Worries are the mother of many diseases: general practitioners and refugees in the Netherlands on stress, being ill and prejudice

OBJECTIVE: To confront the views of refugee patients and general practitioners in the Netherlands, focusing on medically unexplained physical symptoms (MUPS). METHODS: The study is based on in depth interviews with refugees from Afghanistan (n = 36) and Somalia (n = 30). Additionally, semi-structured interviews were conducted with 24 general practitioners. Text fragments concerning the relationship between mental worries and health or physical ailments were subject of a secondary analysis, the results of which are presented. RESULTS: Medically unexplained physical symptoms were a key issue for both refugees and GPs. The GPs saw MUPS as a significant part of the illness presentation by refugee patients. Refugees felt GPs were often prejudiced, too readily using their difficult background as an explanation for physical symptoms. A 'general narrative' circulating in the refugee communities undermines trust. The GPs applied different strategies in dealing with MUPS presented by their refugee patients. A 'human interest strategy' is distinguished from a 'technical strategy'. The results are discussed in the wider context of the literature on MUPS and patient satisfaction. CONCLUSION: No fundamental difference in paradigms was found between refugees and GPs as to the negative influence worries and bad experiences can have on health. For a fruitful cooperation to develop, based on trust, GPs need to invest in the relationship with individual refugees, and avoid actions based on prejudice. PRACTICE IMPLICATIONS: The importance of (a lack of) trust is underestimated in medical practice. Phenomena undermining trust are often out of sight for practitioners. Critical reflection is needed on the strategies practitioners employ to deal with MUPS.     

`There's a lot of it about': clinical strategies in family practice

Is there a difference in the way family physicians and specialists deal with clinical problems? Family physicians, in contrast to specialists, work in a practice environment in which there is a high prevalence of symptomatic discomfort, but a low prevalence of frank disease. These circumstances result in clinical strategies that are very different to those used in secondary and tertiary levels of care, and which run counter to what are usually accepted as medical norms. The primary care physician must often diagnose what things are not, rather than what they are, must make management decisions prior to, or instead of, diagnostic decisions and must resist the temptation to be `thorough'' These imperatives are reflected in the language family physicians sometimes use in their conversations with patients. Clinical reasoning in primary care involves important but poorly understood intellectual processes which may be of significance to all levels of medicine.     

Metacognitive factors in chronic fatigue syndrome

Chronic fatigue syndrome (CFS), which is characterized by fatigue and flu-like symptoms that are not alleviated by rest, is a poorly understood condition and an often controversial diagnosis. Earlier research has indicated that general metacognitions are associated with the severity of symptoms in patients with CFS. In the current study, we aimed to determine whether specific metacognitive factors are implicated in CFS. Using the metacognitive profiling interview template we investigated the following: (1) whether patients held positive or negative metacognitions about conceptual processes; (2) what their goals with respect to engaging in these processes were; and (3) what indicated that it was appropriate to stop. We also examined attention focus when experiencing CFS symptoms, and its advantages and disadvantages. Results showed that patients endorsed positive and negative metacognitions pertaining to conceptual processes. The goals of engaging in these processes were to identify the cause of, and devise strategies to cope with, symptoms. Patients were either unable to identify a stop signal for conceptual processing or identified an improvement in fatigue-related symptoms as representing the stop signal. Finally, patients reported that their attention focus when experiencing symptoms included distraction and monitoring of symptoms. Advantages to these strategies included symptom management, whereas disadvantages included an escalation of negative affect. The present findings provide preliminary evidence that specific metacognitive factors may be involved in CFS. Copyright ? 2011 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Metacognitive profiling that may aid assessment and conceptualisation of psychological distress in CFS.     

Differences in clinical characteristics between patients assessed for NHS specialist psychotherapy and primary care counselling

Objectives . Although several studies have described patient populations in primary care counselling settings and NHS (National Health Service) specialist psychotherapy settings, there is a paucity of studies specifically comparing differences in clinical characteristics between the two groups of patients. The aim of this study is to ascertain if specialist psychotherapy referrals represent a more challenging client group than primary care counselling patients. Design . We compare the socio‐demographic features and severity of presentation in the symptomatic, interpersonal problems and global adjustment dimensions of a sample of patients (N=384) assessed by a primary care counselling service located in North London and a sample of patients (N=853) assessed in eight NHS psychotherapy centres located within urban settings in England. Methods . Both the groups completed the Brief Symptom Inventory, the Inventory of Interpersonal Problems and Clinical Outcomes in Routine Evaluation Outcome Measure. Results . Patients referred for specialist psychotherapy services were more dysfunctional than those referred for primary care counselling. The linear function constructed to discriminate the groups showed that a combination of more psychotic symptoms, social inhibitions and higher risk of self‐harm effectively identified those referred to psychotherapy services, while patients exhibiting greater levels of somatic and anxiety symptoms and non‐assertiveness were more likely to be seen in primary care settings. However, similarities between the two samples were also marked, as shown by the overlap in the distribution of clinical outcomes in routine evaluation clinical scores in the two samples. Conclusions . The findings are discussed in terms of their implications for policy and service delivery of these two types of psychological therapy services.     

Disagreement in doctor's and patient's rating about medically unexplained symptoms and health care use

Background

Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care. It remains unclear to what extent patients and their general practitioners (GPs) agree upon the etiology of physical symptoms as well as on the number of visits to the GP.

Purpose

The purpose of this study is to determine patient–physician agreement on reported symptoms.

Method

A sample of 103 persons provided information on MUS and health care utilization (HCU) during the previous 12 months. The persons' GPs (n?=?103) were asked for the same information. By determining patient–physician agreement on reported symptoms, the sample was subdivided into a concordance group (high agreement: Pt?=?GP) and two discordance groups (substantial disagreement: Pt?>?GP, Pt?<?GP).

Results

Patients and their GPs showed substantial disagreement concerning physical symptom reports for the prior 12 months. On means, patients named 3.26 (SD?=?3.23; range 0–21) physical complaints of which 71.6% were considered to be medically unexplained (MUS), whereas GPs only determined 1.77 (SD?=?1.94; range 0–11) symptoms of which 57.5% were MUS. Substantial patient–physician agreement regarding the number of reported MUS was detected in 29.1% of the cases (Pt?=?GP). Patients of all groups underestimated their HCU.

Conclusion

Since patients' and GPs' reports differ substantially concerning the etiology of symptoms and concerning HCU, both sources of data gathering should be treated carefully in primary care research.     

Views of cancer care reviews in primary care: a qualitative study

Background

The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown.

Aim

To describe: (1) implementation of the QOF cancer care review; (2) patients'' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients'' views on optimal care; and (4) the views of primary care professionals regarding their cancer care.

Design of study

Qualitative study using thematic analysis and a framework approach.

Setting

Six general practices in the Thames Valley area.

Method

Semi-structured interviews with cancer patients and focus groups with primary care teams.

Results

Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients'' needs and closer links with secondary care to facilitate a more involved role.

Conclusion

Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care.     

Qualitative study of patients'' perceptions of the quality of care for depression in general practice.

BACKGROUND: Research into quality of care in primary mental health care has largely focused on the role of the general practitioner (GP) in the detection and management of patients' problems. AIM: To explore depressed patients' perceptions of the quality of care received from GPs. DESIGN OF STUDY: Qualitative study using semi-structured interviews. SETTING: General practices in Greater Manchester. METHOD: Purposive sampling and semi-structured interviewing of 27 patients who had received care from 10 GPs for depression. RESULTS: Quality of care in depression depends on good communication between the doctor and the patient, but patients who are depressed often have difficulty in discussing their problems with doctors. They are also unlikely to be active in seeking care; for example, in making follow-up appointments, especially when they are uncertain that depression is a legitimate reason for seeing the doctor. Patients sometimes accept care that does not meet professional standards, either because of low expectations of what the National Health Service (NHS) can provide, or because of low self-worth associated with their problem. CONCLUSION: The depressed person may feel that they do not deserve to take up the doctor's time, or that it is not possible for doctors to listen to them and understand how they feel. Doctors need to be active in providing care that meets professional standards. We advocate a model of care in which patients with depression are followed up systematically.     

An international study of the relation between somatic symptoms and depression.

BACKGROUND AND METHODS: Patients with depression, particularly those seen by primary care physicians, may report somatic symptoms, such as headache, constipation, weakness, or back pain. Some previous studies have suggested that patients in non-Western countries are more likely to report somatic symptoms than are patients in Western countries. We used data from the World Health Organization's study of psychological problems in general health care to examine the relation between somatic symptoms and depression. The study, conducted in 1991 and 1992, screened 25,916 patients at 15 primary care centers in 14 countries on 5 continents. Of the patients in the original sample, 5447 underwent a structured assessment of depressive and somatoform disorders. RESULTS: A total of 1146 patients (weighted prevalence, 10.1 percent) met the criteria for major depression. The range of patients with depression who reported only somatic symptoms was 45 to 95 percent (overall prevalence, 69 percent; P=0.002 for the comparison among centers). A somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio, 1.8; 95 percent confidence interval, 1.2 to 2.7). Half the depressed patients reported multiple unexplained somatic symptoms, and 11 percent denied psychological symptoms of depression on direct questioning. Neither of these proportions varied significantly among the centers. Although the overall prevalence of depressive symptoms varied markedly among the centers, the frequencies of psychological and physical symptoms were similar. CONCLUSIONS: Somatic symptoms of depression are common in many countries, but their frequency varies depending on how somatization is defined. There is substantial variation in how frequently patients with depression present with strictly somatic symptoms. In part, this variation may reflect characteristics of physicians and health care systems, as well as cultural differences among patients.     

Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations.

Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially over the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chronic heart failure is a serious condition with high morbidity and mortality. There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction improves symptoms and signs, slows progression of heart failure, reduces hospitalisation rates, and improves survival. Despite this evidence, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a key step in the appropriate management of heart failure. The aim of this paper is to review the evidence about the usefulness of signs, symptoms, and investigations in diagnosing heart failure in primary care. To identify relevant studies for this review, four strategies were used: a MEDLINE search from 1993 to January 1998 using the diagnosis search filter; a MEDLINE search from 1993 to January 1998 using the guideline search filter to locate published heart failure guidelines; a search for review articles in the Cochrane Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis'. All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to primary care. The review shows that symptoms and signs are important because they alert clinicians to the possibility of heart failure as a diagnosis. However, they are not sufficiently specific for confirming left ventricular systolic dysfunction. From the evidence available, a patient with suspected heart failure must have objective tests to confirm the diagnosis. These should include an electrocardiogram and, ideally, an echocardiogram. Further research is also needed on the usefulness of signs and symptoms in primary care, as most studies of heart failure have been conducted in secondary care.     

Patients’ expectations for and experiences with primary healthcare services received from a patient centered medical home

ObjectiveExpectations for and experiences with healthcare services are summarized for 1143 patients receiving care in a statewide demonstration of Patient Centered Medical Homes (PCMH).MethodsPatients were recruited from 91 primary care clinics for semi-structured interviews to determine what patients expect, what they plan to do and how they intend to execute their plans in partnership with their healthcare team.ResultsThe majority (78%) of patients defined the patient-team partnership as a collaborative and problem-solving effort. Overall, 68% defined responsibility for own health as a personal responsibility; 55% defined listening to patient’s concerns and answering questions as a responsibility of their healthcare team. Diet and exercise came up most frequently whether as a personal responsibility, issues for receiving additional help from their clinic, or plans for personal change.ConclusionPatients’ preferred a collaborative, problem-solving healthcare team partnership but also had boundaries for what additional services they wanted from this team.Practice Implications: Patients’ expectations for a collaborative partnership, acceptance of personal responsibility and interest in diet and exercise expands opportunities for patient education and teamwork. Clinics’ engagement with broader resources would be needed to address patients’ many and varied challenges to taking care of their health.     

Using ePROMs for follow-up after palliative radiotherapy: An exploratory study with patients and health care providers

ObjectivesPatients treated with palliative radiotherapy may experience symptoms decreasing their quality of life. Electronic patient-reported outcome measures (ePROMs) could provide an opportunity to follow-up patients after treatment.MethodsA mixed-method study was performed using self-constructed questionnaires, focus groups and interviews with patients and health care professionals (HCP). A qualitative approach was used to code the data.ResultsForty-two patients, 21 radiation-oncologists, 15 general practitioners (GPs) and 24 home-care nurses completed a questionnaire. Ten patients, 6 radiation-oncologists, 14 GPs and 5 nurses were interviewed or participated in a focus group. Although patients and HCP are satisfied with current care, they believe ePROMs could improve follow-up, communication, continuity of care and self-management of symptoms. An easy to use, versatile ePROM platform seems to be important for successful implementation. Self-care tips and contact information should be added to relevant ePROM-questions, on both physical and psychological symptoms.ConclusionPatients and HCP agree that ePROMs could improve systematical clinical follow-up after palliative radiotherapy, with self-management support being the primary objective of such a system. Practice implications ePROMs after palliative radiotherapy seem feasible, the exact patient population that could benefit the most will need to be explored further; as the palliative population is very diverse.     

The Heterogeneity of Illness Behaviors in Patients with Medically Unexplained Physical Symptoms

Purpose

To investigate the heterogeneity of illness behavior in patients with medically unexplained physical symptoms (MUPS), we clustered patients in regard to their degree of engaging in different aspects of illness behavior and identified related variables with these behaviors.

Method

A sample of N?=?224 patients attending treatment in primary care with a history of MUPS (at least two symptoms) was investigated by analyzing different aspects of illness behavior with the self-reported number of doctor visits during the last 6 months and the Scale for the Assessment of Illness Behavior (SAIB; e.g., expression of symptoms).

Results

Two distinct clusters were identified by cluster analysis: a low (n?=?106) and a high (n?=?118) illness behavior clusters. The high illness behavior cluster exhibited a significantly higher rate of health anxiety than the low illness behavior cluster. Regression analysis revealed a particular effect of sex in the high illness behavior cluster: whereas being male was associated with increased illness behavior as measured by the SAIB, being female was linked to a higher number of doctor visits. Increased health anxiety was associated with the SAIB illness behavior in both clusters. Depression and anxiety did not show incremental associations with all aspects of illness behavior.

Conclusion

Knowledge of the pattern of illness behavior in patients with MUPS enables us to improve psychological treatments that directly address specific aspects of illness behavior or health anxiety. Differences between sexes in illness behaviors require more differentiated consideration in future research.

     

Attitudes toward integration of complementary and alternative medicine in primary care: perspectives of patients, physicians and complementary practitioners

OBJECTIVE: Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians' role regarding CAM, and models for CAM referral and treatment. We compared patients' perspectives regarding integration of CAM into primary care with attitudes of primary care physicians (PCPs) and CAM practitioners. METHODS: We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups: a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health maintenance organization in Israel. RESULTS: A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to PCPs' expectations of prescribing CAM (62% vs. 30%; p=0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p<0.0001). Patients supported CAM practitioners providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p<0.0001). CONCLUSION: Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent, that they actually provide CAM treatment themselves. PRACTICE IMPLICATIONS: PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable, skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better collaborate with CAM practitioners to the benefit of their patients.     

Family influences in a cross-sectional survey of higher child attendance.

BACKGROUND: A quarter of all consultations are for children, but there is little quantitative evidence documenting what parental factors are important in the decision to consult. AIM: To assess parental factors in higher child attendance (three or more times per year)--the 32% responsible for most (69%) general practice consultations with children. DESIGN OF STUDY: A random sample of 4000 individuals (one per household), including 670 children. SETTING: Six general practices within a 30-mile radius of the administrative centre. METHOD: Parents completed a postal questionnaire for themselves and their child. The adult questionnaire documented lifestyle, attitude to doctors and medicine, Kokko's personality types, perceived health, health anxiety, number of medical problems, medically unexplained somatic symptoms, and willingness to tolerate symptoms. The child questionnaire documented perceived health, the number of medical problems, somatic symptom inventory, willingness to tolerate symptoms, and self-reported attendance. RESULTS: (Adjusted odds ratios, test for trend, 95% confidence intervals.) A response rate of 490/670 (73%) paired adult and child questionnaires was obtained. Reported higher attendance was valid compared with the notes (likelihood ratio positive test = 5.2, negative test = 0.24), and was independently predicted by the child's age, medical problems, council house occupancy, and by the parents' assessment of the severity of the child's ill health. After controlling for these variables, higher attendance was more likely if the parents were higher attenders (adjusted OR = 3.71, 95% CI = 2.31-5.98), and if they perceived their children had medically unexplained physical symptoms (MUPS) (for 0, 1, 2, 3+ symptoms; adjusted ORs (95% CIs) = 1, 3.1 (1.7-5.7), 2.30 (0.97-5.5), 4.2 (1.8-9.6) respectively, P < or = 0.001). Attendance was less likely if they were willing to tolerate symptoms in their children (score for seven normally self-limiting scenarios = 0-17, 18-29 and 30+; adjusted ORs = 1, 0.71, 0.39 respectively, z for trend P = 0.03), willingness to tolerate symptoms and parental perception of child MUPS were associated with council house tenancy and health anxiety. Parents' perception of child MUPS also related to perception of child health and the parents' own MUPS. Parents of higher attenders were more likely to be depressed (HAD depression scale = 0-7, 8-10, 11+ respectively; adjusted ORs (95% CIs) = 1, 2.04 (1.27-3.27), 1.60 (0.75-3.42)) or anxious (anxiety scale 0-7, 8-10, 11+, respectively; adjusted ORs [95% CIs] = 1, 1.60 [0.99-2.58], 1.97 [1.20-3.26]). CONCLUSION: Important parental factors are council house tenancy, the parents' perception of and willingness to tolerate, somatic symptoms in the child, and the parents' own attendance history, health anxiety, and perception of somatic symptoms Doctors should be sensitive to the parental and family factors that underlie the decision to consult and of the needs of parents of high-attending children.     

How accurate is diagnosis of asthma in a general practice database? A review of patients' notes and questionnaire-reported symptoms.

BACKGROUND: Planned care of patients with chronic diseases in primary care depends on being able to identify them. A recorded label of asthma does not necessarily mean that the patient is currently symptomatic, and failure to record the diagnosis may influence future care. AIM: To determine the degree of under- and over-reporting of the diagnosis of asthma for patients aged 16-55 years inclusive in one large general practice. DESIGN: A questionnaire validated for the detection of bronchial hyper-reactivity was sent to all patients recorded as having asthma and their matched controls. Patients with a diagnosis of asthma and symptomatic bronchial hyper-reactivity were considered to have asthma. Evidence of asthma in the written and computer records was sought for two groups: patients with asthma and without symptoms of bronchial hyper-reactivity, and controls with symptoms of bronchial hyper-reactivity. SETTING: A semi-rural group practice with 14 830 patients. METHOD: Questionnaires were sent to 833 patients and 831 controls matched by age and sex. RESULTS: Response rates were 79.1% (659/833)for patients with asthma and 70.6% (587/831) for control patients. Of the patients with asthma who replied, 60.5% (399/659) had symptomatic bronchial hyper-reactivity. Of those with asthma and a negative bronchial hyper-reactivity status (based on the questionnaire), 190/260 (73.1%) were considered to have had asthma when diagnosed, on review of their primary care records.There was no evidence to suggest asthma in 45 (17.3%) of the 260 patients who had a negative bronchial hyper-reactivity status. Of the control patients, 41 (7.0%) of the 587 responders had symptomatic bronchial hyper-reactivity and nine of these may have asthma. By extrapolation, we estimate that there were possibly another 99 patients with symptoms of asthma, who had not been labelled as having asthma, and 362 patients with symptoms of bronchial hyper-reactivity who had not reported them to their doctors or had not had them recognised. CONCLUSIONS: There is an 89.4% chance that a patient recorded as having asthma has, or has had, asthma.     

Symptomatic diagnosis of prostate cancer in primary care: a structured review.

BACKGROUND: Prostate cancer has the second highest cancer incidence and mortality in European men. Most prostate cancers are diagnosed after lower urinary tract symptoms (LUTS) are presented to primary care, but such symptoms more often have a benign cause. A general practitioner (GP) has to try and identify which of these patients have prostate cancer. AIMS: To review the presenting features of symptomatic prostate cancer. DESIGN OF STUDY: Structured review. METHOD: We searched Medline from 1980 to 2003 for symptoms, signs, and investigations reported in prostate cancer. This list was then expanded by secondary searches of reference lists. We excluded studies on post-diagnostic topics, such as staging, treatment, and prognosis; studies on non-Western patients; and studies on investigations that are not available in primary care. A second cycle of exclusions removed studies whose results would not guide a GP in deciding whether a patient has prostate cancer. RESULTS: No studies from primary care compared prostate cancer patients directly with controls. Two secondary care studies had enough information to allow a comparison of symptoms in cases compared with controls. In these studies, symptoms were generally more prevalent in cases, but the differences were small. Screening and secondary care studies suggest that early prostate cancer is symptomless, and that locally advanced cancer has LUTS that are similar to those for benign prostatic hypertrophy. CONCLUSION: There is a very weak evidence base for the primary care diagnosis of prostate cancer in men with lower urinary tract symptoms.     

Assessment and Psychological Treatment of Depression in Older Adults with Terminal or Life-Threatening Illness

Depression decreases the quality of life and hinders efforts to palliate symptoms of adults with terminal or life-threatening illness. Nevertheless, depression often may go undetected and untreated in palliative care and hospice settings due to a number of factors, including the overlap of depressive symptoms with those of serious medical illness and concern that frail elderly patients cannot tolerate psychotherapy or antidepressant treatment. In this paper we review the available research regarding assessment and treatment of depression in older adults with terminal or life-threatening illness, focusing on patients who are seen in palliative care, cancer treatment, or hospice settings. Although the prevalence of depression is relatively high in these settings in mixed-age adult samples, studies focused exclusively on older adults are rare and there appear to be no randomized controlled trials of psychotherapy conducted to date that specifically address their needs. There are, however, promising psychological approaches featured in case reports and pilot studies that are consistent with empirically supported therapies for the general treatment of depression in older adults. Based on these preliminary findings and reports, we offer tentative recommendations for the assessment and treatment of depression in terminally ill older adults. We conclude that controlled research on psychotherapy for late-life depression is both feasible and urgently needed in palliative care, cancer care, and hospice settings.     

Diagnosis of asthma and chronic obstructive pulmonary disease in general practice.

There may be an overlap between the clinical pictures of asthma and chronic obstructive pulmonary disease which hampers a clear distinction between the two diseases. Most symptoms presented by patients do not clearly belong exclusively to either asthma or chronic obstructive pulmonary disease. By the nature of their discipline and training, general practitioners focus mainly on symptoms presented, which do not give a decisive answer in the differential diagnosis between the two diseases. Therefore, general practitioners must rely on objective parameters, such as determining the presence and degree of reversibility of airway obstruction, diurnal peak flow variability, bronchial hyper-responsiveness and allergy. This paper puts forward a pragmatic, primary care definition of asthma and chronic obstructive pulmonary disease.