Healthcare utilization in general practice before and after psychological treatment: a follow-up data linkage study in primary care

OBJECTIVE

Literature suggests that serious mental health problems increase the use of health services and psychological interventions can reduce this effect. This study investigates whether this effect is also found in primary care patients with less serious mental health problems.

DESIGN/SETTING

Routine electronic health records (EHR) from a representative sample of 128 general practices were linked to patient files from 150 primary care psychologists participating in the NIVEL Primary Care Database, using a trusted third party. Data were linked using the date of birth, gender, and postcode. This yielded 503 unique data pairs that were listed in one of the participating GP practices in 2008-2010, for people who had psychological treatment from a psychologist that ended in 2009.

MAIN OUTCOME MEASURES

The number of contacts, health problems presented, and prescribed medication in general practice were analysed before and after the psychological treatment.

RESULTS

Nearly all 503 patients consulted their GP during the six months preceding the psychological treatment (90.9%) and also in the six months after this treatment had ended (83.7%). The frequency of contacts was significantly higher before than after the psychological treatment (6.1 vs. 4.8). Fewer patients contacted their GPs specifically for psychological or social problems (46.3% vs. 38.8%) and fewer patients had anxiolytic drug prescriptions (15.5% vs. 7.6%) after psychological treatment.

CONCLUSION

After psychological treatment, patients contact their GPs less often and present fewer psychological or social problems. Although contact rates seem to decrease, clients of psychologists are still frequent GP attenders.

Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study

BACKGROUND

There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement.

METHODS

This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records.

RESULTS

721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes.

CONCLUSION

The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

[Appropriate care for anxiety and depression]

OBJECTIVE

To evaluate care received for anxiety and depression, to identify which patient-, GP- and practice factors obstruct delivery of care in accordance with Dutch College of General Practitioners' (NHG) practice guidelines, and to evaluate the costs and effects of guideline-concordant care.

DESIGN

Descriptive study.

METHODS

During the baseline assessment of the Netherlands study of depression and anxiety--which has followed a large number of adults with and without psychiatric complaints since 2004--various questionnaires and diagnostic interviews were completed. At one year follow-up, the severity of symptoms of anxiety and depression, overall functioning or dysfunction, healthcare use and absenteeism from employment over the past year were assessed. Data from electronic medical patient records were studied to determine whether NHG practice guidelines had been followed.

RESULTS

Of the 721 patients with an anxiety or depressive disorder, 57% (n = 413) indicated receiving some form of care; two-thirds of this group received appropriate care according to NHG practice guidelines (n = 281). At patient level the severity of depressive symptoms, the self-evaluated need for care, a high level of education and accessibility of care were most strongly associated with guideline adherence; at general practitioner level, collaboration with other mental health professionals was most strongly associated with guideline adherence. On average, all patients had symptoms that were less serious than a year previously, irrespective of which care they had received. Guideline-concordant care was significantly more expensive.

CONCLUSION

Half of the patients who had not received care did not think that they needed it. Of those who had received care, those with more severe symptoms and greatest need for care were most likely to have received guideline-concordant care. Both patients and general practitioners seemed well able to assess whether care was needed or not.

Patient factors associated with guideline-concordant treatment of anxiety and depression in primary care

OBJECTIVE

To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care.

DESIGN

Analysis of data from the Netherlands Study of Depression and Anxiety (NESDA).

PARTICIPANTS

Seven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included.

MEASURES

Diagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners.

RESULTS

Two hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%-CI = 1.05-1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%-CI = 1.84-4.85; p < 0.001), counseling (OR = 2.25; 95%-CI = 1.29-3.95; p = 0.005) or a referral (OR = 1.83; 95%-CI = 1.09-3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%-CI = 0.11-0.98; p = 0.04) of receiving guideline-concordant care.

CONCLUSIONS

This study shows that education level, accessibility of care and patients' perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs' communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary care.

Receiving treatment for common mental disorders

OBJECTIVE

Anxiety and depressive disorders are widely prevalent, but patients are only treated in a minority of cases. In this study, the explanation of receiving mental health treatment is sought in predisposing and enabling characteristics and indicators for objective and self-perceived need.

METHODS

Cross-sectional analysis of data collected in the Netherlands Study of Depression and Anxiety (NESDA) among 743 persons with an anxiety and/or depression diagnosis as assessed by the CIDI. Receipt of mental health treatment was assessed in the face-to-face interview, as well as indicators of predisposing and enabling factors and variables evaluating need for care.

RESULTS

Of the total sample, 57% received treatment in the past 6 months in the general practice setting (50%) or the mental health care setting (14%). Younger patients, patients who evaluated their providers better on communicative abilities and patients who perceived mental health problems themselves had greater odds of having professional mental health contacts in the primary care setting. Confidence in professional help and higher severity of mental problems were associated with greater odds of having specialized mental health care.

CONCLUSION

Receiving help for common mental disorders depends not only on the objective need of the patient but also at least as much on the patients' own recognition that their problems have a mental health origin. Furthermore, in primary care especially, the patients' judgment of their providers' affective abilities may be decisive for being treated. For receiving specialized care, patients are also directed by their confidence in professional help.

Low relationship satisfaction and high partner involvement predict sexual problems of women with fibromyalgia

To examine the predictive potential of relationship variables on sexual functioning in women with fibromyalgia, we instructed 63 women (age 21-54 years) to fill out several questionnaires. Low relationship satisfaction was the strongest and most-frequent predictor of problematic sexual functioning. In addition, more fatigue and--only after taking account of relationship satisfaction--more active engagement (i.e., involvement) of the spouse were associated with reduced sexual functioning and satisfaction. Our study suggests that for women with fibromyalgia, relationship satisfaction is good for sexual functioning. Although having an involved spouse is good for the relationship, it may be bad for sexual functioning.

Sexual functioning of women with fibromyalgia

OBJECTIVE

To examine sexual functioning at the specific phases of the sexual response cycle among women with fibromyalgia.

METHODS

The Questionnaire for screening Sexual Dysfunctions - Short Form (QSD-SF) was filled out by 63 premenopausal, heterosexual women with fibromyalgia (age: 21-54 years) who were recruited at meetings of regional patient associations.

RESULTS

The women with fibromyalgia did not differ from healthy women of an age reference group with respect to functioning in the excitement and the orgasm phases, but reported more problems with sexual desire and satisfaction, more pain in their body, and insensitivity (but not pain) in their genitals before, during or after having sex. Mental distress, but not pain, was a significant predictor of virtually all aspects of sexual dysfunction.

CONCLUSION

Our study generates the hypothesis that the psychological but not the physiological aspect of the sexual response cycle is more disturbed than normal in fibromyalgia. This finding needs confirmation in a more representative population.