Treatment delivery and guidelines in primary care

Conceptualizations of postpartum depression by public-sector health care providers in Mexico

In this article we describe the knowledge frameworks that 61 physicians, nurses, social workers, and psychologists from five public-sector health care facilities in Mexico used to conceptualize postpartum depression. We also demonstrate how providers applied social and behavioral antecedents in their conceptualizations of postpartum depression. Using grounded theory, we identify two frameworks that providers used to conceptualize postpartum depression: biochemical and adjustment. We highlight an emerging model of the function of social and behavioral antecedents within the frameworks, as well as the representation of postpartum depression by symptoms of distress and the perception among providers that these symptoms affected responsibilities associated with motherhood. The results provide a foundation for future study of how providers' conceptualizations of postpartum depression might affect detection and treatment practices and might be useful in the development of training materials to enhance the quality of care for women who experience any form of distress in the postpartum period.

Efficacy and acceptability of pharmacological treatments for depressive disorders in primary care: systematic review and network meta-analysis

PURPOSE

The purpose of this study was to investigate whether antidepressants are more effective than placebo in the primary care setting, and whether there are differences between substance classes regarding efficacy and acceptability.

METHODS

We conducted literature searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO up to December 2013. Randomized trials in depressed adults treated by primary care physicians were included in the review. We performed both conventional pairwise meta-analysis and network meta-analysis combining direct and indirect evidence. Main outcome measures were response and study discontinuation due to adverse effects.

RESULTS

A total of 66 studies with 15,161 patients met the inclusion criteria. In network meta-analysis, tricyclic and tetracyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), a serotonin-noradrenaline reuptake inhibitor (SNRI; venlafaxine), a low-dose serotonin antagonist and reuptake inhibitor (SARI; trazodone) and hypericum extracts were found to be significantly superior to placebo, with estimated odds ratios between 1.69 and 2.03. There were no statistically significant differences between these drug classes. Reversible inhibitors of monoaminoxidase A (rMAO-As) and hypericum extracts were associated with significantly fewer dropouts because of adverse effects compared with TCAs, SSRIs, the SNRI, a noradrenaline reuptake inhibitor (NRI), and noradrenergic and specific serotonergic antidepressant agents (NaSSAs).

CONCLUSIONS

Compared with other drugs, TCAs and SSRIs have the most solid evidence base for being effective in the primary care setting, but the effect size compared with placebo is relatively small. Further agents (hypericum, rMAO-As, SNRI, NRI, NaSSAs, SARI) showed some positive results, but limitations of the currently available evidence makes a clear recommendation on their place in clinical practice difficult.

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

BACKGROUND

Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment.

AIM

The study sought to understand conversational influences on physician decision making about treatment for depression.

DESIGN

A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication.

METHOD

The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.

RESULTS

Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.

CONCLUSION

Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the 'action' in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients' views and preferences.

Identification and recognition of depression in community care assessments: impact of a national policy in England

BACKGROUND

Depression continues to be under-recognized in older people. Most policies addressing this issue focus on the primary health care team. However, recognition may be improved by use of assessment tools and collaboration between secondary health and social care, particularly at the assessment stage. This study aimed to evaluate whether the Single Assessment Process (SAP), introduced in England from April 2004, promoting such processes, improved the identification and correct recognition of depression by enhancing the content of statutory community care assessments by social services care managers.

METHODS

An observational study compared depression identification and its accuracy ("correct recognition") in samples of older people before and after SAP introduction. Participants were interviewed using standardized measures including the Geriatric Depression Scale (GDS). Depression elicited from the GDS was compared with that recorded in community care assessments with calculation of inter-rater reliabilities (kappa statistic) pre- and post-SAP. Logistic regression examined the associations between the policy's introduction, potential confounding factors (depression, cognitive impairment, function, behavior and characteristics) and the identification and correct recognition of depression.

RESULTS

Whilst the identification of depression was more likely after SAP, its correct recognition did not improve after the policy, with only slight agreement between GDS and community care assessments. The existence of depression and cognitive impairment made identification, but not correct recognition, more likely.

CONCLUSIONS

Correct recognition of depression was not improved in these statutory care assessments following the policy. Recognizing and thus responding to depression in a coordinated and appropriate way in the community requires further action.

Is major depression adequately diagnosed and treated by general practitioners? Results from an epidemiological study

OBJECTIVES

The aim of this study was to (1) to explore the validity of the depression diagnosis made by the general practitioner (GP) and factors associated with it, (2) to estimate rates of treatment adequacy for depression and factors associated with it and (3) to study how rates of treatment adequacy vary when using different assessment methods and criteria.

METHODS

Epidemiological survey carried out in 77 primary care centres representative of Catalonia. A total of 3815 patients were assessed.

RESULTS

GPs identified 69 out of the 339 individuals who were diagnosed with a major depressive episode according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (sensitivity 0.22; kappa value: 0.16). The presence of emotional problems as the patients' primary complaint was associated with an increased probability of recognition. Rates of adequacy differed according to criteria: in the cases detected with the SCID-I interview, adequacy was 39.35% when using only patient self-reported data and 54.91% when taking into account data from the clinical chart. Rates of adequacy were higher when assessing adequacy among those considered depressed by the GP.

CONCLUSION

GPs adequately treat most of those whom they consider to be depressed. However, they fail to recognise depressed patients when compared to a psychiatric gold standard. Rates of treatment adequacy varied widely depending on the method used to assess them.

The treatment of common mental health problems in general practice

BACKGROUND

Previous studies report GPs under-treat mental health disorders, particularly depression, and treatments are non-specific and lack an evidence base. They conclude further training and education of GP's is required.

OBJECTIVE

To describe the treatment of common mental health disorders in relation to the level and severity of psychological problems as defined by the GP and external assessment.

METHODS

Cross sectional survey of General Practice attenders in New Zealand. Fifty consecutive adult patients were recruited from each practice of 70 randomly selected GP's. The psychological status of 773 respondents selected via the General Health Questionnaire (GHQ) was assessed, and details of management provided. Management options were compared with the level of psychological problem identified by the GP.

RESULTS

Treatment varied depending on the level of problem identification, and frequency of consultation, from 93% given treatment when an explicit diagnosis was made to 22.3% in patients with subclinical symptoms. The most commonly given treatment with an explicit diagnosis was psychotropic medication [73% (95% CI 63.6-82.9)] while for those patients with subclinical symptoms the most common form of treatment was discussion and counselling [15.7% (7.1-24.2)]. Only 1.7% (0.3-3.0) of patients with subclinical symptoms received psychotropics.

CONCLUSION

There is a clear association between the level of psychological problem identified and treatment. In contrast to previous views that treatment often appears to be given regardless of diagnosis, these results provide a picture of general practice management of common mental disorders more in line with evidence-based practice than previously described.

Challenges in the treatment of anxiety disorders: beyond guidelines

Anxiety disorders are highly prevalent, come in many forms and are often chronic, with many patients requiring long-term maintenance therapy. Anxiety and depression may also be comorbid in up to 50% of patients, leading to problems during diagnosis and treatment. Despite their frequency, the recognition and treatment of anxiety disorders is frequently suboptimal, with as few as 15% of patients obtaining treatment consistent with evidence-based care recommendations. Current treatment guidelines for anxiety disorders include a range of pharmacological and non-pharmacological approaches. However, the use of these guidelines alone may not be sufficient to improve patient outcomes. Optimal treatments for anxiety should be based on chronic disease management and balance efficacy with long-term tolerability. Current first-line therapies should include broad-spectrum agents that have proven efficacy in treating both anxiety and depression and are effective across all treatment phases. The allosteric serotonin reuptake inhibitor (ASRI), escitalopram, is a particularly effective treatment, offering high rates of remission combined with relatively low rates of discontinuation due to adverse events. Combination therapy involving medication and psychological approaches, e.g., cognitive behavioral therapy, may also be helpful. Novel approaches to delivering psychotherapy and self-management via the Internet may address accessibility issues for evidence-based psychological treatments.

Women's and doctors' accounts of their experiences of depression in primary care: the influence of social and moral reasoning on patients' and doctors' decisions

BACKGROUND

Little is known about how general practitioners (GPs) manage depression within everyday clinical practice, particularly in relation to the issue of 'problem definition'. In addition, there has been relatively little research on the patients' perspective of depression and its management in primary care.

METHODS

Qualitative interviews explored women's and GPs' experiences of recognizing depression and their experiences of the management of depression. Thirty-seven women and 20 GPs were recruited from practices in four National Health Service Board areas of Scotland. Each participant was interviewed at the start of the study, and 30 women and 19 GPs were revisited approximately 9-12 months later so that the process of care could be reviewed.

RESULTS

The findings demonstrate the social and moral reasoning that lies behind women's decisions to seek help and to subsequently accept their GPs' explanation and advice, and that the acceptance of antidepressants created a moral dilemma for the women. For GPs, the diagnosis and management of depression led to contemplating the boundaries of their professional role, and social and moral reasoning was also evident in their decision-making processes.

DISCUSSION

The implication is that, for the majority of women, a chronic-disease model for the management for depression in primary care would be likely to increase rather than reduce the moral dilemma. In addition, the management of depression is not solely based on clinical decisions, so the applicability of a chronic-disease model to primary care requires further consideration.

Physicians' constructions of depression: inside/outside the boundaries of medicalization

A qualitative study explored primary care physicians' experiences of diagnosing and treating depression. Twenty physicians participated in semi-structured interviews. Interview questions asked physicians to consider a range of topics such as the etiology of depression, the diagnostic process and treatment of depression. Transcripts were analyzed discursively with a view to exploring the ways in which physicians construct depression. In this article, physicians' constructions of depression are examined through exploration of their descriptions of this condition, as well as their recognition of the social context of depression. Based on this analysis, it was concluded that physicians' medicalized understandings of depression conflict with recognition of the social context of depression. The result of this conflict is dissonant descriptions of depression. One implication of this research is that physicians' training would benefit from the integration of multidisciplinary perspectives on depression, which would better reflect physicians' experiences in routine practice situations.

Improving the quality of mental health services in Personal Medical Services pilots: a longitudinal qualitative study

BACKGROUND

A series of government initiatives in the UK have included strategies to improve the quality of services received by patients, including fundholding, the development of National Service Frameworks, clinical governance, and Personal Medical Services (PMS). PMS represents a new contractual arrangement between government and general practitioners (GPs) which provides new investment in return for more detailed specification of processes and outcomes of care.

OBJECTIVES

To evaluate the effects of PMS on the quality of primary mental health care between 1998 and 2001.

DESIGN

Multiple longitudinal case studies. Semi-structured interviews with key staff within practices (GPs, nurses, practice managers) and outside (health authority and primary care group/trust managers).

SAMPLE

Six first wave PMS sites which had specifically planned to improve their mental health care.

RESULTS

Improvements in mental health care were found in some PMS practices and not in others. Five mechanisms associated with successful quality improvement in mental health were identified: clear goals, effective teamwork within the practice, routine use of protocols and audits, additional resources, and effective collaboration with community and secondary care. Sites where these factors were not present struggled to meet their objectives.

CONCLUSION

The five mechanisms which resulted in improved mental health care were facilitated by the new contractual arrangements in PMS. The new contracts were not a necessary part of these changes, but they enabled sites with an identified interest and motivation to make the changes. The contractual changes were not in themselves sufficient to improve care.

The Impact of Clinical Guidelines on Surgical Management in Patients with Thyroid Cancer

AIMS

Thyroid cancer is an uncommon but highly curable disease if treated optimally. The aim of this study was to determine whether clinical guidelines introduced locally at the beginning of 1999 were associated with better surgical outcome, using radioiodine uptake as a surrogate measure of completeness of thyroidectomy.

MATERIALS AND METHODS

We reviewed the medical records of all patients with thyroid cancer referred to a cancer centre (n=176) 3 years before and 3 years after the introduction of guidelines. The uptake of radioiodine in the thyroid bed after thyroidectomy and before radioiodine ablation was used to assess the completeness of primary surgical treatment.

RESULTS

The number of new cases referred to our centre increased from 80 in the 1996-1998 period to 94 during 1999-2001. This was largely because of an excess of papillary thyroid cancers. Documentation in the medical records of the pathological primary tumour size improved from 47.5% to 80.8% following the introduction of guidelines. A significant reduction in radioiodine uptake in the thyroid bed was observed following the introduction of guidelines (5.03% +/- 6.82 (SD) vs 2.75% +/- 5.10 (SD); P=0.005). Linear regression analysis of clinical variables indicated that the year of surgery was the only significant factor influencing radioiodine uptake in the thyroid bed (P=0.014). Twelve hospitals within the Northern Cancer Network carried out thyroid surgery for thyroid cancer in the pre-guideline era compared with seven hospitals in the post-guideline era. Surgeons who were members of the regional multidisciplinary thyroid cancer team operated on 35% of cases in the 1996-1998 period and 56.4% in the 1999-2001 period (P<0.01).

CONCLUSIONS

The introduction of clinical guidelines in 1999 was associated with a reduction in the size of thyroid remnant after primary surgical treatment. This was accompanied by fewer hospitals undertaking thyroid surgery and more patients being operated on by surgeons who were members of the thyroid cancer multidisciplinary team.

Improving the detection and management of depression in primary care

The effectiveness of screening and organisational strategies to improve the recognition and management of depression in primary care published in a recent issue of Effective Health Care is reviewed.