Help-seeking preferences for psychological distress in primary care:: effect of current mental state

Background

There is much debate over when it is appropriate to intervene medically for psychological distress, and limited evidence on patients'' perspectives about a broad range of possible treatment options. It is currently unclear whether preferences may differ for those patients with milder symptoms compared to those experiencing more severe distress.

Aim

To determine patient preferences for professional, informal, and alternative help for psychological distress in primary care, and the impact of their current mental state on these.

Design of study

Cross-sectional survey in seven general practices across suburban/urban London.

Method

Participants were 1357 consecutive general practice attenders aged 18 years and over. The main outcome measure was the General Health Questionnaire 12-item version and a questionnaire on help-seeking preferences.

Results

Overall, only 47% of participants reported wanting ‘some help’ if feeling stressed, worried, or low and it was affecting their daily life. Those currently experiencing mild-to-moderate distress preferred informal sources of help such as friends/family support, relaxation/yoga, exercise/sport, or massage along with general advice from their GP and talking therapies. Self-help (books/leaflets or computer/internet) was not popular at any level of distress, and less favoured by those with mild-tomoderate distress (odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.35 to 0.70). Those experiencing severe distress were much more likely to want talking therapies (OR = 3.43, 95% CI = 2.85 to 4.14), tablets (OR = 3.07, 95% CI = 2.00 to 4.71), and support groups (OR = 3.07, 95% CI = 1.72 to 5.47).

Conclusion

People with mild-to-moderate distress appear to prefer informal sources of help and those involving human contact, compared to medication or self-help. This has implications for the implementation of potential interventions for psychological distress in primary care.     

Better access to psychological treatments through Medicare: Rejoinder to Carey,Rickwood and Baker

The inclusion of evidence‐based psychological interventions within Medicare through Better Access addresses an inequity within the Australian health system against people with mental disorders. The question of “Who is qualified to provide these services” is the overriding focus of many commentaries on Better Access within psychology. Carey et al. (2009) argue for examination of the Medicare data to answer this question. We show that Carey et al. (2009) fail to clarify if and how the Medicare data could be used to answer the questions they put and that the reasons for the current eligibility requirements within the Medicare Benefits Schedule are transparent, justifiable and responsible. The preoccupation with within‐profession distinctions is counterproductive because it distracts from a proper examination of the impact of Better Access on mental health care in Australia. Research dollars need to be directed to questions that most directly affect the quality of care, such as how can interventions under Better Access be delivered appropriately according to best practice, improve access and equity for everyone and be most cost efficient? Given the current policy agenda in primary care favouring integrated, multidisciplinary models of care, these questions are the critical ones for the future direction of Better Access.     

Connected care in a fragmented world: lessons from rural health care.

This paper uses the phenomenon of very high satisfaction with remote rural health services in Scotland as a trigger for exploring what consumers want and like in health service utilisation - and why. It draws on the business literature in customer services marketing and economic sociology to illuminate why long-term associations between consumers and providers in health care are important and beneficial. In doing so, it highlights wider lessons about the experience of good health care to be learned from the satisfaction expressed by rural residents and suggests, as health services become increasingly fragmented, the relevance of maintaining a connected experience for patients.     

Context factors in consultations of general practitioner trainees and their impact on communication assessment in the authentic setting

Objective

Acquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance.

Methods

In a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed.

Results

All previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57).

Conclusions

GP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way.

Practice implications

GP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments.     

Context factors in consultations of general practitioner trainees and their impact on communication assessment in the authentic setting

ObjectiveAcquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance.MethodsIn a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed.ResultsAll previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57).ConclusionsGP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way.Practice implicationsGP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments.     

Interpersonal continuity of care: a cross-sectional survey of primary care patients'' preferences and their experiences

BACKGROUND: Developments in primary care may make the provision of interpersonal continuity more difficult. AIM: To identify those patients who regard interpersonal continuity as important and determine what makes it difficult for them to obtain this. Design of study: Cross sectional survey. SETTING: Twenty-two practices and a walk-in centre in West London and Leicestershire, UK. METHOD: Administration of a questionnaire on preferences for and experiences of interpersonal and informational continuity. Interpersonal continuity was defined in three questions: choosing a particular person; choosing someone known and trusted; and choosing someone who knows the patient and medical condition. RESULTS: One thousand four hundred and thirty-seven (46.5%) patients responded. Consulting someone known and trusted was important to 766 (62.6%) responders, although 105 (13.7%) of these reported that they had not experienced it at their last consultation. Seven hundred and eighty-eight (65.2%) responders regarded being able to consult a particular person as important, but 168 (21.3%) of these were unable to. Being in work and consulting for a new problem were associated with failing to obtain interpersonal continuity. Ethnic group was associated with failing to see someone with time to listen when this was preferred. CONCLUSION: In view of the response rate, which was particularly low among young males, some caution is required in applying the findings. Most patients experience the aspects of care important to them, although interpersonal continuity is important to many and certain groups find difficulty in obtaining it. Practices should have flexible appointment systems to account for the difficulties some patients have in negotiating for the type of care they want.     

A systematic review of the relationship between psychological disorders or substance use and self-reported cognitive failures

Introduction: Cognitive failures are errors in normal everyday functioning. Individuals with psychological disorders may possess heightened vulnerability. We sought to review the literature on cognitive failures in psychological disorders to determine the nature of this association, and whether failures relate to neuropsychological performance. We also examine the relationship between cognitive failures and substance use since it is relevant to everyday cognition and co-occurs in many psychological disorders.

Methods: We conducted a systematic review of self-reported cognitive failures in psychological disorders and substance use, identifying 21 papers in total.

Results: Papers identified studied trauma, mood, and anxiety disorders, and schizophrenia. Substance use papers included nicotine, alcohol, cannabis, and ecstasy use. Cognitive failures were increased in some but not all papers; the most consistent findings were for depression, PTSD, and daily smokers of nicotine. Subjective failures did not correlate closely with neuropsychological outcomes in any disorders. We were unable to discern distinct profiles of failures for each disorder; rather they may reflect emotional dysregulation more broadly.

Conclusions: The real world cognitive experiences of people with psychological disorders may differ to their performance in the clinic or lab. It is important that self-reports of minor cognitive issues are considered as both a potential risk and a maintaining factor of illness. Substance use also needs to be considered in assessing cognitive failures.     

Past experience, ‘shadow of the future’, and patient trust: a cross-sectional survey

Recent changes to the organisation and delivery of primary care in the UK have the potential to reduce continuity of care markedly, but it is not clear how this will have an impact on patient trust. This study aims to test the associations between specific aspects of continuity in the GP–patient relationship, and patient trust, informed by the theoretical framework of behavioural game theory. A cross-sectional survey of patients in three Leicestershire general practices was conducted. Regression analysis showed that ratings of the GP''s interpersonal care, past experience of cooperation, and expectation of continuing care from the GP were all independent predictors of patient trust. These findings highlight the value of longitudinal aspects of the GP–patient relationship.     

The effects of gender on diagnosis of psychological disturbance

This research examines the effect of patient gender on the detection of psychological disturbance. In Study 1, primary-care patients were requested to complete the General Health Questionnaire (GHQ), a measure of nonpsychiatric psychological disturbance, prior to their consultation. The patient's GHQ score was compared with physician judgments about the level of disturbance in that patient (N=1913). Although there were a similar number of GHQ high scorers among males and females, the physicians classified significantly more females than males as disturbed. The doctors classified as disturbed a larger proportion of nondisturbed women than nondisturbed men. In order to explore the behavior of recent medical graduates, Study 2 examined the detection behavior of interns in an outpatient department with 384 of their patients. The interns behaved in a similar manner to the primary-care physicians.This study was part of two large research projects, one undertaken by the Newcastle Primary Care Research Group, funded by NH & MRC, and one looking at quality of care in interns, supported by RADGAC. The principal Investigator for both studies was R.W. Sanson-Fisher, Professor of Behavioural Science in Relation to Medicine.     

The nature of informational continuity of care in general practice

Background

The availability of patient information to practitioners forms the basis of informational continuity of care. Changes in family practice that now encourage multiphysician clinics have meant that informational continuity of care has become crucial because it is likely that a patient will not continuously see the same doctor. Therefore a review of the nature of informational continuity is useful.

Aim

To answer the question ‘How is informational continuity developed in general practice?’.

Design of study

A rigorous systematic review of relevant electronic databases.

Method

Databases were searched for articles answering the research question. Articles focused on family medicine and informational continuity of care were included. Data from reviewed articles were independently extracted and reviewed by two researchers. Conceptual and evidence-based articles were included.

Results

Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review. Of these, 34 articles were included in the final systematic review. Results show that informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor–patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details.

Conclusion

These findings have implications for newer styles of primary care that may have a negative impact in the successful management of chronic illnesses in particular.     

Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study.

BACKGROUND: The Global Mental Health Assessment Tool-Primary Care Version (GMHAT/PC) has been developed to assist health professionals to make a quick and comprehensive standardised mental health assessment. It has proved to be a reliable and valid tool in a previous study involving GPs. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings. AIM: To assess the feasibility of using a computer-assisted diagnostic interview by nurses and to examine the level of agreement between the GMHAT/PC diagnosis and psychiatrists' clinical diagnosis. DESIGN OF STUDY: Cross-sectional validation study. SETTING: Primary care, general healthcare (cardiac rehabilitation clinic), and community mental healthcare settings. METHOD: A total of 215 patients between the ages of 16 and 75 years were assessed by nurses and psychiatrists in various settings: primary care centre (n = 54), cardiac rehabilitation centre (n = 98), and community mental health clinic (n = 63). The time taken for the interview, and feedback from patients and interviewers were indicators of feasibility, and the kappa coefficient (kappa), sensitivity, and specificity of the GMHAT/PC diagnosis were measures of validity. RESULTS: Mean duration of interview was under 15 minutes. The agreement between nurses' GMHAT/PC interview-based diagnosis and psychiatrists' International Classification of Diseases (ICD)-10 criteria-based clinical diagnosis was 80% (kappa = 0.76, sensitivity = 0.84, specificity = 0.92). CONCLUSION: The GMHAT/PC can assist nurses to make accurate mental health assessment and diagnosis in various healthcare settings and it is acceptable to patients.     

Impact of Advanced Access on access, workload, and continuity: controlled before-and-after and simulated-patient study.

BACKGROUND: Case studies from the US suggest that Advanced Access appointment systems lead to shorter delays for appointments, reduced workload, and increased continuity of care. AIM: To determine whether implementation of Advanced Access in general practice is associated with the above benefits in the UK. DESIGN OF STUDY: Controlled before-and-after and simulated-patient study. SETTING: Twenty-four practices that had implemented Advanced Access and 24 that had not. METHOD: Anonymous telephone calls were made monthly to request an appointment. Numbers of appointments and patients consulting were calculated from practice records. Continuity was determined from anonymised patient records. RESULTS: The wait for an appointment with any doctor was slightly shorter at Advanced Access practices than control practices (mean 1.00 day and 1.87 days respectively, adjusted difference -0.75; 95% confidence interval [CI] = -1.51 to 0.004 days). Advanced Access practices met the NHS Plan 48-hour access target on 71% of occasions and control practices on 60% of occasions (adjusted odds ratio 1.61; 95% CI = 0.78 to 3.31; P = 0.200). The number of appointments offered, and patients seen, increased at both Advanced Access and control practices over the period studied, with no evidence of differences between them. There was no difference between Advanced Access and control practices in continuity of care (adjusted difference 0.003; 95% CI = -0.07 to 0.07). CONCLUSION: Advanced Access practices provided slightly shorter waits for an appointment compared with control practices, but performance against NHS access targets was considerably poorer than officially reported for both types of practice. Advanced Access practices did not have reduced workload or increased continuity of care.     

Neurotransmitter deficits in behavioural and psychological symptoms of Alzheimer's disease

Behavioural and psychological symptoms of dementia (BPSD) occur in 50-90% of Alzheimer's disease (AD) patients. Imbalance of different neurotransmitters (acetylcholine, dopamine, noradrenaline and serotonin), involvement of specific brain regions responsible for emotional activities (parahippocampal gyrus, dorsal raphe and locus coeruleus) and cortical hypometabolism have been proposed as neurobiological substrate of BPSD. Compared to with respect to the neurochemical component, the cholinergic dysfunction seems to play a major role in contributing to BPSD occurrence. This view is also supported by the findings of recent trials with cholinesterase inhibitors, showing that these drugs are effective in controlling and/or improving BPSD, independent on effects on cognitive dysfunction. On the site of psychotropic drugs, atypical or novel antipsychotics represent the reference drugs for treating BPSD, whereas classic antipsychotic drugs for their profile and the potential side effects should be avoided.     

Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms

Background

Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component.

Purpose

We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines.

Data sources

We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites.

Study selection

Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers.

Data extraction

From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength.

Data synthesis

No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation.

Limitations

The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori.

Conclusion

Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed.     

Health characteristics and consultation patterns of people with intellectual disability: a cross-sectional database study in English general practice

Background

People with intellectual disability (ID) are a group with high levels of healthcare needs; however, comprehensive information on these needs and service use is very limited.

Aim

To describe chronic disease, comorbidity, disability, and general practice use among people with ID compared with the general population.

Design and setting

This study is a cross-sectional analysis of a primary care database including 408 English general practices in 2012.

Method

A total of 14 751 adults with ID, aged 18–84 years, were compared with 86 221 age-, sex- and practice-matched controls. Depending on the outcome, prevalence (PR), risk (RR), or odds (OR) ratios comparing patients with ID with matched controls are shown.

Results

Patients with ID had a markedly higher prevalence of recorded epilepsy (18.5%, PR 25.33, 95% confidence interval [CI] = 23.29 to 27.57), severe mental illness (8.6%, PR 9.10, 95% CI = 8.34 to 9.92), and dementia (1.1%, PR 7.52, 95% CI = 5.95 to 9.49), as well as moderately increased rates of hypothyroidism and heart failure (PR>2.0). However, recorded prevalence of ischaemic heart disease and cancer was approximately 30% lower than the general population. The average annual number of primary care consultations was 6.29 for patients with ID, compared with 3.89 for matched controls. Patients with ID were less likely to have longer doctor consultations (OR 0.73, 95% CI = 0.69 to 0.77), and had lower continuity of care with the same doctor (OR 0.77, 95% CI = 0.73 to 0.82).

Conclusion

Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use. Ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness, will help address these greater healthcare needs. Continuity of care and longer appointment times are important potential improvements in primary care.     

GPs' role in the detection of psychological problems of young people: a population-based study

Background

Among young people, about one in three females and one in five males report experiencing emotional distress but 65–95% of them do not receive help from health professionals.

Aim

To assess the differences among young people who seek help and those who do not seek help for their psychological problems, considering the frequency of consultations to their GP and their social resources.

Design of study

School survey.

Setting

Post-mandatory school.

Method

Among a Swiss national representative sample of 7429 students and apprentices (45.6% females) aged 16–20 years, 1931 young people reported needing help for a problem of depression/sadness (26%) and were included in the study. They were divided into those who sought help (n = 256) and those who did not (n = 1675), and differences between them were assessed.

Results

Only 13% of young people needing help for psychological problems consulted for that reason and this rate was positively associated with the frequency of consultations to the GP. However, 80% of young people who did not consult for psychological problems visited their GP at least once during the previous year. Being older or a student, having a higher depression score, or a history of suicide attempt were linked with a higher rate of help seeking. Moreover, confiding in adults positively influenced the rate of help seeking.

Conclusion

The large majority of young people reporting psychological problems do not seek help, although they regularly consult their GP. While young people have difficulties in tackling issues about mental health, GPs could improve the situation by systematically inquiring about this issue.     

维吾尔族女性妊娠心理精神因素对分娩方式及妊娠结局的影响

目的探讨维吾尔族女性妊娠心理因素对分娩方式及妊娠结局的影响。方法对2006年1月至2011年1月乌鲁木齐市妇幼保健院分娩的132例健康维吾尔族女性妊娠心理研究,以汉密顿焦虑量表（HAS）和抑郁量表（HDS）评定精神心理状态,（其中12例终止妊娠,仅对120例进行分析）,对所有妊娠维吾尔族女性予以产科常规指导分娩方式的选择,观察其分娩方式及妊娠结局;并按妊娠心理精神因素及分娩方式不同分出剖宫产组、顺产组、产钳助娩组;并根据妊娠结局的不同分出良好妊娠结局及不良妊娠结局。结果 120例维吾尔族妊娠女性焦虑发生率35%,抑郁发生率28.3%,焦虑并抑郁发生率16.7%。剖宫产组、产钳助娩组的焦虑及抑郁评分明显高于顺产组,而妊娠结局不良的的焦虑及抑郁评分亦明显高于妊娠结局良好的评分。结论维吾尔族妊娠妇女心理精神因素对分娩方式及妊娠结局有一定影响。