Deciding who gets treatment for depression and anxiety: a study of consecutive GP attenders

BACKGROUND: Most research has focused on recognition by GPs of the common mental disorders: depression and anxiety. However, less is known about the factors that determine whether patients with those disorders that are recognised receive any active treatment. AIM: To investigate factors associated with receiving active treatment among consecutive attenders identified by GPs as having a common mental disorder. SETTING: Data were collected as part of a cluster randomised controlled trial in 30 general practices in the south of Bristol, UK, on the impact of mental health guidelines in primary care. METHOD: We studied 439 consecutive general practice attenders aged 16-64 years who were given a diagnosis of depression, anxiety, or chronic mixed anxiety and depression by their GP. The main outcome measure was the provision of any active treatment, whether pharmacological or psychological, for these disorders. Patient, GP, and practice level data, including sociodemographic, clinical, and administrative data were explored as predictors in a logistic regression model. Huber White variance estimates were used to account for hierarchical clustering. RESULTS: Of those patients identified as having a common mental disorder by the GP, 54% were offered active treatment. Higher symptom score, as measured by the General Health Questionnaire (GHQ) (odds ratio [OR] = 1.09; 95% confidence interval [CI] = 1.06 to 1.13; P<0.001) and being male (OR = 1.54; 95% CI = 1.13 to 2.09; P = 0.006), were both associated with an increased likelihood of being offered active treatment. Patients with anxiety (OR = 0.24; 95% = CI 0.14 to 0.41; P<0.001), or chronic mixed anxiety/depression (OR = 0.41; 95% CI = 0.23 to 0.73; P = 0.003) were less likely to be offered active treatment than those considered to have depression. CONCLUSION: When deciding to offer active treatment for common mental disorders, GPs appear to be influenced by the severity of symptoms rather than their 'understandability' in relation to recent life stresses or the social context of distress. Further research is needed to investigate why men are more likely and those with an anxiety disorder less likely, to be offered active treatment.     

Recruitment of women by GPs for pap tests: a meta-analysis.

General practitioners (GPs) have a pivotal role to play in recruiting women for Pap tests. In recent times, considerable attention has been paid to the role of reminder systems in encouraging women to have regular Pap tests. Although a number of studies have investigated the effectiveness of reminder systems, there has been no comprehensive review. This paper aims to determine the effectiveness of patient and GP reminders in increasing the proportion of women screened for cervical cancer. Two electronic databases were searched for English-language randomized controlled trials conducted in a general practice or family medicine setting, and examining the effectiveness of GP and patient reminders in increasing the proportion of women screened for cervical cancer. Ten trials were identified, and meta-analytic techniques were employed to analyse the data from these trials. The women whose GPs had been prompted to remind them to have a Pap test were significantly more likely to do so than were control women (typical risk difference (TRD) = 6.6%, 95% CI = 5.2%-8.0%). The typical risk difference for the patient reminder studies was 4.9% (95% CI = 2.6%-7.2%). In both cases, sensitivity analysis revealed that one study stood out as an exceptional result. The omission of this study induced homogeneity among the remaining studies. Once this study was removed, the TRDs for the GP reminder and patient reminder studies were 7.9% (95% CI = 6.5%-9.4%) and 10.8% (95% CI = 8.1%-13.6%), respectively. The results strongly suggest that GPs should make use of GP and patient reminder systems.     

PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care.

BACKGROUND: Common mental health problems account for up to 40% of all general practitioner (GP) consultations. Patients have limited access to evidence-based psychological therapies. Cognitive behavioural therapy self-help strategies offer one potential solution. AIM: To determine differences in clinical outcome, patient satisfaction and costs, between a cognitive behavioural-based self-help package facilitated by practice nurses compared to ordinary care by GPs for mild to moderate anxiety and depression. DESIGN OF STUDY: Randomised controlled trial. SETTING: Seventeen primary healthcare teams. METHOD: Patients presenting to their GP with mild to moderate anxiety and/or depression were recruited to the study and randomised to receive either a self-help intervention facilitated by practice nurses or ordinary care. The self-help intervention consisted of up to three appointments: two 1 week apart and a third 3 months later. There were no restrictions on ordinary care. RESULTS: Intention-to-treat analysis showed that patients treated with practice nurse-supported cognitive behavioural therapy self-help attained similar clinical outcomes for similar costs and were more satisfied than patients treated by GPs with ordinary care. On-treatment analysis showed patients receiving the facilitated cognitive behavioural therapy self-help were more likely to be below clinical threshold at 1 month compared to the ordinary care group (odds ratio [OR] = 3.65, 95% confidence interval [CI] = 1.87 to 4.37). This difference was less well marked at 3 months (OR = 1.36, 95% CI = 0.52 to 3.56). CONCLUSION: Facilitated cognitive behavioural self-help may provide a short-term cost-effective clinical benefit for patients with mild to moderate anxiety and depression. This has the potential to help primary care provide a choice of effective psychological as well as pharmacological treatments for mental health problems.     

Frequency of consultations and general practitioner recognition of psychological symptoms.

BACKGROUND: General practitioners (GPs) are widely reported to 'miss' half of the psychological problems present in their patients. AIMS: To describe the relationship between frequency of consultations and GP recognition of psychological symptoms. DESIGN OF STUDY: Survey of GPs and their patients. Setting: General practices in the southern part of New Zealand's North Island. METHOD: Participants were randomly selected GPs (n = 70), and their patients (n = 3414, of whom a sub-set of 386 form the basis of this study). The main measure was the comparison between GP and composite international diagnostic interview (CIDI) recognition of psychological problems. RESULTS: Of the GPs selected, 90% participated. The CIDI was completed by 70% of selected patients. In patients (n = 386) with a CIDI-diagnosed disorder, 63.7% (95% confidence interval [CI] = 53.3 to 74.1) were considered by the GP to have had psychological symptoms in the last year; 40.1% (CI = 31.0 to 49.2) to have had clinically significant psychological problems, and 33.8% (CI = 24.9 to 42.6) were given an explicit diagnosis. However, in those CIDI-diagnosed patients who had been seen five or more times during the previous year, these recognition figures increased to 80.2% (CI = 68.9 to 91.4), 59.4% (CI = 45.9 to 72.9) and 53.6% (CI = 40.1 to 67.1) respectively, and dropped to 28.8% (CI = 13.0 to 44.7), 13.6% (CI = 3.4 to 23.7), and 10.7% (CI = 1.4 to 19.9) among patients not consulting during the previous year. GPs often differed from the CIDI in their assessment of clinical significance and diagnosis. CONCLUSION: GP non-recognition of psychological problems was at a problematic level only among patients with little recent contact with the GP. Efforts to improve GP recognition of mental disorder may be more effective if they target new or infrequent attenders, and encourage patient disclosure of psychological issues.     

Sex and attitude: a randomized vignette study of the management of depression by general practitioners.

BACKGROUND: The management and detection of depression varies widely, and the causes of variation are incompletely understood. AIMS: To describe and explain general practitioners' (GPs') current practice in the recognition and management of depression in young adults, their attitudes towards depression, and to investigate associations of GP characteristics and patient sex with management. METHOD: All GP principals in the Greater Glasgow Health Board were randomized to receive questionnaires with vignettes describing increasingly severe symptoms of depression in either male or female patients, and asked to indicate which clinical options they would be likely to take. The Depression Attitude Questionnaire was used to elicit GP attitudes. RESULTS: As the severity of vignette symptoms increased, GPs responded by changing their prescribing and referral patterns. For the most severe vignette, the majority of GPs would prescribe drugs (76.4%) and refer the patient for further help (73.7%). Male and female patients were treated differently: GPs were less likely to ask female patients than male patients to attend a follow-up consultation (odds ratio [OR] = 0.55), and female GPs were less likely to refer female patients (OR = 0.33). GPs with a pessimistic view of depression, measured using the 'inevitable course of depression' attitude scale, were less willing to be actively involved in its treatment, being less likely to discuss a non-physical cause of symptoms (OR = 0.77) or to explore social factors in moderately severe cases (OR = 0.68). CONCLUSIONS: Accepting the limitations of the method, GPs appear to respond appropriately to increasingly severe symptoms of depression, although variation in management exists. Educational programmes should be developed with the aim of enhancing GP attitudes towards depression, and the effects on detection and management of depression should be rigorously evaluated.     

Detecting suicidal ideation in older patients: identifying risk factors within the general practice setting

BACKGROUND: GPs are the most frequently accessed health professional among suicidal individuals in the community.AIM: To determine the prevalence of psychological distress and suicidal ideation among patients aged 60 years and older presenting to GPs, and the relationship between these variables in detecting patients who may be contemplating suicide.Design of study: Cross-sectional analysis of older patients presenting to Australian GPs between 2002 and 2003. SETTING: One thousand and sixty-one consecutive patients aged 60 years or over attending one of 54 randomly selected Western Australian GPs. METHOD: Prior to their medical consultation, patients completed a self-report questionnaire, which included questions about current suicidal ideation (Depressive Symptom Inventory Suicidality Subscale [DSI-SS]) and depression (Center for Epidemiological Studies Depression Scale [CES-D]). Patients' chief complaints were obtained from consultation summary sheets completed by their GP. RESULTS: Although only 5.1% of patients presented with psychological complaints, 5.8% acknowledged current suicidal ideation and 23.8% had clinically significant levels of depressive symptomatology. Suicidal ideation was associated with CES-D scores greater than 16 (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.5 to 8.9), feelings of depression (OR = 7.7, 95% CI = 3.4 to 17.7), and previous suicide attempt (OR = 7.4, 95% CI = 2.7 to 20.2) in a logistic regression model, but not with poor self-perceived health, use of licit drugs (smoking, alcohol, and hypnotics), or type of presenting complaint at the time of assessment. CONCLUSIONS: Although older general practice patients tend to present for issues related to their physical health, approximately a quarter of this cohort also possess high levels of psychological distress, including current thoughts of suicide. Older patients who show any signs of depression or distress should be asked about psychological symptoms, including suicidal ideation.     

Access to complementary medicine via general practice.

BACKGROUND: The popularity of complementary medicine continues to be asserted by the professional associations and umbrella organisations of these therapies. Within conventional medicine there are also signs that attitudes towards some of the complementary therapies are changing. AIM: To describe the scale and scope of access to complementary therapies (acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, and osteopathy) via general practice in England. DESIGN OF STUDY: A postal questionnaire sent to 1226 individual general practitioners (GPs) in a random cluster sample of GP partnerships in England. GPs received up to three reminders. SETTING: One in eight (1226) GP partnerships in England in 1995. METHOD: Postal questionnaire to assess estimates of the number of practices offering 'in-house' access to a range of complementary therapies or making National Health Service (NHS) referrals outside the practice; sources of funding for provision and variations by practice characteristics. RESULTS: A total of 964 GPs replied (78.6%). Of these, 760 provided detailed information. An estimated 39.5% (95% CI = 35%-43%) of GP partnerships in England provided access to some form of complementary therapy for their NHS patients. If all non-responding partnerships are assumed to be non-providers, the lowest possible estimate is 30.3%. An estimated 21.4% (95% CI = 19%-24%) were offering access via the provision of treatment by a member of the primary health care team, 6.1% (95% CI = 2%-10%) employed an 'independent' complementary therapist, and an estimated 24.6% of partnerships (95% CI = 21%-28%) had made NHS referrals for complementary therapies. The reported volume of provision within any individual service tended to be low. Acupuncture and homoeopathy were the most commonly available therapies. Patients made some payment for 25% of practice-based provision. Former fundholding practices were significantly more likely to offer complementary therapies than non-fundholding practices, (45% versus 36%, P = 0.02). Fundholding did not affect the range of therapies offered, and patients from former fundholding practices were no more likely to pay for treatment. CONCLUSION: Access to complementary health care for NHS patients was widespread in English general practices in 1995. This data suggests that a limited range of complementary therapies were acceptable to a large proportion of GPs. Fundholding clearly provided a mechanism for the provision of complementary therapies in primary care. Patterns of provision are likely to alter with the demise of fundholding and existing provision may significantly reduce unless the Primary Care Groups or Primary Care Trusts are prepared to support the 'levelling up' of some services.     

Psychological distress in primary care patients with heart failure: a longitudinal study.

BACKGROUND: Psychological distress is a common phenomenon in patients with heart failure. Depressive symptoms are often under-diagnosed or inadequately treated in primary care. AIM: To analyse anxiety and/or depression in primary care patients with heart failure according to psychosocial factors, and to identify protective factors for the resolution of psychological distress. DESIGN OF STUDY: Longitudinal observation study. SETTING: Primary care practices in lower Saxony, Germany. METHOD: In 291 primary care patients with heart failure the following factors were measured using validated questionnaires at baseline and 9 months later: anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), quality of life (Minnesota Living with Heart Failure Questionnaire), coping with illness (Freiburg questionnaire for coping with illness), and social support (social support questionnaire). Severity of heart failure (New York Heart Association [NYHA] classification and Goldman's Specific Activity Scale), and sociodemographic characteristics were documented using self-report instruments. RESULTS: Twenty-six (32.5%) of the 80 patients who were distressed at baseline had normal HADS scores 9 months later, while the remainder stayed distressed. In logistic regression, baseline distress (odds ratios [OR] 5.51; 95% confidence intervals [CI] = 2.56 to 11.62), emotional problems (OR = 1.08; 95% CI = 1.00 to 1.17), social support (OR = 0.54; 95% CI = 0.35 to 0.83), and NYHA classification (OR = 1.70; 95% CI = 1.05 to 2.77) independently predicted distress at follow up. High social support contributed to a resolution of anxiety or depression, while partnership and low levels of emotional problems protected patients who began the study in a good emotional state from psychological distress. CONCLUSION: In everyday practice it is important to consider that a high NYHA classification and emotional problems may contribute to anxiety or depression, while high social support and living in a relationship may positively influence the psychological health of patients with heart failure.     

The work hours of GPs: survey of English GPs

BACKGROUND: There is no current information about the hours worked by English GPs. AIM: To compare the reported hours worked by GPs with that of other professions and to explain the variation in GP hours worked and on call. Design of study: National postal survey of 1871 GPs in February 2004. SETTING: English general practice. METHOD: Multiple regression analyses of part-time versus full-time status, hours worked, and hours on call. RESULTS: Full-time male GPs report more hours worked (49.6; 95% CI [confidence interval] = 48.9 to 50.2) than males in other professional occupations (47.9; 95% CI = 47.6 to 48.1) and male managers (49.1; 95% CI = 48.8 to 49.5). Full-time female GPs report fewer hours (43.2; 95% CI = 42.0 to 44.3) than females in other professional occupations (44.7; 95% CI = 44.4 to 45.0) and female managers (44.1; 95% CI = 43.7 to 44.5). The number of hours worked decreased with practice list size, and increased with the number of patients per GP. GPs work longer hours in practices with older patients and with a higher proportion of patients in nursing homes. Fewer hours are worked in practices with higher 'additional needs' payments. Having children under 18 years of age increased the probability that female GPs work part-time but has no effect on the probability of male GPs working part-time. Given full-time/part-time status, having children under 18 years of age reduces the hours of male and female GPs. CONCLUSION: Male English GPs report longer hours worked than other professional groups and managers. The sex differences between GPs in hours worked are mostly attributable to the differential impact of family circumstances, particularly the number of children they have. Perversely, 'additional needs' payments are higher in practices where GPs work fewer hours.     

Inequalities in morbidity and consulting behaviour for socially vulnerable groups.

BACKGROUND: The focus of health policy on improving health and reducing inequality for socially vulnerable groups. AIM: To examine self-report of condition-specific morbidity and consultation with the general practitioner (GP) for socially vulnerable groups. DESIGN OF STUDY: Cross-sectional survey using a modified version of the General Practitioner Assessment Survey (GPAS). SETTING: Ten general practices in each of six health authorities. METHOD: A random sample of 200 patients was selected from each practice. The questionnaire elicited information about experience of specific acute and chronic conditions and whether the GP had been consulted. Four sub-samples were selected from the 4493 registered patients who responded to the self-completion questionnaire. They were lone mothers (n = 160), elderly living alone (n = 417), the unemployed (n = 100), and members of ethnic minority groups (n = 316). RESULTS: Logistic regression analyses showed that, after adjustment for age, sex, smoking, and housing tenure, only lone motherhood and ethnic minority group status were consistently and independently associated with poorer health outcomes. Lone motherhood was associated with a higher likelihood of anxiety (odds ratio [OR] = 2.03, 95% confidence interval [CI] = 1.34 to 3.08) and sleep problems (OR = 1.83, 95% CI = 1.18 to 2.83) and ethnic minority group status with a higher likelihood of depression (OR = 2.02, 95% CI = 1.34 to 3.04), diabetes (OR = 4.03, 95% CI = 2.54 to 6.39, migraine (OR = 1.72, 95% CI = 1.26 to 2.35), and minor respiratory symptoms (OR = 1.75, 95% CI = 1.33 to 2.29). Ethnic minority group status was the only source of social vulnerability that was independently associated with a higher likelihood of GP consultation, particularly for episodes of illness such as backache (OR = 3.28, 95% CI = 2.06 to 5.21), indigestion (OR = 2.94, 95% CI = 1.53 to 5.65), migraine (OR = 3.22, 95% CI = 1.75 to 5.93), minor respiratory symptoms (OR = 3.53, 95% CI = 2.26 to 5.50) and sleep problems (OR = 4.72, 95% CI = 2.56 to 8.71). CONCLUSIONS: Social vulnerability can be a risk factor for poorer health, but this is dependent on the source of vulnerability and is condition-specific. No association was found between inequity in the utilisation of primary care and social vulnerability. The propensity for members of ethnic minority groups to consult more than white people, particularly for acute conditions, requires further exploration.     

A survey of access to medical services in nursing and residential homes in England.

BACKGROUND: Residential and nursing homes make major demands on NHS services. AIM: To investigate patterns of access to medical services for residents in homes for older people. DESIGN OF STUDY: Telephone survey. SETTING: All nursing and dual registered homes and one in four residential homes located in a stratified random sample of 72 English primary care group/trust (PCG/T) areas. METHOD: A structured questionnaire investigating home characteristics, numbers of general practitioners (GPs) or practices per home, homes' policies for registering new residents with GPs, existence of payments to GPs, GP services provided to homes, and access to specialist medical care. RESULTS: There were wide variations in the numbers of GPs providing services to individual homes; this was not entirely dependent on home size. Eight percent of homes paid local GPs for their services to residents; these were more likely to be nursing homes (33%) than residential homes (odds ratio [OR] = 10.82, [95% CI = 4.48 to 26.13], P<0.001) and larger homes (OR for a ten-bed increase = 1.51 [95% CI = 1.28 to 1.79], P<0.001). Larger homes were more likely to encourage residents to register with a 'home' GP (OR for a ten-bed increase = 1.16 [95% CI = 1.04 to 1.31], P = 0.009). Homes paying local GPs were more likely to receive one or more additional services, over and above GPs' core contractual obligations. Few homes had direct access to specialist clinicians. CONCLUSION: Extensive variations in homes' policies and local GP services raise serious questions about patient choice, levels of GP services and, above all, about equity between residents within homes, between homes and between those in homes and in the community.     

Retention of young general practitioners entering the NHS from 1991-1992.

BACKGROUND: The supply of general practitioners (GPs) in the National Health Service (NHS) is dynamic and there are fears that there will be an inadequate number of doctors to meet the needs of the NHS. There are particular concerns about changes in the career trajectory of young GPs and what they mean for overall supply. AIM: To identify predictors of retention among young, new entrant GPs entering the NHS between 1 October 1991 and 1 October 1992. METHOD: Two-year retention rates of young (35 years of age or less) new entrant GPs have been modelled using a multilevel logit model. Retention is defined as young, new entrant GPs remaining in their initial health authority for two years or more. RESULTS: Two hundred and fifty-two (13.0%) members of the study group left general practice within two years of entry (i.e. were not retained). Sex (females had lower retention [95% CI = 0.43-0.75]), practice size (young GPs in larger practices had higher retention [95% CI = 1.10-1.29]), and belonging to a practice in one of 16 Greater London Health Authorities (which had lower retention [95% CI = 0.39-0.82]) were identified as major predictors of retention. Deprivation, measured at the individual GP patient list level, had a very slight association with retention (P = 0.097; 95% CI = 1.00-1.02). Deprivation measured at the health authority level (95% CI = 0.99-1.01) was not found to be a statistically significant predictor of retention (P = 0.83). CONCLUSION: None of the statistically significant predictors of retention suggest any policy panacea to end this phenomenon. The challenge for policy is to learn to deal with the dynamic nature of the GP workforce with a non-crisis mentality.     

Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting

Background

Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.

Aim

To assess whether GPs prescribe antidepressants appropriately.

Design of study

Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.

Setting

Four practices in Grampian, Scotland.

Method

Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.

Results

A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.

Conclusion

There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.     

GPs' awareness of patients' preference for place of death

Background

Being able to die in one''s place of choice is an indicator of the quality of end-of-life care. GPs may play a key role in exploring and honouring patients'' preferences for place of death.

Aim

To examine how often GPs are informed about patients'' preferred place of death, by whom and for which patients, and to study the expressed preferred place of death and how often patients die at their preferred place.

Design of study

One-year nationwide mortality retrospective study.

Setting

Sentinel Network of GPs in Belgium, 2006.

Method

GPs'' weekly registration of all deaths (patients aged ≥1 year).

Results

A total of 798 non-sudden deaths were reported. GPs were informed of patients'' preferred place of death in 46% of cases. GPs obtained this information directly from patients in 63%. GP awareness was positively associated with patients not being hospitalised in the last 3 months of life (odds ratio [OR] = 3.9; 95% confidence interval [CI] = 2.8 to 5.6), involvement of informal caregivers (OR = 3.3; 95% CI = 1.8 to 6.1), use of a multidisciplinary palliative care team (OR = 2.5; 95% CI = 1.8 to 3.5), and with presence of more than seven contacts between GP and patient or family in the last 3 months of life (OR = 3.0; 95% CI = 2.2 to 4.3). In instances where GPs were informed, more than half of patients (58%) preferred to die at home. Overall, 80% of patients died at their preferred place.

Conclusion

GPs are often unaware of their patients'' preference for place of death. However, if GPs are informed, patients often die at their preferred location. Several healthcare characteristics might contribute to this and to a higher level of GP awareness.     

Work and family roles and the association with depressive and anxiety disorders: differences between men and women

BACKGROUND: This study examined the associations of (combinations of) social roles (employee, partner and parent) with the prevalence of anxiety and depressive disorders and whether social roles contribute to the explanation of the female preponderance in these disorders. METHOD: This was a cross-sectional study using data from 3857 respondents aged 25-55 of NEMESIS (Netherlands Mental Health Survey and Incidence Study). Depression and anxiety disorders were measured using the CIDI 1.1. RESULTS: The OR of depressive disorders and anxiety disorders among women compared to men was 1.71 (95% CI: 1.40-2.10). Among both genders, the partner role was associated with decreased risks of depression and anxiety and the parent role was not. The work role was a significant protective factor of depression and anxiety for men (OR=0.40; 95% CI: 0.24-0.69) but not for women (OR=0.86; 95% CI: 0.66-1.12). The effect of the work role was positive among women without children (OR=0.28; 95% CI: 0.14-0.54), but not among those with children (OR=1.01; 95% CI: 0.75-1.35). The gender risk for depression and anxiety decreased significantly by adding the work role variables into the model. LIMITATIONS: This was a cross-sectional study. This study did not give insight into the quality of social roles. CONCLUSION: The work role contributed to the explanation of the female preponderance in depression and anxiety disorders. Considering depression and anxiety among women, a focus upon quality and meaning of the work role, and barriers in combining the work role and parent role may be essential.     

Psychomotor retardation in elderly depressed patients

BACKGROUND: Up to 70% of older people who commit suicide consult a general practitioner (GP) in the month prior to their death. The purpose of this study was to identify the clinical and demographic characteristics of older adults who are contemplating suicide and are in contact with a GP. METHODS: We utilised a cross-sectional study to investigate the association between suicidal ideation and clinical/demographic variables of 504 consecutive patients aged 60 years or over, attending 1 of 54 randomly selected Western Australian GPs. Prior to their medical consultation, patients completed a self-report questionnaire, which included questions about suicidal ideation (Depressive Symptom Inventory-Suicidality Subscale, DSI-SS), demographic factors, lifestyle factors, physical health and mental health, including depression (Center for Epidemiologic Studies-Depression Scale, CES-D). RESULTS: Within our sample of older patients, 6.3% acknowledged current suicidal ideation. Multivariate analyses indicated that current suicidal ideation was strongly associated with being depressed at least occasionally during the previous week (OR=7.3, 95% CI=2.3-23.0), CES-D scores of 16 points or greater (OR=3.6, 95% CI=1.0-12.1), and a prior history of attempted suicide (OR=15.5, 95% CI=4.0-60.6). Limitations: Our results and conclusions are limited to suicidal ideation, and may not apply to suicidal behaviour. CONCLUSIONS: Depressive symptomatology is strongly associated with suicidal ideation in later life. Strategies that enhance GPs' identification and treatment of affective illness in older patients should have the greatest impact on suicide rates within this age group.     

How do patients referred to neurologists for headache differ from those managed in primary care?

BACKGROUND: Headache is the neurological symptom most frequently presented to GPs and referred to neurologists, but little is known about how referred patients differ from patients managed by GPs. AIM: To describe and compare headache patients managed in primary care with those referred to neurologists. DESIGN OF STUDY: Prospective study. SETTING: Eighteen general practices in south-east England. METHOD: This study examined 488 eligible patients consulting GPs with primary headache over 7 weeks and 81 patients referred to neurologists over 1 year. Headache disability was measured by the Migraine Disability Assessment Score, headache impact by the Headache Impact Test, emotional distress by the Hospital Anxiety and Depression Scale and illness perception was assessed using the Illness Perception Questionnaire. RESULTS: Participants were 303 patients who agreed to participate. Both groups reported severe disability and very severe impact on functioning. Referred patients consulted more frequently than those not referred in the 3 months before referral (P = 0.003). There was no significant difference between GP-managed and referred groups in mean headache disability, impact, anxiety, depression, or satisfaction with care. The referred group were more likely to link an increased number of symptoms to their headaches (P = 0.01), to have stronger emotional representations of their headaches (P = 0.006), to worry more (P = 0.001), and were made anxious by their headache symptoms (P = 0.044). CONCLUSION: Patients who consult for headache experience severe disability and impact, and up to a third report anxiety and/or depression. Referral is not related to clinical severity of headaches, but is associated with higher consultation frequency and patients' anxiety and concern about their headache symptoms.     

The FIP study: a randomised, controlled trial of screening and recognition of psychiatric disorders.

BACKGROUND: Research on questionnaires as screening tools for psychiatric disorders has yielded conflicting results. AIM: To examine the effect of a routinely administered questionnaire on recognition of common psychiatric disorders in general practice. DESIGN OF STUDY: Randomised controlled trial. SETTING: Twenty-eight general practices in Aarhus County, Denmark. METHOD: Thirty-eight general practitioners (GPs) and 1785 consecutive patients, aged 18-65 years old, presenting with a new health problem, participated. Before consultation, patients were screened using a brief screening questionnaire (SQ) including somatisation, anxiety, depression, and alcohol abuse scales. Patients were randomised to one of two groups: 900 questionnaires were disclosed and scored by the GPs, 885 were blinded. A stratified subsample of 701 patients was interviewed after the consultation using a standardised psychiatric research interview (SCAN). RESULTS: Overall the GPs' recognition rates were 14% (95% confidence interval [CI] = -2 to 30) better for depression and 35% (95% CI = 2 to 68) better for alcohol problems when SQs were disclosed. Recognition rates for anxiety improved 8% (95% CI = -9 to 26) overall. In the case of somatoform disorders, disclosure showed no effect overall. Among those with high SQ scores, however, disclosure increased recognition rates on any mental disorder evaluated. CONCLUSION: This study demonstrated limited usefulness for routine screening for common psychiatric disorders. However, findings suggest that the SQ may be useful for case-finding among a subgroup of patients with high SQ scores.     

Patients' involvement in decisions about medicines: GPs' perceptions of their preferences.

BACKGROUND: Patients vary in their desire to be involved in decisions about their care. AIM: To assess the accuracy and impact of GPs' perceptions of their patients' desire for involvement. DESIGN OF STUDY: Consultation-based study. SETTING: Five primary care centres in south London. METHOD: Consecutive patients completed decision-making preference questionnaires before and after consultation. Eighteen GPs completed a questionnaire at the beginning of the study and reported their perceptions of patients' preferences after each consultation. Patients' satisfaction was assessed using the Medical Interview Satisfaction Scale. Analyses were conducted in 190 patient-GP pairs that identified the same medicine decision about the same main health problem. RESULTS: A total of 479 patients participated (75.7% of those approached). Thirty-nine per cent of these patients wanted their GPs to share the decision, 45% wanted the GP to be the main (28%) or only (17%) decision maker regarding their care, and 16% wanted to be the main (14%) or only (2%) decision maker themselves. GPs accurately assessed patients' preferences in 32% of the consultations studied, overestimated patients' preferences for involvement in 45%, and underestimated them in 23% of consultations studied. Factors protective against GPs underestimating patients' preferences were: patients preferring the GP to make the decision (odds ratio [OR] 0.2 per point on the five-point scale; 95% confidence interval [CI] = 0.1 to 0.4), and the patient having discussed their main health problem before (OR 0.3; 95% CI = 0.1 to 0.9). Patients' educational attainment was independently associated with GPs underestimation of preferences. CONCLUSION: GPs' perceptions of their patients' desire to be involved in decisions about medicines are inaccurate in most cases. Doctors are more likely to underestimate patients' preferred level of involvement when patients have not consulted about their condition before.