Depressive symptomatology in older adults treated with behavioral activation: A network perspective

BACKGROUND

Late-life depression is a serious mental health problem. Behavioral Activation (BA) is an effective, accessible psychotherapeutic treatment for older adults. However, little is known about which symptoms decrease and how associations between depressive symptoms change during BA treatment.

METHODS

Using data from a cluster-randomized trial for older adults with late-life depression, we estimated a partial correlation network and a relative importance network of depressive symptoms before and after 8 weeks of BA treatment in primary care (n = 96). Networks were examined with measures of network structure, connectivity, centrality as well as stability.

RESULTS

The most central symptoms at baseline and post-treatment were anhedonia, fatigue, and feeling depressed. In contrast, sleeping problems had the lowest centrality. The post-treatment network was significantly more interconnected than at baseline. Moreover, all symptoms were significantly more central at post-treatment.

CONCLUSION

Our findings highlight the utility of the network approach to better understand symptom networks of depressed older adults before and after BA treatment. Results show that network connectivity and centrality of all symptoms increased after treatment. Future studies should investigate longitudinal idiographic networks to explore symptom dynamics within individuals over time.

Measuring persistent somatic symptom related stigmatisation: Development of the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP)

OBJECTIVE

Persistent somatic symptoms (PSS) describe recurrent or continuously occurring symptoms such as fatigue, dizziness, or pain that have persisted for at least several months. These include single symptoms such as chronic pain, combinations of symptoms, or functional disorders such as fibromyalgia or irritable bowel syndrome. While stigmatisation by healthcare professionals is regularly reported, there are limited measurement instruments demonstrating content validity. This study develops a new instrument to measure stigmatisation by healthcare professionals, the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP).

METHODS

Development was an iterative process consisting of research team review, item generation and cognitive interviewing. We generated a longlist of 60 items from previous reviews and qualitative research. We conducted 18 cognitive interviews with healthcare professionals in the United Kingdom (UK). We analysed the relevance, comprehensibility and comprehensiveness of items, including the potential for social desirability bias.

RESULTS

After research team consensus and initial feedback, we retained 40 items for cognitive interviewing. After our first round of interviews (n = 11), we removed 20 items, added three items and amended five items. After our second round of interviews (n = 7), we removed four items and amended three items. No major problems with relevance, comprehensibility, comprehensiveness or social desirability were found in remaining items.

CONCLUSIONS

The provisional version of the PSSS-HCP contains 19 items across three domains (stereotypes, prejudice, discrimination), demonstrating sufficient content validity. Our next step will be to perform a validation study to finalise item selection and explore the structure of the PSSS-HCP.

Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial

INTRODUCTION

Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the cost-effectiveness compared to treatment as usual (TAU) is unknown.

METHODS

An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios.

RESULTS

Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -€485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs.

DISCUSSION

Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.

Behavioural Activation versus Treatment as Usual for Depressed Older Adults in Primary Care: A Pragmatic Cluster-Randomised Controlled Trial

INTRODUCTION

Effective non-pharmacological treatment options for depression in older adults are lacking.

OBJECTIVE

The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated.

METHODS

In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up.

RESULTS

Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = -2.77, 95% CI = -4.19 to -1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42-1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = -1.53, 95% CI = -2.81 to -0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07-0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = -0.89 (-2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = -0.82 to 0.24).

CONCLUSIONS

BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Cardiovascular risk management in patients with severe mental illness or taking antipsychotics: A qualitative study on barriers and facilitators among dutch general practitioners

BACKGROUND

Patients with severe mental illness (SMI) or receiving treatment with antipsychotics (APs) have an increased risk of cardiovascular disease. Cardiovascular risk management (CVRM) increasingly depends on general practitioners (GPs) because of the shift of mental healthcare from secondary to primary care and the surge of off-label AP prescriptions. Nevertheless, the uptake of patients with SMI/APs in CVRM programmes in Dutch primary care is low.

OBJECTIVES

To explore which barriers and facilitators GPs foresee when including and treating patients with SMI or using APs in an existing CVRM programme.

METHODS

In 2019, we conducted a qualitative study among 13 Dutch GPs. During individual in-depth, semi-structured interviews a computer-generated list of eligible patients who lacked annual cardiovascular risk (CVR) screening guided the interview. Data was analysed thematically.

RESULTS

The main barriers identified were: (i) underestimation of patient CVR and ambivalence to apply risk-lowering strategies such as smoking cessation, (ii) disproportionate burden on GPs in deprived areas, (iii) poor information exchange between GPs and psychiatrists, and (iv) scepticism about patient compliance, especially those with more complex conditions. The main facilitators included: (i) support of GPs through a computer-generated list of eligible patients and (ii) involvement of family or carers.

CONCLUSION

This study displays a range of barriers and facilitators anticipated by GPs. These indicate the preconditions required to remove barriers and facilitate GPs, namely adequate recommendations in practice guidelines, improved consultation opportunities with psychiatrists, practical advice to support patient adherence and incentives for practices in deprived areas.

[Fatigue]

Many patients with fatigue do not visit a physician. In patients who do consult the general practitioner, the cause of their fatigue is explained in about a quarter: 8 percent has a somatic cause while psychosocial causes explain 16 percent. In about three quarters the cause of fatigue remains unexplained. Because of the low prevalence of somatic causes the general practitioner will be reluctant to perform additional examinations but a thorough physical examination is essential. In patients with a longer duration of fatigue (> 6 months) it is indicated to expand inquiries. This starts with extending history taking in the direction of consanguinity and hereditary diseases. More comprehensive blood tests and investigation of sleep are important further steps. Referral to a specialist is essential as specialists are more familiar with scripts of rare diseases. The prognosis of longer lasting fatigue is bad, especially in the case of fatigue meeting criteria for ME/CFS. Treatment of longer lasting fatigue could compromise of psycho-education, exercise and specific therapies for sleeping disorders.

How Does Behavioural Activation Work? A Systematic Review of the Evidence on Potential Mediators

INTRODUCTION

Behavioural activation is an effective treatment for depression, but little is known about its working mechanisms. Theoretically, its effect is thought to rely on an interplay between activation and environmental reward.

OBJECTIVE

The present systematic review examines the mediators of behavioural activation for depression.

METHODS

A systematic literature search without time restrictions in Medline, EMBASE, PsycINFO, The Cochrane Library, and CINAHL resulted in 14 relevant controlled and uncontrolled prospective treatment studies that also performed formal mediation analyses to investigate their working mechanisms. After categorising the mediators investigated, we systematically compared the studies' methodological quality and performed a narrative synthesis of the findings.

RESULTS

Most studies focused on activation or environmental reward, with 21 different mediators being investigated using questionnaires that focused on psychological processes or beliefs. The evidence for both activation and environmental reward as mediators was weak.

CONCLUSIONS

Non-significant results, poor methodological quality of some of the studies, and differences in questionnaires employed precluded any firm conclusions as to the significance of any of the mediators. Future research should exploit knowledge from fundamental research, such as reward motivation from neurobiology. Furthermore, the use of experience sampling methods and idiographic analyses in bigger samples is recommended to investigate potential causal pathways in individual patients.

Motives for non-adherence to colonoscopy advice after a positive colorectal cancer screening test result: a qualitative study

SETTING

Participants with a positive faecal immunochemical test (FIT) in screening programs for colorectal cancer (CRC) have a high risk for colorectal cancer and advanced adenomas. They are therefore recommended follow-up by colonoscopy. However, more than ten percent of positively screened persons do not adhere to this advice.

OBJECTIVE

To investigate FIT-positive individuals' motives for non-adherence to colonoscopy advice in the Dutch CRC screening program.

SUBJECTS

Non-adherent FIT-positive participants of the Dutch CRC screening program.

DESIGN

We conducted semi structured in-depth interviews with 17 persons who did not undergo colonoscopy within 6 months after a positive FIT. Interviews were undertaken face-to-face and data were analysed thematically with open coding and constant comparison.

RESULTS

All participants had multifactorial motives for non-adherence. A preference for more personalised care was described with the following themes: aversion against the design of the screening program, expectations of personalised care, emotions associated with experiences of impersonal care and a desire for counselling where options other than colonoscopy could be discussed. Furthermore, intrinsic motives were: having a perception of low risk for CRC (described by all participants), aversion and fear of colonoscopy, distrust, reluctant attitude to the treatment of cancer and cancer fatalism. Extrinsic motives were: having other health issues or priorities, practical barriers, advice from a general practitioner (GP) and financial reasons.

CONCLUSION

Personalised screening counselling might have helped to improve the interviewees' experiences with the screening program as well as their knowledge on CRC and CRC screening. Future studies should explore whether personalised screening counselling also has potential to increase adherence rates. Key points Participants with a positive FIT in two-step colorectal cancer (CRC) screening programs are at high risk for colorectal cancer and advanced adenomas. Non-adherence after an unfavourable screening result happens in all CRC programs worldwide with the consequence that many of the participants do not undergo colonoscopy for the definitive assessment of the presence of colorectal cancer. Little qualitative research has been done to study the reasons why individuals participate in the first step of the screening but not in the second step. We found a preference for more personalised care, which was not reported in previous literature on this subject. Furthermore, intrinsic factors, such as a low risk perception and distrust, and extrinsic factors, such as the presence of other health issues and GP advice, may also play a role in non-adherence. A person-centred approach in the form of a screening counselling session may be beneficial for this group of CRC screening participants.

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

Background

Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.

Methods

We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.

From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.

Results

We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.

Conclusion

CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

Do Women With Severe Persistent Fatigue Present With Fatigue at the Primary Care Consultation?

Abstract. Recent studies have shown underdiagnosis of severe persistent fatigue in primary care. To study how patients with severe persistent fatigue present in primary care and whether they differ from patients with less severe fatigue and patients with no fatigue. A 4-year retrospective database study combined with a questionnaire, including all female patients 25–50 years ( n = 917) who are registered in one primary care group practice. Based on the results of a validated self-administered questionnaire, patients were divided into three groups: patients with severe persistent fatigue ( n = 42), patients with fatigue ( n = 174), and patients with no fatigue ( n = 246). Data on frequency of consulting, reason for encounter, and diagnoses from 2009 to 2013 were obtained from the electronic medical health record. Data were analyzed using odds ratios. Women with severe persistent fatigue more often were unemployed and had lower education. They visited the general practitioners (GP) more often than other women. However, more than half of the women with severe persistent fatigue did not visit their GP with fatigue as reason for encounter at all during the 4 years of study. A minority of the women with severe persistent fatigue received a psychological diagnosis or social diagnosis (36% and 19%, respectively) during these 4 years. Underdiagnosis of severe persistent fatigue is partly a consequence of patients not presenting or reporting this to their GP. The reasons for this behavior are not clear.

Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review

OBJECTIVE

The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research.

METHODS

A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity.

RESULTS

We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions.

CONCLUSIONS

Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.

[Complexity in general practice]

In general practice, we see complexity in the patient ('case complexity'), in the treatment ('care complexity'), and, to an important degree, in the context in which patient characteristics and environmental factors together lead to disease ('complexity thinking'). This context makes linear medical thinking, i.e. in which a symptom of a disease has one direct biological cause, problematic and the outcomes of interventions based on this thinking are uncertain. Complex patients make much greater demands on a practice than average. Complex interventions occur mainly in the context of coordination of collaboration with other professionals. Complex systems thinking has taken root in general practice, certainly in the scientific field. General practice is often complex, and the only good way to practice is to provide personal care with a focus on the context in which the health problems occur.

Discontinuation of antidepressant medication in primary care supported by monitoring plus mindfulness-based cognitive therapy versus monitoring alone: design and protocol of a cluster randomized controlled trial

Background

Antidepressant use continues to rise, mainly explained by an increase in the proportion of patients receiving long term treatment. Although treatment guidelines recommend discontinuation after sustained remission, discontinuing antidepressants appears to be challenging for both patients and general practitioners (GPs). Mindfulness-Based Cognitive Therapy (MBCT) is an effective intervention that reduces the risk of relapse in recurrent depression and might facilitate discontinuation by teaching patients to cope with withdrawal symptoms and fear of relapse. The current study aims to investigate the effectiveness of the combination of Supported Protocolized Discontinuation (SPD) and MBCT in comparison with SPD alone in successful discontinuation of long-term use of antidepressants in primary care.

Methods

This study involves a cluster-randomized controlled trial conducted in primary care patients with long-term use antidepressants with baseline and 6, 9 and 12 months follow-up assessments. Patients choosing to discontinue their medication will be offered a combination of SPD and MBCT or SPD alone. Our primary outcome will be full discontinuation of antidepressant medication (= 0 mg) within 6 months after baseline assessment. Secondary outcome measures will be the severity of withdrawal symptoms, symptoms of depression and anxiety, psychological well-being, quality of life and medical and societal costs.

Discussion

In theory, stopping antidepressant medication seems straightforward. In practice however, patients and their GPs appear reluctant to initiate and accomplish this process. Both patients and professionals are in need of appropriate tools and information to better support the process of discontinuing antidepressant medication.

Trial registration

ClinicalTrials.gov PRS ID: NCT03361514 retrospectively registered October 2017.

Affecting patients with work-related problems by educational training of their GPs: a cost-effectiveness study

Background

Assessing the cost effectiveness of training aimed at increasing general practitioners’ (GP) work awareness and patients’ work-related self-efficacy and quality of life.

Methods

A cluster randomized controlled trial in twenty-six GP practices in the southeast of the Netherlands with 32 participating GPs. GPs working in an intervention group practice received training and GPs working in a control group practice delivered usual care. The training intervention consisted of lectures and workshops aimed at increasing GPs’ work awareness and more proactive counseling for patients with work-related problems (WRP). Subjects were working age patients with paid work for at least 12 h per week, who visited one of the participating GPs during the study period. As outcome measures we used the Return to Work Self Efficacy scale to assess patients’ work-related self-efficacy and the Euroquol to assess quality of life. We also measured health care costs and productivity costs. With a 4-item questionnaire we asked patients to assess their GPs’ work awareness. Data were collected at baseline, after 6 and 12 months.

Results

Data of 280 patients could be analyzed. The patient related outcomes did not improve after GP training. The change in GP work awareness and the overall mean cost difference (of €770) in favor of the intervention group were not significant.

Conclusions

The training intervention presented in this paper was not cost-effective. Training which is further personalized and targeted at high risk groups with respect to WRP, is more likely to be cost effective.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0924-9) contains supplementary material, which is available to authorized users.

Central sensitization in chronic pain and medically unexplained symptom research: A systematic review of definitions, operationalizations and measurement instruments

OBJECTIVE

Central sensitization (CS), a mechanism explaining the persistence of symptoms, has been the focus of many research projects. Explanations given to patients with chronic pain are often based on this mechanism. It is hypothesized that CS also plays an important role in the persistence of medically unexplained symptoms (MUS). However, definitions and operationalizations of CS vary. We conducted a systematic review of definitions, operationalizations and measurement instruments of CS.

METHODS

We searched in PubMed, EMBASE, PsycINFO, Cinahl and The Cochrane Library till September 2017 and included papers that addressed CS in relation to chronic pain and/or MUS. Two reviewers independently selected, analysed and classified information from the selected publications. We performed a thematic analysis of definitions and operationalizations. We listed the measurement instruments.

RESULTS

We included 126 publications, 79 publications concerned chronic pain, 47 publications concerned MUS. Definitions of CS consistently encompass the theme hyperexcitability of the central nervous system (CNS). Additional themes are variably present: CNS locations, nature of sensory input, reduced inhibition and activation and modulation of the NDMA receptor. Hyperalgesia and allodynia are widely mentioned as operationalizations of CS. Quantitative sensory testing (QST) and (f)MRI are the most reported measurement instruments.

CONCLUSIONS

There is consensus that hyperexcitability is the central mechanism of CS. Operationalizations are based on this mechanism and additional components. There are many measurement instruments available, whose clinical value has still to be determined. There were no systematic differences in definitions and operationalizations between the publications addressing MUS and those addressing chronic pain.

Patients' attitudes to discontinuing not-indicated long-term antidepressant use: barriers and facilitators

BACKGROUND

Long-term antidepressant use has increased exponentially, though this is not always according to guidelines. Our previous randomized controlled trial (RCT) showed that participants using antidepressants long term without a proper indication were apprehensive to stop: only half were willing to attempt to discontinue their antidepressant use. The objective of this study was to explore participants' barriers and facilitators for stopping long-term antidepressant use without a current proper indication.

METHODS

Semistructured interviews with participants from the intervention group of our RCT, a cluster-RCT in general practice in the Netherlands. The latter study was a stop trial with patients on long-term antidepressant use without a current indication (no psychiatric diagnosis). Participants of the intervention group of the RCT had been provided with advice to stop antidepressants. Participants of the current interview study were purposively sampled (from the intervention group of the RCT) to ensure diversity in age, sex, and intention to discontinue the antidepressant. Analysis was performed as an iterative process, based on the constant comparative method. Data collection proceeded until saturation was reached.

RESULTS

A total of 16 participants were interviewed. Fear (of recurrence, relapse, or to disturb the equilibrium) was the most important barrier; prior attempts fueled these anticipations. Also prominent as a barrier was the notion that antidepressants are necessary to counter a deficiency of serotonin. Facilitators were information on duration of usage given at the time of first prescription and confidence in a successful attempt. We found many participants struggling between barriers and facilitators to discontinue and participants not discontinuing while experiencing no barriers (ambivalence).

CONCLUSION

Fear is an important motive for patients considering discontinuation of antidepressants. Serotonin deficiency as explanation for antidepressant effectiveness promotes life-long use and hinders discontinuation of antidepressant treatment. The prospect of discontinuation at first prescription can facilitate a future discontinuation attempt. General practitioners should be aware of their patients' fears, expectations, and attributions toward antidepressant use/discontinuation, and of new developments in taper methods.

[How to read a qualitative research paper?]

Many readers of medical journals are trained in the 'quantitative approach'. This can therefore lead to the misinterpretation of results from qualitative research. By considering four key points, readers can interpret a qualitative paper. The chosen research method should fit the research question. Within medicine, the most common types of qualitative research are: (a) in-depth interviews, (b) focus groups, (c) participating observation, and (d) document analysis. The researchers should sufficiently describe their own role in the study. The results should be illustrated with quotes from study participants. The research should be conducted in a technically correct manner. Certain characteristics will highlight this, such as iterative data collection and saturation, the latter meaning that data collection was discontinued when no new insights or themes were identified anymore. The conclusion should be drawn from results obtained within the study. A common error made by researchers is to interpret the results from a qualitative study in a quantitative manner.

Behavioural activation by mental health nurses for late-life depression in primary care: a randomized controlled trial

BACKGROUND

Depressive symptoms are common in older adults. The effectiveness of pharmacological treatments and the availability of psychological treatments in primary care are limited. A behavioural approach to depression treatment might be beneficial to many older adults but such care is still largely unavailable. Behavioural Activation (BA) protocols are less complicated and more easy to train than other psychological therapies, making them very suitable for delivery by less specialised therapists. The recent introduction of the mental health nurse in primary care centres in the Netherlands has created major opportunities for improving the accessibility of psychological treatments for late-life depression in primary care. BA may thus address the needs of older patients while improving treatment outcome and lowering costs.The primary objective of this study is to compare the effectiveness and cost-effectiveness of BA in comparison with treatment as usual (TAU) for late-life depression in Dutch primary care. A secondary goal is to explore several potential mechanisms of change, as well as predictors and moderators of treatment outcome of BA for late-life depression.

METHODS/DESIGN

Cluster-randomised controlled multicentre trial with two parallel groups: a) behavioural activation, and b) treatment as usual, conducted in primary care centres with a follow-up of 52 weeks. The main inclusion criterion is a PHQ-9 score > 9. Patients are excluded from the trial in case of severe mental illness that requires specialized treatment, high suicide risk, drug and/or alcohol abuse, prior psychotherapy, change in dosage or type of prescribed antidepressants in the previous 12 weeks, or moderate to severe cognitive impairment. The intervention consists of 8 weekly 30-min BA sessions delivered by a trained mental health nurse.

DISCUSSION

We expect BA to be an effective and cost-effective treatment for late-life depression compared to TAU. BA delivered by mental health nurses could increase the availability and accessibility of non-pharmacological treatments for late-life depression in primary care.

TRIAL REGISTRATION

This study is retrospectively registered in the Dutch Clinical Trial Register NTR6013 on August 25th 2016.

Why patients self-refer to the Emergency Department: A qualitative interview study

RATIONALE, AIMS, AND OBJECTIVES

There have been multiple studies investigating reasons for patients to self-refer to the Emergency Department (ED). The majority made use of questionnaires and excluded patients with urgent conditions. The goal of this qualitative study is to explore what motives patients have to self-refer to an ED, also including patients in urgent triage categories.

METHODS

In a large teaching hospital in the Netherlands, a qualitative interview study focusing on reasons for self-referring to the ED was performed. Self-referred patients were included until no new reasons for attending the ED were found. Exclusion criteria were as follows: not mentally able to be interviewed or not speaking Dutch. Patients who were in need of urgent care were treated first, before being asked to participate. Interviews followed a predefined topic guide. Practicing cyclic analysis, the interview topic guide was modified during the inclusion period. Interviews were recorded on an audio recorder, transcribed verbatim, and anonymized. Two investigators independently coded the information and combined the codes into meaningful clusters. Subsequently, these were categorized into themes to build a framework of reasons for self-referral to the ED. Characteristic quotes were used to illustrate the acquired theoretical framework.

RESULTS

Thirty self-referred patients were interviewed. Most of the participants were male (63%), with a mean age of 46 years. Two main themes emerged from the interviews that are pertinent to the patients' decisions to attend the ED: (1) health concerns and (2) practical issues.

CONCLUSIONS

This study found that there are 2 clearly distinctive reasons for self-referral to the ED: health concerns or practical motives. Self-referral because of practical motives is probably most suitable for strategies that aim to reduce inappropriate ED visits.

"Medically unexplained" symptoms and symptom disorders in primary care: prognosis-based recognition and classification

BACKGROUND

Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions.

DISCUSSION

We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors.

CONCLUSION

Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.

Negotiating explanations: doctor-patient communication with patients with medically unexplained symptoms-a qualitative analysis

BACKGROUND

Patients with medically unexplained physical symptoms (MUPS) seek explanations for their symptoms, but often find general practitioners (GPs) unable to deliver these. Different methods of explaining MUPS have been proposed. Little is known about how communication evolves around these explanations.

OBJECTIVE

To examine the dialogue between GPs and patients related to explanations in a community-based clinic for MUPS. We categorized dialogue types and dialogue outcomes.

METHODS

Patients were ≥18 years with inclusion criteria for moderate MUPS: ≥2 referrals to specialists, ≥1 functional syndrome/symptoms, ≥10 on the Patient Health Questionnaire-15 and GP's judgement that symptoms were unexplained. We analysed transcripts of 112 audio-recorded consultations (39 patients and 5 GPs) from two studies on the Symptoms Clinic Intervention, a consultation intervention for MUPS in primary care. We used constant comparative analysis to code and classify dialogue types and outcomes.

RESULTS

We extracted 115 explanation sequences. We identified four dialogue types, differing in the extent to which the GP or patient controlled the dialogue. We categorized eight outcomes of the sequences, ranging from acceptance to rejection by the patient. The most common outcome was holding (conversation suspended in an unresolved state), followed by acceptance. Few explanations were rejected by the patient. Co-created explanations by patient and GP were most likely to be accepted.

CONCLUSION

We developed a classification of dialogue types and outcomes in relation to explanations offered by GPs for MUPS patients. While it requires further validation, it provides a framework, which can be used for teaching, evaluation of practice and research.

Context as a drug: some consequences of placebo research for primary care

OBJECTIVE

On the basis of emerging research evidence, this review aims to discuss the importance of the context surrounding the doctor-patient encounter for the success of treatment.

DESIGN AND SETTING

Discussion paper based on placebo-nocebo and pain studies conducted in the western world.

MAIN OUTCOME MEASURES

Literature-based theory about impact of communication elements on seriousness of symptoms in clinical practice.

RESULTS

The therapeutic outcome seems to be impacted by rituals around a clinical encounter and by the doctor patient communication and relation. A warm, friendly and empathic attitude is crucial in the first contact with the practice and during the consultation as it influences the patient's perceived outcome. It is important to raise positive expectations when discussing the prognosis, conducting treatment and prescribing medications as the effect may be reduced if the physician expresses doubt about the effectiveness of the medication. Additionally, overly focus on side effects in the doctor-patient conversation about proposed treatments seems to influence the magnitude of perceived side effects in the patient. Thus, shared decision-making might be a desirable tool for ensuring better expectations in the patient and successful symptom relief.

CONCLUSIONS

The context of the doctor-patient interplay matters. Placebo-nocebo research provides strong evidence for this link. The therapeutic context induces biomedical processes in the patient's brain that may enhance or reduce the effects of chosen interventions. The context thus works as a drug, with real effects and side effects. KEY POINTS Increased awareness of the context drug may help GPs alleviate symptoms and better motivate patients for treatment. Treatment is affected by multiple types of context, as also confirmed by placebo-nocebo research. The therapeutic context influences the biomedical processes, which may enhance or reduce intervention effects on symptoms. The impact of context should be considered in daily general practice as it may serve as a drug, with real effects and side effects.

Big Five personality traits and medically unexplained symptoms in later life

BACKGROUND

Personality dysfunction has been postulated as the most clinically salient problem of persons suffering from medically unexplained symptoms (MUS) but empirical studies are scarce. This study aims to compare the personality profile of older patients suffering from MUS with two comparison groups and a control group.

METHODS

Ninety-six older patients with MUS were compared with 153 frequent attenders in primary care suffering from medically explained symptoms (MES), 255 patients with a past-month depressive disorder (DSM-IV-TR), and a control group of 125 older persons. The Big Five personality domains (NEO-Five-Factor Inventory) were compared between groups by multiple ANCOVAs adjusted for age, sex, education, partner status and cognitive functioning. Linear regression analyses were applied to examine the association between health anxiety (Whitley Index) and somatization (Brief Symptom Inventory).

RESULTS

The four groups differed with respect to neuroticism (P<0.001), extraversion (P<0.001), and agreeableness (P=0.045). Post hoc analyses, showed that MUS patients compared to controls scored higher on neuroticism and agreeableness, and compared to depressed patients lower on neuroticism and higher on extraversion as well agreeableness. Interestingly, MUS and MES patients had a similar personality profile. Health anxiety and somatization were associated with a higher level of neuroticism and a lower level of extraversion and conscientiousness, irrespective whether the physical symptom was explained or not.

CONCLUSIONS

Older patients with MUS have a specific personality profile, comparable to MES patients. Health anxiety and somatization may be better indicators of psychopathology than whether a physical symptom is medically explained or not.

The value of reasons for encounter in early detection of colorectal cancer

BACKGROUND

Symptoms with a high predictive power for colorectal cancer (CRC) do not exist.

OBJECTIVE

To explore the predictive value of patients' reason for encounter (RFE) in the two years prior to the diagnosis of CRC.

METHODS

A retrospective nested case-control study using prospectively collected data from electronic records in general practice over 20 years. Matching was done based on age (within two years), gender and practice. The positive likelihood ratios (LR+) and odds ratios (OR) were calculated for RFE between cases and controls in the two years before the index date.

RESULTS

We identified 184 CRC cases and matched 366 controls. Six RFEs had significant LR + and ORs for CRC, which may have high predictive power. These RFEs are part of four chapters in the International Classification of Primary Care (ICPC) that include tiredness (significant at 3-6 months prior to the diagnosis; LR+ 2.6 and OR 3.07; and from 0 to 3 months prior to the diagnosis; LR+ 2.0 and OR 2.36), anaemia (significant at three months before diagnosis; LR+ 9.8 and OR 16.54), abdominal pain, rectal bleeding and constipation (significant at 3-6 months before diagnosis; LR+ 3.0 and OR 3.33; 3 months prior to the diagnosis LR+ 8.0 and OR 18.10) and weight loss (significant at three months before diagnosis; LR+ 14.9 and OR 14.53).

CONCLUSION

Data capture and organization in ICPC permits study of the predictive value of RFE for CRC in primary care.

How GPs value guidelines applied to patients with multimorbidity: a qualitative study

OBJECTIVES

To explore and describe the value general practitioner (GPs) attribute to medical guidelines when they are applied to patients with multimorbidity, and to describe which benefits GPs experience from guideline adherence in these patients. Also, we aimed to identify limitations from guideline adherence in patients with multimorbidity, as perceived by GPs, and to describe their empirical solutions to manage these obstacles.

DESIGN

Focus group study with purposive sampling of participants. Focus groups were guided by an experienced moderator who used an interview guide. Interviews were transcribed verbatim. Data analysis was performed by two researchers using the constant comparison analysis technique and field notes were used in the analysis. Data collection proceeded until saturation was reached.

SETTING

Primary care, eastern part of The Netherlands.

PARTICIPANTS

Dutch GPs, heterogeneous in age, sex and academic involvement.

RESULTS

25 GPs participated in five focus groups. GPs valued the guidance that guidelines provide, but experienced shortcomings when they were applied to patients with multimorbidity. Taking these patients' personal circumstances into account was regarded as important, but it was impeded by a consistent focus on guideline adherence. Preventative measures were considered less appropriate in (elderly) patients with multimorbidity. Moreover, the applicability of guidelines in patients with multimorbidity was questioned. GPs' extensive practical experience with managing multimorbidity resulted in several empirical solutions, for example, using their 'common sense' to respond to the perceived shortcomings.

CONCLUSIONS

GPs applying guidelines for patients with multimorbidity integrate patient-specific factors in their medical decisions, aiming for patient-centred solutions. Such integration of clinical experience and best evidence is required to practise evidence-based medicine. More flexibility in pay-for-performance systems is needed to facilitate this integration. Several improvements in guideline reporting are necessary to enhance the applicability of guidelines in patients with multimorbidity.

Are asthma patients at increased risk of clinical depression? A longitudinal cohort study

OBJECTIVE

In this study, we assessed whether adult patients with asthma are more likely to be diagnosed with depression than diabetes patients or "healthy" controls during follow-up in primary care.

METHODS

Data from the Nijmegen Continuous Morbidity Registration were used to assess the risk for a first depression. Patients with asthma were compared with patients with diabetes and with two healthy controls matched on age, gender, socioeconomic status and attending general practice. With Cox proportional hazard analysis, we compared the risk of depression between these groups. These analyses were corrected for relevant covariates including a time-depending variable for multimorbidity. Explorative subgroup analyses were done for age, gender, socioeconomic status and multimorbidity.

RESULTS

Cumulative incidence of depression in asthma patients was 5.2%, in DM patients 4.1% and in control subjects 3.3%. The hazard ratios for a first episode of depression in the asthma patients (n = 795) compared to DM patients (n = 1033) and control subjects after correction for covariates were 1.11 (95% CI 0.60-2.04) and 1.18 (95% CI 0.78-1.79), respectively. Exploratory analyses showed that asthma patients without multimorbidity were at higher risk for a depression compared to reference groups, while asthma patients with multimorbidity were at lower risk for depression.

CONCLUSION

Asthma patients were not more likely to be diagnosed with a first depression compared to "healthy" control subjects or diabetes patients. The influence of multimorbidity on depression risk in asthma patients warrants further study.

Colic in infants

INTRODUCTION

Colic in infants leads one in six families (17%) with children to consult a health professional. One systematic review of 15 community-based studies found a wide variation in prevalence, which depended on study design and method of recording.

METHODS AND OUTCOMES

We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments for colic in infants? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview).

RESULTS

At this update, searching of electronic databases retrieved 47 studies. After deduplication and removal of conference abstracts, 22 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 10 studies and the further review of 12 full publications. Of the 12 full articles evaluated, three systematic reviews and four RCTs were added at this update. We performed a GRADE evaluation for six PICO combinations.

CONCLUSIONS

In this systematic overview, we categorise the efficacy for seven interventions based on information relating to the effectiveness and safety of casein hydrolysate milk, cranial osteopathy, Lactobacillus reuteri (probiotic), low-lactose milk, soya-based infant feeds, spinal manipulation, and whey hydrolysate milk.

Cost-utility analysis of a treatment advice to discontinue inappropriate long-term antidepressant use in primary care

BACKGROUND

Antidepressant prescriptions have increased exponentially, burdening health care costs.

OBJECTIVE

To evaluate the costs and effects of an antidepressant cessation advice in case of inappropriate long-term use in primary care, i.e. long-term usage without a (current) indication.

METHODS

A economic evaluation during 1-year follow-up was performed, from a societal perspective, as part of a cluster-randomised controlled clinical trial (PANDA). Costs were assessed using the Trimbos/iMTA questionnaire for costs associated with psychiatric illness. Health-related quality of life was measured using the EuroQol 5D. Outcome was costs per quality adjusted life year (QALY). Missing values were estimated using multiple imputation, bootstrap simulations were performed to address the uncertainty surrounding the incremental cost-effectiveness ratios (ICERs).

RESULTS

There was no difference in average QALYs between the intervention (0.70) and control group (0.72) [difference -0.02 (95% CI -0.05 to 0.10)]. The intervention group, however, was less expensive than the control group (total costs €3636 versus €5267, respectively). Most cost-effectiveness pairs were located in the south-west quadrant of the cost-effectiveness plane, implying the intervention was less effective but also less costly. The ICER of the pooled data was €70,180, meaning that for one QALY lost, €70,180 is saved.

CONCLUSIONS

This study shows that an antidepressant cessation advice given to patients (and their FPs) with inappropriate long-term antidepressant usage, albeit not effective, does seem to result in a reduction of societal costs. This reduction in costs is mostly due to reduction of productivity losses, possibly due to patient empowerment and loss of stigma.

Different answers to different questions: exploring clinical decision making by general practitioners and psychiatrists about depressed patients

PURPOSE

Exploring three perspectives on differences between general practitioners (GP) and psychiatrists in clinical decision making about depressed patients. The gold standard perspective focuses on differences in decisions (output) as a result of lack of expertise, the input perspective relates differences to different information use and to other roles, and the throughput perspective attributes differences to other information processing.

METHODS

Twenty-six psychiatrists and 25 GPs gave their clinical judgment on four on-line vignettes of increasingly severely depressed patients. Supplementary information on 15 themes could be asked for by clicking on underlined phrases. Dependent variables were the amount and type of extra information used, time needed and judgments of the severity of symptoms, appropriate treatment and health care providers.

RESULTS

Compared to psychiatrists, GPs were more reluctant to refer to specialized care, they needed less supplementary information and reached their conclusion in less time. Their processing of information appeared to be more contextual. Psychiatrists used a more stable procedure in which information inspection took place independently of differences in the vignettes.

CONCLUSIONS

GPs and psychiatrists not only give different answers (treatment advices) because they have different expertise, but also because they have different questions due to other roles, and they use different clinical decision procedures. Insight in these differences can be useful for ameliorating collaborative mental health care.

Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: a randomized controlled trial

BACKGROUND

Patients with medically unexplained symptoms make heavy demands on the health care system. An offer for psychological treatment is often declined. There is a need for acceptable and effective treatments. We assessed the acceptability and effectiveness of mindfulness-based cognitive therapy (MBCT) for patients with persistent medically unexplained symptoms.

METHOD

A randomized controlled trial comparing MBCT (n = 64) to enhanced usual care (EUC; n = 61). Participants were the 10% most frequently attending patients in primary care. The primary outcome measure was general health status at the end of treatment. Secondary outcome measures were mental and physical functioning. Assessments took place at the end of treatment and at the 9-month follow-up.

RESULTS

Health status and physical functioning did not significantly differ between groups. However, participants in the MBCT group reported a significantly greater improvement in mental functioning at the end of treatment (adjusted mean difference, 3.9; 95% CI, 0.24-7.6), in particular with regard to vitality and social functioning. In addition, at 9 months of follow-up, the mindfulness skills 'observing' and 'describing' were significantly higher in the MBCT group. Within the MBCT group, almost half of the outcome measures had significantly improved at the end of treatment, whereas in the EUC group none had.

CONCLUSIONS

MBCT was feasible for frequently attending patients with persistent medically unexplained symptoms in primary care. Although MBCT did not lead to a significant difference in general health status between the two groups, it did result in a significant improvement in mental functioning.

Experienced continuity of care in patients at risk for depression in primary care

BACKGROUND

Existing studies about continuity of care focus on patients with a severe mental illness.

OBJECTIVES

Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure.

METHODS

Explorative study comparing patients at risk for depression with chronic heart failure patients. Continuity of care was measured using a patient questionnaire and defined as ( 1 ) number of care providers contacted (personal continuity); ( 2 ) collaboration between care providers in general practice (team continuity) (six items, score 1-5); and ( 3 ) collaboration between GPs and care providers outside general practice (cross-boundary continuity) (four items, score 1-5).

RESULTS

Most patients at risk for depression contacted several care providers throughout the care spectrum in the past year. They experienced high team continuity and low cross-boundary continuity. In their general practice, they contacted more different care providers for their illness than heart failure patients did (P < 0.01). Patients at risk for depression experienced a slightly better collaboration between these care providers in their practice: a mean score of 4.3 per item compared to 4.0 for heart failure patients (P = 0.03). The perceived cross-boundary continuity, however, was reversed: a mean score of 3.5 per item for patients at risk for depression, compared to 4.0 for heart failure patients (P = 0.01).

CONCLUSION

The explorative comparison between patients at risk for depression and heart failure patients shows small differences in experienced continuity of care. This should be analysed further in a more robust study.

Generalist solutions to complex problems: generating practice-based evidence--the example of managing multi-morbidity

Background

A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare?

Discussion

Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem.

We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem.

Summary

Answers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: a cost-effectiveness study

OBJECTIVE

Our aim was to assess cost-effectiveness of mindfulness-based cognitive therapy (MBCT) compared with enhanced usual care (EUC) in treating patients with persistent medically unexplained symptoms(MUS).

METHODS

A full economic evaluation with a one year time horizon was performed from a societal perspective. Costs were assessed by prospective cost diaries. Health-related Quality of Life was measured using SF-6D. Outcomes were costs per Quality-Adjusted Life Year (QALY). Bootstrap simulations were performed to obtain mean costs, QALY scores and incremental cost-effectiveness ratios (ICERs).

RESULTS

MBCT participants (n=55) had lower hospital costs and higher mental health care costs than patients who received EUC (n=41). Mean bootstrapped costs for MBCT were €6269, and €5617 for EUC (95% uncertainty interval for difference: -€1576; €2955). QALYs were 0.674 for MBCT and 0.663 for EUC. MBCT was on average more effective and more costly than EUC, resulting in an ICER of €56,637 per QALY gained. At a willingness to pay of €80,000 per QALY, the probability that MBCT is cost-effective is 57%.

CONCLUSION

Total costs were not statistically significantly different between MBCT and EUC. However, MBCT seemed to cause a shift in the use of health care resources as mental health care costs were higher and hospital care costs lower in the MBCT condition. Due to the higher drop-out in the EUC condition the cost-effectiveness of MBCT might have been underestimated. The shift in health care use might lead to more effective care for patients with persistent MUS. The longer-term impact of MBCT for patients with persistent MUS needs to be further studied.

Prescribing ANtiDepressants Appropriately (PANDA): a cluster randomized controlled trial in primary care

BACKGROUND

Inappropriate use of antidepressants (AD), defined as either continuation in the absence of a proper indication or continuation despite the lack of therapeutic efficacy, applies to approximately half of all long term AD users.

METHODS/DESIGN

We have designed a cluster randomized controlled clinical trial to assess the (cost-) effectiveness of an antidepressant cessation advice in the absence of a proper indication for maintenance treatment with antidepressants in primary care.We will select all patients using antidepressants for over 9 months from 45 general practices. Patients will be diagnosed using the Composite International Diagnostic Interview (CIDI) version 3.0, extended with questions about the psychiatric history and previous treatment strategies. General practices will be randomized to either the intervention or the control group. In case of overtreatment, defined as the absence of a proper indication according to current guidelines, a cessation advice is given to the general practitioner. In the control groups no specific information is given. The primary outcome measure will be the proportion of patients that successfully discontinue their antidepressants at one-year follow-up. Secondary outcomes are dimensional measures of psychopathology and costs.

DISCUSSION

This study protocol provides a detailed overview of the design of the trial. Study results will be of importance for refining current guidelines. If the intervention is effective it can be used in managed care programs.

TRIAL REGISTRATION

NTR2032.

[Allergy testing in atopic dermatitis: often unnecessary]

Atopic dermatitis (AD) is a chronic inflammatory skin disease from which many children and adults suffer. In the Netherlands, the majority of patients with AD are treated in the primary health care setting. There is no clear consensus about whether or not to conduct allergy testing in patients with AD. Determining sensitization to inhalant allergens in children with AD has no consequences for its treatment and course and is therefore not necessary. Allergy testing is useful if the child is suspected of having allergic asthma or allergic rhinoconjunctivitis. Determining sensitization to food allergens in children with AD without a positive history of acute allergic reactions to food has no therapeutic consequences and could result in the unnecessary prescription or following of elimination diets.- Similarly, determining sensitization to inhalant and food allergens has no influence on the treatment regimen for adults with AD. This type of testing is therefore not useful, unless the medical history reveals indications for the occurrence of acute allergic reactions to certain allergens.

How family physicians address diagnosis and management of depression in palliative care patients

PURPOSE

Depression is highly prevalent in palliative care patients. In clinical practice, there is concern about both insufficient and excessive diagnosis and treatment of depression. In the Netherlands, family physicians have a central role in delivering palliative care. We explored variation in family physicians' opinions regarding the recognition, diagnosis, and management of depression in palliative care patients.

METHODS

We conducted a focus group study in a sample of family physicians with varied practice locations and varying expertise in palliative care. Transcripts were analyzed independently by 2 researchers using constant comparative analysis in ATLAS.ti.

RESULTS

In 4 focus group discussions with 22 family physicians, the physicians described the diagnostic and therapeutic process for depression in palliative care patients as a continuous and overlapping process. Differentiating between normal and abnormal sadness was viewed as challenging. The physicians did not strictly apply criteria of depressive disorder but rather relied on their clinical judgment and strongly considered patients' context and background factors. They indicated that managing depression in palliative care patients is mainly supportive and nonspecific. Antidepressant drugs were seldom prescribed. The physicians described difficulties in diagnosing and treating depression in palliative care, and gave suggestions to improve management of depression in palliative care patients in primary care.

CONCLUSIONS

Family physicians perceive the diagnosis and management of depression in palliative care patients as challenging. They rely on open communication and a long-standing physician-patient relationship in which the patient's context is of great importance. This approach fits with the patient-centered care that is promoted in primary care.

The reassuring value of diagnostic tests: a systematic review

OBJECTIVE

This review is a narrative synthesis of the RCTs which studied the efficacy of using diagnostic tests to reassure patients.

METHODS

We searched for RCTs that examined the level of reassurance after diagnostic testing in outpatients. We used PubMed, Psychinfo, Cochrane Central, Ongoing Trials Database and Scopus.

RESULTS

We found 5 randomized controlled trials that included 1544 patients. The trials used different diagnostic tests (ECG, radiography of lumbar spine, MR brain scan, laboratory tests, MR of lumbar spine) for different complaints (e.g. chest pain, low back pain and headache). Four out of 5 RCTs did not find a significant reassuring value of the diagnostic tests. One study reported a reassuring effect at 3 months which had disappeared after one year.

CONCLUSION

Despite the sparse and heterogeneous studies, the results point in the direction of diagnostic tests making hardly any contribution to the level of reassurance. We recommend further studies on the use of diagnostic tests and other strategies to reassure the patient.

PRACTICE IMPLICATIONS

A clear explanation and watchful waiting can make additional diagnostic testing unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test information about normal test results.

Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network

BACKGROUND

Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP.

AIM

To investigate whether unexplained symptoms as presented to the GP predict mental disorders.

DESIGN AND SETTING

Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands.

METHOD

All data about contacts between patients (n = 16,000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined.

RESULTS

All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression.

CONCLUSION

Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.

The psychometric properties of the panic disorder module of the Patient Health Questionnaire (PHQ-PD) in high-risk groups in primary care

AIMS

To study the validity of detecting panic disorder (PD) using the Patient Health Questionnaire (PHQ) in a high-risk population in primary care and to test whether modified evaluation algorithms improve the operating characteristics of this questionnaire. Furthermore, the influence of psychiatric comorbidity on the test characteristics of the panic module was studied.

METHODS

The PHQ was administered in a primary care sample with patients at high-risk for psychiatric disorders. The total sample of 479 high-risk patients comprised 311 frequent attenders (FA), 39 patients with unexplained somatic complaints (USC) and 191 patients with mental health problems (MHP). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID- I) was the reference standard for the presence of PD. Sensitivity, specificity, and predictive values were calculated. The conditional test characteristics were calculated based on the observed prevalence of PD in the three high-risk groups.

RESULTS

PD was diagnosed in 4.8% of the FAs, in 9.8% of the USCs and in 7.6% of the MHPs. The PHQ achieved moderate operating characteristics. Modified evaluation algorithms of the questionnaire led to an improvement of test characteristics, especially the screening question: sensitivity .71 and specificity .83. Psychiatric comorbidity increased sensitivity while decreasing specificity.

CONCLUSION

The original and modified algorithms of the PHQ-PD performed moderately in screening for panic disorder. Using only the first question of the PHQ-PD showed the best psychometric properties (sensitivity). For screening purposes requiring high sensitivity we endorse to use the screening question instead of the original algorithm.

Effectiveness of problem-solving treatment by general practice registrars for patients with emotional symptoms

INTRODUCTION: In general practice many patients present with emotional symptoms. Both patients and physicians desire effective non-pharmacological treatments. AIM: To study the effectiveness of problem-solving treatment (PST) delivered by trained general practice registrars (GP registrars) for patients with emotional symptoms. METHODS: In a controlled clinical trial we compared the effectiveness of PST versus usual care for patients with emotional symptoms. Dutch GP registrars provided either PST or usual care, according to their own preference. Patients were included if they (a) had presented for three or more consultations with emotional symptoms in the past six months; and (b) scored four or more on the 12-item General Health Questionnaire. Outcomes at three- and nine-month follow-up were standard measures of depression, anxiety and quality of life. RESULTS: Thirty-eight GP registrars provided PST and included 98 patients; 43 provided usual care and included 104 patients. PST patients improved significantly more than usual care patients: at nine-month follow-up, recovery rates for somatoform disorder and anxiety were higher in the PST group (OR 6.50, p=0.01 respectively OR 11.25, p=0.03). PST patients had improved significantly more on the domains social functioning, role limitation due to emotional problems and general health perception. DISCUSSION: Patients with emotional symptoms improved significantly more after PST delivered by motivated GP registrars than after usual care by GP registrars. Further research, with randomisation of interested registrars or interested GPs, is needed. KEYWORDS: Problem-solving treatment; emotional symptoms; mental health; general practice; GP registrars

Effects of educational interventions on primary dementia care: A systematic review

OBJECTIVE

To determine the effects of educational interventions about dementia, directed at primary care providers (PCPs).

DESIGN

We searched Medline, Embase, PsycInfo, Cinahl and the Cochrane library for relevant articles. Two researchers independently assessed the citations identified against the following inclusion criteria: educational intervention on dementia directed at PCPs and study designs being randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) or interrupted time series (ITS) analyses. Outcomes of interest were PCPs' knowledge and attitude on dementia, and quality of dementia care at PCP and patient level.

RESULTS

Of 3953 citations identified, six articles representing five studies (four cluster RCTs and one CBA) were eligible, describing educational interventions directed at 1904 PCPs. Compliance to the interventions varied from 18 to 100%. Systematic review of the studies showed moderate positive results. Five articles reported at least some effects of the interventions. A small group workshop and a decision support system (DSS) increased dementia detection rates. An interactive 2-h seminar raised GPs' suspicion of dementia. Adherence to dementia guidelines only improved when an educational intervention was combined with the appointment of dementia care managers. This combined intervention also improved patients' and caregivers' quality of life. Effects on knowledge and attitudes were minor.

CONCLUSION

Educational interventions for PCPs that require active participation improve detection of dementia. Educational interventions alone do not seem to increase adherence to dementia guidelines. To effectively change professionals' performance in primary dementia care, education probably needs to be combined with adequate reimbursement or other organizational incentives.

Brief cognitive behavioral therapy compared to general practitioners care for depression in primary care: a randomized trial

Background

Depressive disorders are highly prevalent in primary care (PC) and are associated with considerable functional impairment and increased health care use. Research has shown that many patients prefer psychological treatments to pharmacotherapy, however, it remains unclear which treatment is most optimal for depressive patients in primary care.

Methods/Design

A randomized, multi-centre trial involving two intervention groups: one receiving brief cognitive behavioral therapy and the other receiving general practitioner care. General practitioners from 109 General Practices in Nijmegen and Amsterdam (The Netherlands) will be asked to include patients aged between 18-70 years presenting with depressive symptomatology, who do not receive an active treatment for their depressive complaints. Patients will be telephonically assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to ascertain study eligibility. Eligible patients will be randomized to one of two treatment conditions: either 8 sessions of cognitive behavioral therapy by a first line psychologist or general practitioner's care according to The Dutch College of General Practitioners Practice Guideline (NHG- standaard). Baseline and follow-up assessments are scheduled at 0, 6, 12 and 52 weeks following the start of the intervention. Primary outcome will be measured with the Hamilton Depression Rating Scale-17 (HDRS-17) and the Patient Health Questionnaire-9 (PHQ-9). Outcomes will be analyzed on an intention to treat basis.

Trial Registration

ISRCTN65811640