Variations in the diagnosis of psychosocial disorders: a general practice observation study

Anxiety and depressive symptoms among adults with obesity and chronic pain: the role of anxiety sensitivity

Obesity and chronic pain frequently co-occur, and this co-occurrence can have potential negative consequences, particularly as it relates to mental health. As such, there is a need to understand potential risk factors for poor mental health among this co-morbid population. Thus, the current study examined the predictive role of anxiety sensitivity (and its sub-facets) on anxiety and depressive symptoms among adults (82.5% female, M_age = 40.2 years, SD = 10.92) with obesity and chronic pain. Results revealed that greater levels of anxiety sensitivity were associated with greater levels of both anxiety and depressive symptoms, with medium to large effect sizes. Post hoc analyses also indicated that specific sub-facets of anxiety sensitivity (cognitive and social concerns) were significant predictors of the criterion variables. The current study highlights the potential clinical utility in targeting anxiety sensitivity among individuals with co-occurring obesity and chronic pain in the treatment of anxiety and depressive symptoms.

Working in social prescribing services: a qualitative study

Purpose

Social prescribing (SP) is an emerging area of public health that has the potential to alleviate pressure on primary care by offering non-clinical solutions to health problems. Whilst there is an increasing body of literature exploring service design and impact, there is little research that focuses specifically on the SP workforce. The purpose of this paper is to explore routes into SP, worker’s experiences of the sector and potential career progression.

Design/methodology/approach

For this qualitative study, semi-structured interviews were conducted with eight members of the SP workforce with varying levels of responsibility from within six different organisations in an urban/suburban area of South West England. Interviews were analysed using thematic analysis.

Findings

Pathways into the sector were varied, and those without direct experience often brought transferable skills from other professions. Careers in SP were clearly rewarding, and some providers had established good support structures for staff. However, some participants were in need of additional training in areas such as collaborative working and staff management. Staff working at a more senior level – particularly in community-based organisations – seemed less well supported overall, with limited career progression. Staff in such organisations also reported working beyond contractual hours.

Originality/value

This study has revealed inconsistencies between the experiences of staff in some community organisations vs those associated with larger, more established services. It has also highlighted a need for further training and capacity building in some areas. These findings may be of interest to those commissioning or funding SP services in the future.

Nature of the Medical Encounter

The medical interview has become an increasingly important diagnostic and therapeutic tool in the era of managed care. This article reviews the current literature on the relationship between specific interviewing skills and outcomes of care. In the context of three clinical vignettes, these results are discussed in relationship to interviewing geriatric patients.

Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies

OBJECTIVE

To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants.

METHODS

A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search.

RESULTS

Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour.

CONCLUSIONS

Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed.

PRACTICE IMPLICATIONS

Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part I: the GP perspective

OBJECTIVES

This study aimed to describe social problems presented to general practitioners (GPs) in UK inner cities and GPs' responses; describe patients' help-seeking pathways; and consider how these pathways can be improved.

METHODS

The study involved a pilot survey and follow-up qualitative interviews with patients in two inner city areas in London and Salford in 2001-2. The pilot survey involved five practices in each locality. GPs completed questionnaires on 57 people presenting with social problems. A diversity sample of 12 patients were followed up for interview.

RESULTS

Study results are presented in two parts. This paper focuses on the GP survey results. People were presenting with a wide range of social problems, and multiple problems were also common. Problems with welfare benefits and housing were the most common, but GPs were most likely to refer to counselling services and to a lesser extent to generic advice services. Some GPs would have preferred to refer patients to more problem-specific services but did not believe these were available.

CONCLUSIONS

The study highlights the role GPs play in helping people deal with social problems but also identifies limitations in their response to these problems. It points to the need for more integrated pathways to help and advice for social problems. Primary care can make existing pathways more visible and accessible, and create new pathways through, for example, the new commissioning role and extending the scope of social prescribing.

Factors associated with identification and management of maternal depression by pediatricians

OBJECTIVE

We sought to identify characteristics of pediatricians that were associated with identification or management (referral and/or treatment) of mothers with depression.

METHODS

A cross-sectional survey was mailed to a random sample of 1600 of the 50,818 US nonretired members of the American Academy of Pediatrics. Overall, 832 responded, with 745 responses from nontrainee members. The 662 fellow nontrainee members who engaged in direct patient care and completed information on identifying, referring, and treating maternal depression were included in the analyses.

RESULTS

A total of 511 of 662 respondents reported identifying maternal depression; of those who reported identifying maternal depression, 421 indicated they referred and 29 that they treated maternal depression in their practices. Pediatricians who are older, work in practices that provide child mental health services, see primarily (> or = 75%) white patients, use > or = 1 method to address maternal depression, agree that pediatricians should be responsible for identifying maternal depression, think that maternal depression has an extreme effect on children's mental health, and are attitudinally more inclined to identify or manage maternal depression had significantly higher odds of reporting identification of maternal depression. Positive correlates of identification and management of maternal depression included practicing in the Midwest, using > or = 1 method to address maternal depression, working in a practice that provides child mental health services, thinking that caregiving problems attributable to maternal health have an extreme effect on children's physical health, having attitudes that are more inclined to identify and to manage maternal depression, and usually inquiring about symptoms routinely to identify maternal depression.

CONCLUSIONS

Pediatricians' practice characteristics and attitudes are associated with their identification and management of mothers with depression.

Do pediatricians recognize mothers with depressive symptoms?

OBJECTIVE

To determine whether pediatric health care providers recognize maternal depressive symptoms and to explore whether maternal, provider, and visit characteristics affect pediatric providers' ability to recognize inner-city mothers with depressive symptoms.

DESIGN

A cross-sectional study was conducted at a hospital-based, inner-city, general pediatric clinic. Two groups of participants completed questionnaires, each unaware of the other's responses: 1) mothers who brought their children ages 6 months to 3 years for health care maintenance or a minor acute illness and 2) pediatric health care providers (attending pediatricians, pediatric trainees, and nurse practitioners). The mothers' questionnaire consisted of sociodemographic items and a self-administered assessment of depressive symptoms using the Psychiatric Symptom Index (PSI). Pediatric providers assessed child, maternal, and family functioning and documented maternal depressive symptoms. Criteria for positive identification of a mother by the pediatric health care provider were met if the provider reported one or more maternal symptoms (from a 10-item list of depressive symptoms), a rating of 4 or less on a scale of functioning, a yes response to the question of whether the mother was acting depressed, or a response that the mother was somewhat to very likely to receive a diagnosis of depression.

RESULTS

Of 338 mothers who completed the questionnaire, 214 (63%) were assessed by 1 of 60 pediatric providers. Seventy-seven percent of surveys were completed by the child's designated pediatric provider. The mean visit length was 23 minutes. Mothers primarily were single, were black or Hispanic, and had a mean age of 26 years (15-45 years). Almost 25% of mothers were living alone with their children. Eighty-six (40%) mothers scored >/=20 on the PSI, representing high symptom levels. Of these, 25 were identified by pediatric providers (sensitivity = 29%). A total of 104 of 128 mothers with a PSI score <20 were identified as such by providers (specificity = 81%). Pediatric providers were more likely to identify mothers who were <30 years old, living alone, and on public assistance. Also, mothers who were assessed by the child's own primary provider or by an attending pediatrician were more likely to be identified accurately than were mothers whose children were seen by a pediatric trainee or a nurse practitioner.

CONCLUSIONS

Pediatric health care providers did not recognize most mothers with high levels of self-reported depressive symptoms. Pediatricians may benefit from asking directly about maternal functioning or by using a structured screening tool to identify mothers who are at risk for developing depressive symptoms. In addition, training pediatric providers to identify mothers with depressive symptoms may be beneficial.

Management of somatisers in primary care: are family doctors motivated?

OBJECTIVE

The aim of this paper is to assess the attitudes of Spanish general practitioners towards somatisers and the degree of involvement that family doctors are ready to adopt in the care of these patients.

METHOD

A postal questionnaire on attitudes was sent to a representative sample (n = 135) of general practitioners from two health districts of the region of Aragon. Seventy (51.8%) of them returned usable questionnaires.

RESULTS

Most of the general practitioners were interested in the treatment of somatisers and considered that they should be treated at primary care level. However, when specific treatment tasks were proposed, they only accepted to act as a filter to specialised care and to care for patients with chronic functional syndromes. Additionally, they refuse to detect presenting somatisers, to prescribe psychotropic drugs or offer any psychological approach, and to avoid reinforcing abnormal illness behaviour in these patients and their families. These findings can be explained because the main emotions somatisers produce in doctors are frustration and anger.

CONCLUSIONS

Family doctors need a lot more help, education and support in the management of somatisers, and psychiatrists need to provide it. Any management program for the treatment of somatisers in primary care should include methods to modify general practitioners' attitudes towards these patients.

What does treatment of depression really cost?

This DataWatch presents estimates of the health care charges for adults who are diagnosed and treated for depression in primary care. More than nine out of ten of these adults sought care for at least one nondepressive illness during the year following treatment initiation. One average, these conditions accounted for more than 70 percent of the total charges. Attempts to manage the costs of caring for depressed persons must consider the impact of nondepressive illness.

Communication in general practice: recognition and treatment of mental illness

From previous studies there is a lot of evidence that in primary care settings, many patients tend to express their mental problems in terms of physical symptoms. Therefore, the general practitioner (GP) needs to recognize mental problems at an early stage. Early recognition allows for adequate treatment that might speed up recovery. The present article reports on a study exploring the GP's ability to recognize mental illness, the communication style that is supposed to support this ability, the subsequent treatment of mental problems, and the patient's recovery. Two databases were used. First, an observation study, involving 351 videotaped consultations held by 15 GPs, yielded information on communication style and recognition abilities. Patients in this study were selected randomly. The second database obtained treatment data and measures of patient recovery from a 1-year follow-up study dealing with the treatment and course of mental illness. Patients in this study were selected because their GPs considered their problems "mainly psychosocial by nature". Half of them were categorized within psychological and social diagnostic categories of the International Classification for Primary Care (ICPC), the other half were categorized within physical disease categories, with an assessment by the GP that the complaints were mainly psychosocial. Results showed no significant relationships between the recognition of mental illness and nine communication features supposed to induce these abilities. There was a tendency however, for a positive association between recommended communicative behaviour of the GP and his or her tendency to give frequently psychosocial evaluations of the patient's complaints. Also, there was a negative tendency between this recommended behaviour and the degree of agreement between the GP's evaluation and the score on a psychiatric screening questionnaire. This agreement is called "accuracy". Frequent psychosocial evaluations were related to exploring behaviour and mental health referral in case of psychosocial complaints. Further, relationships between the GPs' recognition ability and various measures of patients' recovery did not prove univocal. Both positive, negative and absent relationships were found.

Doctor-patient communication and the quality of care

In this article a comparison is made between three independent sources of assessment of medical consultations. A panel of 12 experienced general practitioners rated 103 consultations with hypertensive patients on the quality of psychosocial care. There was a wide consensus between the judges, resulting in a high reliability score. Two contrasting groups were formed: consultations that were rated high and those rated low in quality of psychosocial care. A comparison was made between this general assessment of the quality of psychosocial care and a more detailed assessment of the same consultations on nine much used communication variables made by trained psychologists. Knowledge about doctor-patient communication proved to predict very well as to which quality group the consultations belonged. A very high percentage (95%) was predicted accurately, solely on the basis of these nine communication variables. Affective behaviour, and especially nonverbal affective behaviour had the strongest predictive power. In the last part of the study a third source of assessment, i.e. patients' satisfaction was compared with both other sources. Much lower relationships were found, although most were in the predicted direction. Affective behavior seems to be the most important in determining patient's satisfaction. The implications of these findings are discussed.

Referrals to physiotherapy: the relation between the number of referrals, the indication for referral and the inclination to refer

This article studies the relation between the referral rate and the type of patients general practitioners refer for physiotherapy. The study population consists of GPs participating in the Netherlands' Sentinel Stations Network, who recorded data on all referrals to physiotherapy during one year and filled in a questionnaire. Results show that the pattern of referral indications of high referring GPs does not differ systematically from that of low referring GPs. High referring GPs evaluate their patients complaints more as purely or mainly somatic. High referring GPs were no more inclined to give in to their patients demands, had busier practices, closer relations with physiotherapists and viewed their knowledge of physiotherapy as more satisfactory than low referring GPs. Some policy implications are discussed in respect to these results.

What does a doctor do with psychosocial problems in primary care?

Though a lot has been published on the prevalence of psychosocial disorders in primary care, less is known about the actual treatment, given by primary care providers. This article describes treatment given to complaints which are considered by the physician as being psychosocial by nature. Treatment has been assessed by means of observation. A database of approximately 1500 videotaped consultations, sampled from thirty general practitioners has been used for this purpose. The possibilities and limitations of (generalist) psychosocial treatment in primary care are discussed.