Problems in using the hospital anxiety and depression scale for screening patients in general practice.

A study was made of the feasibility of screening general practice patients for anxiety and depression using the hospital anxiety and depression scale. A group of consecutive patients aged 18 years and over completed the questionnaire at the surgery and an age and sex matched sample were sent questionnaires by post; 94 patients (84%) returned the postal questionnaire. A further group of 170 consecutive patients coming for consultation were recruited. Using a threshold score of eight and over, 51% of patients screened by post were probable 'cases' of psychiatric disorder and using a score of 11 and over, 28% were 'cases'. These proportions were similar for patients screened when attending the surgery. The findings are discussed in the context of well-person screening, and a strategy for follow-up of probable cases is put forward.     

Psychiatric screening in general practice: comparison of the general health questionnaire and the hospital anxiety depression scale

The prevalence of psychiatric disorder in 100 patients attending their general practitioner was found to be 33% based on the criteria of the DSM-3 diagnostic system. Using the DSM-3 diagnosis as a yardstick, the performance of the hospital anxiety depression scale was compared with that of the general health questionnaire. Relative operating coefficient analysis showed good discrimination between `cases' and `non-cases' for both questionnaires, and the optimum threshold score was found to be eight for the hospital anxiety depression scale and five for the general health questionnaire. Using these threshold scores the positive predictive value was 81% for the hospital anxiety depression scale and 77% for the general health questionnaire. The hospital anxiety depression scale appeared more sensitive than the general health questionnaire (90% versus 77%) and simpler to complete. In addition, it does not require a different threshold score for each population studied. The use of screening questionnaires in general practice is discussed.     

ICD-10 criteria for depression in general practice

BACKGROUND: The rate of recognition of depressive disorder in general practice is reported to be low. Current classification systems, i.e. ICD-10 and DSM-III-R, and DSM-IV with operational diagnostic criteria, have led to greater agreement concerning the diagnosis of depressive disorder. The aim of this study was to assess the applicability and validity of the ICD-10 criteria for depression in general practice in Denmark. METHODS: After a 1-day training course in the ICD-10 criteria for depression, ten general practitioners, during an 8-week period assessed all patients aged 18 or older for depressive symptoms in accordance with the ICD-10 criteria. RESULTS: Among a total of 3505 consultations, 116 patients (3.3%) met the criteria for a depressive episode. Of these, 80 (68.8%) accepted to be reinterviewed by a psychiatrist, who confirmed the diagnosis of depressive disorder in 57 of the 80 patients (71.3%). LIMITATIONS: The number of 'false negative' cases are unknown in the study. CONCLUSION: The ICD-10 criteria for depression seem to be appropriate and valid in general practice.     

Diagnosis of depression in general practice

Depression is well recognized as a public health problem that usually runs the risk of becoming chronic, disabling and life threatening if left untreated. Unfortunately depression remains largely under diagnosed in primary care although more than one in ten cases seen in primary care suffers from this condition. Primary care physicians are strategically placed to detect and treat depression early and thus contribute in secondary prevention of this disorder. This article highlights the problems in diagnosis, the ways depressed patients present to the clinicians, the diagnostic criteria, the detailed interview techniques to arrive at a diagnosis of depression. The article also offers an outline of management of depression in primary care.     

The interactive functioning of anxiety and depression in agonistic encounters and reconciliation

This paper explores the well-known overlap of anxiety and depressive symptoms in mood and anxiety disorders. We suggest that the regulation of both negative and positive affects has served important adaptive functions (especially for coping with threats, losses, failures and defeats), and that in some contexts both affect systems require regulation at the same time (e.g. increased anxiety coupled with low positive affect). Here we will focus on how low positive and high negative affect in the individual experiencing losses and defeats regulates their competitive and acquisitive behaviors and in some cases may prevent, de-escalate, and possibly terminate on-going agonistic (hierarchical) encounters. When high negative affect (anxiety) and low positive affect (depression) fail to fulfill their adaptive roles, they tend to persist and often intensify. This may lead each affect control system to stimulate specific types of anxiety and depressive disorders, exhibiting features reminiscent of the original adaptive function of the behavior. Furthermore, as these different systems tend to operate in a synchronous fashion, the psychiatric syndromes they generate are often comorbid.     

Group treatment of general practice anxiety problems

This study examined the effects on anxiety levels and primary care team workload of group psychological treatment for anxiety compared with individual treatment. Patients making high demands on primary care services were selected for group treatment, following which demands for services were considerably reduced. Two types of group treatment were used: the anxiety support group required less staff time to run than the anxiety management group but neither treatment had a clinically significant impact on anxiety symptoms. Individual psychological treatment was more effective in reducing levels of anxiety but required slightly more staff time per patient. These findings show that there is no close correspondence between reduction of anxiety and reduction of service costs and underline the importance of evaluating treatment effects with reference to the specific objectives of treatment.     

Diagnosis and outcome: depression and anxiety in a general population

An assessment of the long-term outcome for depression and anxiety disorders in a general population was made as part of the Stirling County Study. Measuring outcome as a dichotomy between experiencing recurrent episodes or not during a 17-year cohort interval, it was found that 56% of the 'cases' had a poor prognosis. While sex, age and level of severity were not significantly related to outcome, an initial diagnosis of depression was predictive of unfavourable prognosis. Only a few of these 'cases' received psychiatric specialty treatment. Some disorders in the community appear, however, to be as serious as those that come to the attention of psychiatrists.     

Attacking anxiety: a naturalistic study of a multimedia self-help program

The effects of a commercial multimedia self-help program (Attacking Anxiety) were evaluated by examining the outcome of 176 individuals who participated in the treatment. Results suggested that 62 individuals suffering from anxiety achieved clinically significant improvement. An additional 40 achieved reliable change, despite the fact that these individuals had suffered from anxiety-based problems for years prior to their participation. Only one participant experienced negative change. These results are discussed in relation to the growing literature on self-help interventions and the limitations imposed by the naturalistic nature of the investigation.     

Pilot early intervention antenatal group program for pregnant women with anxiety and depression

This study aims to examine the acceptability and effectiveness of an antenatal group intervention designed to reduce the severity of depression and anxiety symptoms and improve maternal attachment in pregnant women with current or emerging depression and anxiety. Women who participated in the program completed pre- and posttreatment measures of depression (Centre of Epidemiological Studies Depression Scale) and Edinburgh Postnatal Depression Scale), anxiety (State-Trait Anxiety Inventory) and maternal attachment (Condon Maternal Antenatal Attachment Scale). Participants also completed a satisfaction questionnaire and provided general feedback about the group intervention and experience. A total of 48 women (M?=?26 weeks of gestation) commenced and 37 (77 %) completed at least 80 % of the six session group intervention. Significant improvements with moderate to large effect sizes were observed for depression as measured on the Centre of Epidemiological Studies Depression Scale (CES-D) (p?p?p?p?=?0.006). Improvements in posttreatment depression scores on the EPDS were maintained at 2 months postpartum. Participants reported that the program had met their expectations. Partners (n?=?21) who completed evaluation forms indicated that their attendance had improved their awareness of their partner’s mental health issues and resources available to their family and would recommend the program to other fathers. These preliminary findings suggest that our antenatal group program is an effective and acceptable intervention for a clinical sample of women and partners. It is a feasible addition or alternative treatment option to perinatal mental health care. Future directions could involve more comprehensive randomised controlled trials (RCT) to examine the effectiveness of the group intervention.     

Self help programme for anxiety in general practice: controlled trial of an anxiety management booklet.

Behavioural methods of treating anxiety have been shown to be highly effective but are not widely available in general practice where most people suffering from anxiety are treated. This study reports a development in service delivery which is simple, inexpensive and does not make great time demands on general practitioners or require them to extend their training and expertise. The study shows that for patients suffering from panic disorder or generalized anxiety disorder the use of an anxiety management booklet in addition to their usual treatment from their general practitioner produces clinically and statistically significant improvements. Of particular importance is the speed of response to the booklet. Within the first two weeks those patients who received the booklet were significantly less anxious than the controls. The booklet was acceptable to patients and recommendations are made about how to incorporate it into clinical practice.     

The virtual anatomy practical: A stereoscopic 3D interactive multimedia computer examination program

Continuing advances in computer visualization and interface technologies have enabled development of “virtual reality” programs that allow users to perceive and to interact with objects in artificial three-dimensional environments. Such technologies were used to create an image database and program for administering a practical examination in human gross anatomy. Stereoscopic image pairs of prepared laboratory dissections were digitized from multiple views of the thorax, abdomen, pelvic region, and upper and lower extremities. For each view, the stereo pairs were interlaced into a single, field-sequential stereoscopic picture using an image processing program. The resulting color-corrected, interlaced image files were organized in a database stored on a large-capacity hard disk. Selected views were provided with structural identification pointers and letters (A and B). For each view, appropriate two-part examination questions were spoken by a human narrator, digitally recorded, and saved as universal audio format files on the archival hard disk. Images and digital narration were organized in an interactive multimedia program created with a high-level multimedia authoring system. At run-time, 24-bit color 3D images were displayed on a large-screen computer monitor and observed through liquid crystal shutter goggles. A 90-second interval timer and tone were provided to give student users a time limit for each question comparable to that of a conventional practical examination. Users could control the program and select regional “subexams” using a mouse and cursor to point-and-click on screen-level control words (“buttons”). Clin. Anat. 11:89–94, 1998. © 1998 Wiley-Liss, Inc.     

A cognitive-behavioural program for adolescents with chronic pain-a pilot study

The purpose of this pilot study is to evaluate the feasibility of a cognitive-behavioural training program for adolescents with chronic pain irrespective of pain localisation. A secondary aim was to give an impression of the effect of the program on pain and quality of life. Eight adolescents (14-18 years) with chronic non-organic pain recruited from the general population (and their parents) participated in this pilot study. The intervention included five group meetings alternated with four telephone contacts (during the self-management weeks) over a period of 9 weeks. The training aimed to change pain behaviour through pain education, relaxation strategies, problem-solving techniques, assertiveness training, cognitive restructuring and by stimulating the adolescent's physical activity level. The training further addresses the social context of pain by inviting parents to attend two meetings for the parents only, and by asking the adolescents to bring a peer to one of the meetings. Adolescents and their parents were positive about the program. Adolescents felt they were more in control of their pain and parents valued the support they experienced in helping their children to master the pain. The training was considered to be feasible in daily life. Further, the preliminary data showed an effect on pain and quality of life in the expected direction. The results underline the need for a definitive study with a larger sample size and a random controlled design.     

Self-help materials for anxiety: a randomized controlled trial in general practice.

The efficacy of a self-help package in treating chronic anxiety was evaluated in a randomized controlled trial in which the intervention group received self-help materials in the form of an audiotape and booklet, in addition to their current treatment. The intervention was successful in terms of mean depression scores (P = 0.01), anxiety scores (P = 0.04) and general health questionnaire scores (P = 0.02) which were significantly lower for the intervention group than for the controls. In addition, the depression scores fell faster for the intervention group than for the controls. The overall mean reduction in three months in adjusted depression scores was approximately two points greater for the intervention group than for the controls (P = 0.02). Clinicians welcomed the package as a valuable addition to the therapies available for managing chronic anxiety problems. Further studies should include larger sample sizes, taking into account the non-response to postal questionnaires over time.     

The severity of depression in patients treated in general practice

The severity of depression, the presence and intensity of suicidal feelings, and the outcome of depressive illness treated in general practice were studied. The results suggest that a consideration of the relatively good outcome at 16 to 18 weeks alone is misleading. At least one in six new patients is suffering from a depression of moderately severe intensity and a similar proportion experience suicidal ideas that are persistent and require active rejection. A sample of patients with chronic depression had only a slightly smaller morbidity. The presence of moderately severe symptoms of depression in both groups of patients has important implications for treatment.     

Prevalence of depression and its correlates in a general medical practice

A screening scale for depression, based on HSCL depression scale items, was used during a one-year period in a rural general medical practice. The estimated prevalence of depression was 8.8% for severe (probable depressive disorder) depression, 18.3% for moderate (depressive syndrome) depression, and 28.3% for mild depression. For all three levels of depression, there were significant relationships to sex and to marital status. For the higher level of depression, probable depressive disorder, there were significant relationships to age and to retirement status; these relationships were not evident at the moderate or the mild levels of depression.