach was employed to explore the perspectives of general practitioners, psychiatrists, and patients with experience of depression. The doctors were chosen via purposive sampling, while patients were recruited through participating general practitioners. Three focus groups and 12 in-depth interviews were conducted. A vignette-based topic guide invited views on three deceptive strategies: post hoc, authorised and minimised deception. The focus groups and interviews were tape-recorded and transcribed. Transcripts were analysed thematically using Framework.

Results

Deception in non-research situations was typically perceived as acceptable within specific parameters. All participants could see the potential utility of introducing deception into trial designs, however views on the acceptability of deception within antidepressant drug trials varied substantially. Authorized deception was the most commonly accepted strategy, though some thought this would reduce the effectiveness of the design because participants would correctly guess the deceptive element. The major issues that affected views about the acceptability of deception studies were the welfare and capacity of patients, practicalities of trial design, and the question of trust.

Conclusion

There is a trade-off between pragmatic and ethical responses to the question of whether, and under what circumstances, elements of deception could be introduced into antidepressant drug trials. Ensuring adequate ethical safeguards within balanced placebo designs is likely to diminish their ability to address the crucial issue of additivity. The balanced placebo designs considered in this study are unlikely to be feasible in future trials of antidepressant medication. However there remains an urgent need to improve the quality of antidepressant drug trials.

Why do primary care physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure

OBJECTIVE

We test predictions from contrasting theories that primary care physicians offer medical care to patients with medically unexplained symptoms in response to a) patients' attribution of symptoms to disease and demand for treatment or b) their progressive elaboration of their symptoms in the attempt to engage their physicians.

METHODS

Primary care physicians identified consecutive patients who consulted with symptoms that the physician considered unexplained by physical disease. Four hundred twenty consultations with 36 physicians were audio recorded and transcribed, and physician and patient speech was coded turn by turn. Hierarchical logistic regression analysis modeled the probability of the physician proposing medical care as a function of the quantity of patients' speech of specific kinds that preceded it.

RESULTS

Whether physicians proposed medical care was unrelated to patients' attributions to disease or demands for treatment. Proposals of explicitly somatic responses (drugs, investigation or specialist referral) became more likely after patients had elaborated their symptoms and less likely after patients indicated psychosocial difficulties. Proposals of a further primary care consultation were responses simply to lengthening consultation.

CONCLUSIONS

The findings are incompatible with the influential assumption that physicians offer medical care to patients with unexplained symptoms because the patients demand treatment for a physical disease. Instead, the reason why many of these patients receive high levels of medical care should be sought by investigating the motivations behind physicians' responses to patients' symptom presentation.

The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms

Patients with symptoms that doctors cannot explain by physical disease are common in primary care. That they receive disproportionate amounts of physical intervention, which is largely ineffective and sometimes iatrogenic, is usually attributed to patients' belief that they are physically diseased, their denial of psychological difficulties, and their demand for physical intervention. The evidence for this view has mainly been doctors' subjective reports. By observing what patients and doctors say in consultation, we tested hypotheses arising from recent qualitative evidence. In particular, that physical intervention is proposed more often by general practitioners (GPs) than by patients, that most patients indicate psychosocial needs, and that GPs offer little effective explanation or empathy. Consultations of 420 consecutive patients identified by British GPs as presenting medically unexplained symptoms (MUS) were audio-recorded, transcribed and coded, utterance-by-utterance, using a specially developed coding scheme based on the previous qualitative analyses of these kinds of consultation. Physical intervention was, as predicted, proposed more often by GPs than patients. Also as predicted, almost all patients provided cues concerning psychosocial difficulties or their need for explanation. Although, contrary to prediction, most GPs did provide explanations other than physical disease, most also suggested physical disease. Few GPs empathised. The findings suggest that the explanation for the high level of physical intervention for MUS lies in GPs' responses rather than patients' demands, and we propose that explanations for 'somatisation' should be sought in doctor-patient interaction rather than in patients' psychopathology.

What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized?

OBJECTIVE

We tested predictions that patients with medically unexplained symptoms (MUS) want more emotional support and explanation from their general practitioners (GPs) than do other patients, and that doctors find them more controlling because of this.

DESIGN

Thirty-five doctors participated in a cross-sectional comparison of case-matched groups. Three hundred fifty-seven patients attending consecutively with MUS were matched for doctor and time of attendance with 357 attending with explained symptoms. Patients self-reported the extent to which they wanted somatic intervention, emotional support, explanation and reassurance. Doctors rated their perception of patients' influence on the consultation. Predictions were tested by multilevel analyses.

RESULTS

Patients with MUS sought more emotional support than did others, but no more explanation and reassurance or somatic intervention. A minority of doctors experienced them as exerting more influence than others. The experience of patient influence was related to the patients' desire for support.

CONCLUSIONS

Future research should examine why GPs provide disproportionate levels of somatic intervention to patients who seek, instead, greater levels of emotional support.

Normalisation of unexplained symptoms by general practitioners: a functional typology

BACKGROUND

Patients often present in primary care with physical symptoms that doctors cannot readily explain. The process of reassuring these patients is challenging, complex and poorly understood.

AIM

To construct a typology of general practitioners' (GPs') normalising explanations, based on their effect on the process and outcome of consultations involving patients with medically unexplained symptoms.

DESIGN OF STUDY

Qualitative analysis of audiotaped consultations between patients and GPs.

SETTING

Seven general practices in Merseyside, United Kingdom.

METHODS

Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively, to identify types of normalising speech used by GPs.

RESULTS

Normalisation without explanation included rudimentary reassurance and the authority of a negative test result. Patients persisted in requesting explanation and elaborated or extended their symptoms, rendering somatic management more likely. Normalisation with ineffective explanation provided a tangible physical explanation for symptoms, unrelated to patient's expressed concerns. This was also counterproductive. Normalisation with effective explanation provided tangible mechanisms grounded in patients' concerns, often linking physical and psychological factors. These explanations were accepted by patients; those linking physical and psychological factors contributed to psychosocial management outcomes.

CONCLUSIONS

The routine exercise of normalisation by GPs contains approaches that are ineffective and may exacerbate patients' presentation. However, it also contains types of explanation that may reduce the need for symptomatic investigation or treatment. These findings can inform the development of well-grounded educational interventions for GPs.

Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners

BACKGROUND

Symptomatic investigation and treatment of unexplained physical symptoms is often attributed to patients' beliefs and demands for physical treatments.

AIM

To test the influential assumption that patients who present symptoms that the general practitioner (GP) considers to be medically unexplained do not generally provide the opportunity for discussion of psychological issues.

DESIGN OF STUDY

Qualitative analysis of audiotaped consultations between patients and GPs.

SETTING

Seven general practices in Merseyside, United Kingdom.

METHODS

Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively to identify opportunities that patients presented for their doctors to address emotional problems or their need for explanation.

RESULTS

All but two patients provided psychological opportunities. They described social or emotional difficulties as problems of stress or mood. They presented their need for explanation by: explicit questions; statements of concern about symptoms; suggestions that disease might be absent; or tentative references to serious disease. In general, GPs did not engage with these cues.

CONCLUSIONS

Patients with unexplained symptoms present opportunities for GPs to address psychological needs. By taking these opportunities, GPs might be able to avoid unnecessary symptomatic intervention.

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial

BACKGROUND

The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care.

AIM

To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs).

DESIGN OF STUDY

Group randomised controlled trial, using the health centre as the unit of randomisation.

SETTING

Primary care teams in north-west England.

METHOD

Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms.

RESULTS

Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%).

CONCLUSION

The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.

Complementary medicine and general practice: an urban perspective

BACKGROUND

Complementary medicine appears to be an increasingly popular option amongst both doctors and patients. General practitioners in more affluent parts of Britain have showed considerable interest in its use.

OBJECTIVES

To ascertain use of and attitudes towards complementary medicine, amongst general practitioners working in a socioeconomically deprived urban area.

METHODS

A postal questionnaire survey of all general practice principles in Liverpool, using freepost envelopes and one reminder after 3 weeks. With respect to eight common complementary therapies, respondents were asked whether they treat with, refer to or endorse each therapy; for their views on NHS funding, effectiveness, adverse reactions, training needs, and theoretical validity, for each therapy.

RESULTS

The response rate was 131/252 (52%), higher amongst women and doctors aged under 40. During the previous week 74 (56%) of respondents had been involved in complementary medical activity with their patients: 13% had treated directly, 31% had referred to and 38% had endorsed one or more complementary therapies. Acupuncture was most popular as an NHS option, and along with osteopathy and chiropractic was the therapy most highly regarded by respondents in terms of effectiveness. Homeopathy and hypnotherapy received a mixed reaction, while medical herbalism, aromatherapy and reflexology were viewed more sceptically. Sixty-two per cent of respondents reported successful outcomes of complementary treatments, compared with 21% reporting adverse reactions. Knowledge and training desires were highest for homeopathy and acupuncture. Respondents were generally uncertain about the theoretical validity of these therapies: 50% though acupuncture had a valid basis, compared with only 23% for homeopathy and 8% for reflexology.

CONCLUSIONS

The degree of support for complementary medicine therapies amongst general practitioners in this socioeconomically deprived urban area was similar to that found elsewhere in Britain. These general practitioners appeared to tolerate high levels of clinical uncertainty, endorsing a wide range of therapies, despite little knowledge of their content or conviction of their validity.

GP frequent attendance in Liverpool and Granada: the impact of depressive symptoms

BACKGROUND

Frequent attendance in general practice increases workload and affects doctor-patient relationships. It is a complex phenomenon, but patients' psychological problems appear to be important.

AIM

To assess whether frequent attendance is more likely to be associated with depressive symptoms than with physical health problems.

METHOD

The study was carried out in two general practices: one in Liverpool and one in Granada. Subjects comprised 127 frequent attenders (FAs) plus 175 matched controls, stratified by age and sex. Measures included demographic factors, Beck Depression Inventory (BDI), self-reported health, and current health problems classified by ICHPPC-2 criteria.

RESULTS

Seventy-five (59%) FAs had a BDI score > or = 13, compared with 9 (5%) controls (odds ratio [OR] = 26.6, 95% confidence interval [CI] = 12.4 to 56.8, P < 0.001). A total of 136 (78%) controls reported their health to be good or excellent, compared with 40 (31%) FAs (OR = 7.6, 95% CI = 4.5 to 12.7, P < 0.001). Respiratory problems were present in 50 (39%) FAs and 47 (27%) controls (chi 2 = 6.992, P < 0.03). Depression rates were similar in Liverpool and Granada, although Liverpool subjects were less likely to report good health. On logistic regression, BDI status was the major predictor of frequent attendance (OR = 17.18, 95% CI = 7.54 to 39.01). Self-reported ill health (OR = 2.67, 95% CI = 1.40 to 5.10) and respiratory problems (OR = 2.20, 95% CI = 1.11 to 4.37) were also associated with frequent attendance.

CONCLUSION

Depressive symptoms were the major predictor of frequent attendance in this study. Clinical and research activity should therefore concentrate on the identification and management of psychological problems among FAs in general practice.

The use of the Beck Depression Inventory to screen for depression in the general population: a preliminary analysis

OBJECTIVE

The aim of the present paper is to study the performance of Beck's Depression Inventory (BDI) as a screening instrument for depressive disorders in a general population sample.

METHODS

1250 subjects, from 18 to 64 years old, were randomly selected from the Santander (Spain) municipal census. A two-stage method was used: in the first stage, all individuals selected completed the BDI; in the second, 'probable cases' (BDI cut-off>/=13) and a random 5% sample of the total sample with a BDI score less than 13 were interviewed by psychiatrists using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), which generates diagnoses of depressive disorders.

RESULTS

Our data confirm the predictive value of the selected cut-off point (12/13): 100% sensitivity, 99% specificity, 0. 72 PPV, 1 NPV, and 98% overall diagnostic value. The area under ROC (AUC) was found to be 0.99. There were no statistical differences in terms of sex or age. We conclude that the BDI is a good instrument for screening depressive disorders in community surveys.