Long-term outcome of patients with neurotic illness in general practice

Characteristics of patients with neurotic disorders requiring long-term treatment: Relationship to "nervous personality" as described in Morita's Shinkeishitsu theory

Aim

Few studies have investigated the association between premorbid personality and the prognosis of neurotic disorders. The aim of this study was to investigate the relationship between the presence of a "nervous personality" described in Morita's Shinkeishitsu theory and the duration of treatment in patients with neurotic disorders.

Methods

The study included 70 patients aged ≥15 years old who first visited the Department of Psychiatry, Toho University Omori Medical Center, between January 2010 and December 2010 and were diagnosed as having neurotic disorders. The subjects' medical records over a 10-year period from 2010 until 2020 were examined retrospectively to determine the influence of the presence of a "nervous personality" in the subjects on the duration of their treatment.

Results

There were no significant differences in the basic demographic characteristics or severity of illness at the first visit between groups with and without a "nervous personality." The mean and median duration of treatment were 25 months and 5 months in the group with a "nervous personality," and 5 months and 2 months in the group without a "nervous personality," respectively. Kaplan-Meier analysis revealed a significant difference in the duration of treatment between the two groups. Multiple regression analysis performed using treatment duration as the dependent variable identified only presence of a "nervous personality" among the independent variables as a significant factor influencing the duration of treatment, with the duration of treatment being 20 months longer in the group of subjects with a "nervous personality."

Conclusion

The presence of a "nervous personality," as described in Morita's Shinkeishitsu theory, may prolong the required duration of treatment in patients with neurotic disorders.

Social integration of people with non-psychotic mental illness over the last 2 decades: the widening gap in the adult population in Belgium

PURPOSE

Social integration is poor among people with mental illness (MI). In recent decades, many countries have developed policies to address this issue. It remains unclear, however, whether their social integration has improved over time. This study aimed to assess the evolution of the social integration of adults with moderate and severe non-psychotic MI compared to the general population without MI between 1997 and 2018 in Belgium.

METHODS

Data on the general adult population were retrieved from the Belgian Health Interview Survey in six cross-sectional waves from 1997 to 2018. Three degrees of non-psychotic MI severity were compared using the 12-items General Health Questionnaire: no MI, moderate MI, and severe MI (score < 4, 4-7, and > 7). Social integration was measured using indicators relating to employment, income, social contacts, and partnership.

RESULTS

Since 1997, the probability of being unemployed, having limited social contacts, and living on less than 60% of the median national income has been increasing among people with severe non-psychotic MI. Between 1997 and 2018, social integration increased among the general population without MI and among people with moderate non-psychotic MI, but decreased among people with severe non-psychotic MI.

CONCLUSION

The gap between the social integration of people with severe non-psychotic MI and people with moderate or no MI has widened over time, despite major reforms of mental health care and policies. Policymakers and clinical practitioners should pay more attention to supporting the social integration of people with more severe MI, particularly in relation to employability and social support.

Use of general practice services 5 years after an episode of mental illness: case-control study using electronic records

BACKGROUND

Depression, anxiety, and emotional distress occur frequently and are usually treated in general practice. Little has been reported about the long-term course of these conditions and the long-term use of medical services.

AIM

To follow up patients with depression, anxiety, and emotional distress in general practice for 5 years and examine the length and number of index episodes, prescribing behaviour, and the use of services in general practice.

DESIGN AND SETTING

A case-control study using data from electronic medical records.

METHOD

Three cohorts of patients with depression (n = 453), anxiety (n = 442), and emotional distress (n = 185) were compared against a cohort of control patients (n = 4156) during a 5-year follow-up from 2007 to 2011. The occurrence or recurrence of the index disorders, other psychological disorders or medical conditions, the numbers of prescriptions, and the number of contacts with the general practice were all examined.

RESULTS

Patients in the depression group had 1.1 followup episodes of depression, those in the anxiety group had 0.9 follow-up episodes of anxiety, and those in the emotional distress group had 0.5 follow-up episodes of emotional distress during the 5 years. All three groups had more consultations (for both psychological and somatic reasons) during each of the follow-up years than control patients. Furthermore, the groups with mental health disorders were given more prescriptions for psychopharmacological treatment.

CONCLUSION

Five years after the index episode in 2007, patients with an episode of depression, anxiety, or emotional distress are still not comparable with control patients, in terms of the prevalence of mental health conditions, the number of prescriptions, and healthcare use.

Practice nurse-led proactive care for chronic depression in primary care: a randomised controlled trial

BACKGROUND

Management of long-term depression is a significant problem in primary care populations with considerable on-going morbidity, but few studies have focused on this group.

AIMS

To evaluate whether structured, nurse-led proactive care of patients with chronic depression in primary care improves outcomes.

METHOD

Participants with chronic/recurrent major depression or dysthymia were recruited from 42 UK general practices and randomised to general practitioner (GP) treatment as usual or nurse intervention over 2 years (the ProCEED trial, trial registration:ISRCTN36610074).

RESULTS

In total 282 people received the intervention and there were 276 controls. At 24 months there was no significant improvement in Beck Depression Inventory (BDI-II) score or quality of life (Euroquol-EQ-VAS), but a significant improvement in functional impairment (Work and Social Activity Schedule, WSAS) of 2.5 (95% CI 0.6-4.3,P= 0.010) in the intervention group. The impact per practice-nurse intervention session was -0.37 (95% CI -0.68 to -0.07,P= 0.017) on the BDI-II score and 70.33 (95% CI 70.55 to -0.10,P= 0.004) on the WSAS score, indicating that attending all 10 intervention sessions could lead to a BDI-II score reduction of 3.7 points compared with controls.

CONCLUSIONS

The intervention improved functioning in these patients, the majority of whom had complex long-term difficulties, but only had a significant impact on depressive symptoms in those engaging with the full intervention.

Effect of neighbourhood deprivation and social cohesion on mental health inequality: a multilevel population-based longitudinal study

BACKGROUND

The common mental disorders (CMDs) of anxiety and depression are the most common form of poor mental health in the general population. Evidence from the small number of previous cohort studies on the role of neighbourhood factors in mental health is inconclusive. We tested the hypothesis that high levels of neighbourhood social cohesion modify an adverse association between change in individual mental health and neighbourhood deprivation.

METHOD

We carried out a longitudinal multilevel analysis using data from the Caerphilly Health and Social Needs Cohort Study with a 7-year follow-up (n = 4426; age range 18-74 years at baseline). Neighbourhood deprivation and neighbourhood social cohesion were assessed at baseline and change in mental health between follow-up and baseline was assessed using the five-item Mental Health Inventory (MHI-5).

RESULTS

Residence in the most deprived neighbourhoods was negatively associated with change in mental health, after adjusting for baseline individual socio-economic risk factors and transitions in life events. This negative effect was significantly reduced in high social cohesion neighbourhoods. The predicted change in mental health score was calculated for the 10th and 90th centiles of the household low-income distribution. The difference between them was -2.8 in the low social cohesion group and 1.1 in the high cohesion group. The difference between the groups was 3.9 [95% confidence interval (CI) 0.2-7.6].

CONCLUSIONS

The public health burden of poor mental health and mental health inequality could potentially be reduced by strengthening social cohesion in deprived neighbourhoods. This offers a mechanism to address the adverse effect of neighbourhood deprivation on population mental health.

Recognizing and treating late-life generalized anxiety disorder: distinguishing features and psychosocial treatment

Generalized anxiety disorder is a highly prevalent and under-recognized public health problem associated with significant impairment and serious disability. Generalized anxiety disorder is the most common anxiety disorder among adults over the age of 60 years. This article discusses distinguishing features of generalized anxiety disorder, such as disorder-specific worry domains and associated features. The relation of the disorder to normal aging, major depression and health is also discussed. Current psychosocial treatment strategies are outlined, with a particular focus on cognitive behavior therapy.

Chronic and recurrent depression in primary care: socio-demographic features, morbidity, and costs

Background. Major depression is often chronic or recurrent and is usually treated within primary care. Little is known about the associated morbidity and costs. Objectives. To determine socio-demographic characteristics of people with chronic or recurrent depression in primary care and associated morbidity, service use, and costs. Method. 558 participants were recruited from 42 GP practices in the UK. All participants had a history of chronic major depression, recurrent major depression, or dysthymia. Participants completed questionnaires including the BDI-II, Work and Social Adjustment Scale, Euroquol, and Client Service Receipt Inventory documenting use of primary care, mental health, and other services. Results. The sample was characterised by high levels of depression, functional impairment, and high service use and costs. The majority (74%) had been treated with an anti-depressant, while few had seen a counsellor (15%) or a psychologist (3%) in the preceding three months. The group with chronic major depression was most depressed and impaired with highest service use, whilst those with dysthymia were least depressed, impaired, and costly to support but still had high morbidity and associated costs. Conclusion. This is a patient group with very significant morbidity and high costs. Effective interventions to reduce both are required.

General practitioners' management of mental disorders: a rewarding practice with considerable obstacles

Background

Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.

Methods

This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.

Results

At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.

Conclusions

To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.

Men and women have specific needs that facilitate enrollment in HIV-prevention counseling

Although reducing HIV risk is a primary motive for the design of HIV prevention interventions, the goals of the clients may be very different. Social theories of gender suggest that women, who often seek to resolve social and relational problems, may see HIV-prevention counseling as a mean of resolving partner violence. In contrast, men, who often worry about their physical strength, may seek to enroll in HIV-prevention programs when they experience physical symptoms unrelated to HIV. An unobtrusive study was conducted to observe enrollment in HIV risk-reduction counseling after measuring partner-violence complaints (e.g., feeling threatened or being hit), emotional complaints (e.g., fatigue or anxiety), and physical complaints (e.g., cardiovascular or digestive symptoms). The sample was a group of 350 participants, 70% clients from a state-health department in North Central Florida and 30% community members. Consistent with predictions, complaints of partner violence had a positive association with enrollment in women but not in men, whereas complaints about physical health had a positive association with enrollment in men, but not in women. Emotional complaints did not predict enrollment in either gender group. This study suggests that broad, gender-specific population needs must be competently addressed within HIV-prevention programs and may be strategically used to increase program enrollment.

Evaluation of a system of structured, pro-active care for chronic depression in primary care: a randomised controlled trial

BACKGROUND

People with chronic depression are frequently lost from effective care, with resulting psychological, physical and social morbidity and considerable social and financial societal costs. This randomised controlled trial will evaluate whether regular structured practice nurse reviews lead to better mental health and social outcomes for these patients and will assess the cost-effectiveness of the structured reviews compared to usual care.The hypothesis is that structured, pro-active care of patients with chronic depression in primary care will lead to a cost-effective improvement in medical and social outcomes when compared with usual general practitioner (GP) care.

METHODS/DESIGN

Participants were recruited from 42 general practices throughout the United Kingdom. Eligible participants had to have a history of chronic major depression, recurrent major depression or chronic dsythymia confirmed using the Composite International Diagnostic Interview (CIDI). They also needed to score 14 or above on the Beck Depression Inventory (BDI-II) at recruitment.Once consented, participants were randomised to treatment as usual from their general practice (controls) or the practice nurse led intervention. The intervention includes a specially prepared education booklet and a comprehensive baseline assessment of participants' mood and any associated physical and psycho-social factors, followed by regular 3 monthly reviews by the nurse over the 2 year study period. At these appointments intervention participants' mood will be reviewed, together with their current pharmacological and psychological treatments and any relevant social factors, with the nurse suggesting possible amendments according to evidence based guidelines. This is a chronic disease management model, similar to that used for other long-term conditions in primary care.The primary outcome is the BDI-II, measured at baseline and 6 monthly by self-complete postal questionnaire. Secondary outcomes collected by self-complete questionnaire at baseline and 2 years include social functioning, quality of life and data for the economic analyses. Health service data will be collected from GP notes for the 24 months before recruitment and the 24 months of the study.

DISCUSSION

558 participants were recruited, 282 to the intervention and 276 to the control arm. The majority were recruited via practice database searches using relevant READ codes.

TRIAL REGISTRATION

ISRCTN36610074.

Long term outcome of primary care depression

We conducted a follow up over 23 years of depressed patients originally presenting to general practice in 1981 and studied in detail at that time. Aims were to assess the long term course and outcome of depression in primary care. Patterns of recovery and recurrence of major depressive episodes, together with other aspects of course, treatment and current state, were assessed at interview. 78% (129) of the original sample were traced to current general practice and outcome data obtained on 54. One third had a prior history of depression. Interview data were obtained on 37 patients. Time to recovery from baseline averaged 10.3 months. The recurrence rate was 64% (23). Most participants suffered at least 2 further episodes that were frequently chronic lasting 2 years on average. Time before first recurrence appeared considerably longer than in comparable psychiatric inpatient samples. No participants were continuously ill. Although loss to follow up limits our conclusions, the course of primary care depression appears worse than suggested by previous, shorter follow ups. Our data suggest that long term risk of a recurrence may be high, but with recurrence delayed.

[Review of the guidelines of the Brazilian Medical Association for the treatment of depression (Complete version)]

OBJECTIVE

Depression is a frequent, recurrent and chronic condition with high levels of functional disability. The Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present a review of the Guidelines Published in 2003 incorporating new evidence and recommendations.

METHOD

This review was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. The Brazilian Medical Association proposed this methodology for the whole project. The review was developed from new international guidelines published since 2003.

RESULTS

The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Strategies for different phases of treatment are also discussed.

CONCLUSION

The Guidelines are an important tool for clinical decisions and a reference for orientation based on the available evidence in the literature.

Antidepressant behavioral effects of duloxetine and amitriptyline in the rat forced swimming test

PURPOSE

To compare the effects of the antidepressant drugs duloxetine and amitriptyline on depressive behaviors in rats.

METHODS

Fifteen male Wistar rats were given systemic injections of duloxetine, amitriptyline or saline prior to a Forced Swimming Test (FST). Immobility and number of stops were measured. Data were analyzed by one-way ANOVA and Kruskall-Wallis.

RESULTS

Rats given injections of duloxetine displayed fewer stops than the amitriptyline and control group (p< 0.05). The control group and Amitriptyline showed no difference (p=0.8).

CONCLUSION

Duloxetine reduced depressive behaviors in the Forced Swimming Test been more effective than amitriptyline.

Cross-sectional survey of patients in receipt of long-term repeat prescriptions for antidepressant drugs in primary care

This cross-sectional survey describes the clinical characteristics of 92 patients from across 12 general medical practices, in receipt of a long-term repeat prescription of an antidepressant for the treatment of depression. Psychiatric diagnoses were determined using the Schedule for Clinical Assessment in Neuropsychiatry. Fifty-three participants (57.6%) failed to meet criteria for any psychiatric diagnosis (95% confidence interval (CI): 47.5-67.7%). Independent clinical assessments based upon diagnoses and other clinical data indicated that 26 (31.0%) participants (95% CI: 28.9-49.7%) had no clear clinical reason for continued receipt of an antidepressant. Reasons for the continued use of antidepressants in this population require further investigation.

Antidepressant behavioral effects of duloxetine and fluoxetine in the rat forced swimming test

PURPOSE: To compare the effects of the antidepressant drugs duloxetine and fluoxetine on depressive behaviors in rodents. METHODS: Eighteen male Wistar rats were given systemic injections of duloxetine, fluoxetine, or saline prior to a Forced Swimming Test (FST). Immobility and number of stops were measured. RESULTS: Rats given injections of fluoxetine displayed significantly less immobility (p = 0.02) and fewer stops than the control group (p = 0.003). Duloxetine significanlty reduced the number of stops (p = 0.003), but did not effect immobility (p = 0.48). CONCLUSION: Duloxetine and fluoxetine reduced depressive behaviors in the Forced FST. However, our findings suggest that fluoxetine is more effective than duloxetine.

Places, people and mental health: a multilevel analysis of economic inactivity

This paper investigates multilevel associations between the common mental disorders of anxiety, depression and economic inactivity measured at the level of the individual and the UK 2001 census ward. The data set comes from the Caerphilly Health & Social Needs study, in which a representative survey of adults aged 18-74 years was carried out to collect a wide range of information which included mental health status (using the Mental Health Inventory (MHI-5) scale of the Short Form-36 health status questionnaire), and socio-economic status (including employment status, social class, household income, housing tenure and property value). Ward level economic inactivity was measured using non-means tested benefits data from the Department of Work and Pensions (DWP) on long-term Incapacity Benefit and Severe Disablement Allowance. Estimates from multilevel linear regression models of 10,653 individuals nested within 36 census wards showed that individual mental health status was significantly associated with ward-level economic inactivity, after adjusting for individual-level variables, with a moderate effect size of -0.668 (standard error=0.258). There was a significant cross-level interaction between ward-level and individual economic inactivity from permanent sickness or disability, such that the effect of permanent sickness or disability on mental health was significantly greater for people living in wards with high levels of economic inactivity. This supports the hypothesis that living in a deprived neighbourhood has the most negative health effects on poorer individuals and is further evidence for a substantive effect of the place where you live on mental health.

Socio-economic position and common mental disorders. Longitudinal study in the general population in the UK

BACKGROUND

Individuals in lower socio-economic groups have an increased prevalence of common mental disorders.

AIMS

To investigate the longitudinal association between socio-economic position and common mental disorders in a general population sample in the UK.

METHOD

Participants (n=2406) were assessed at two time points 18 months apart with the Revised Clinical Interview Schedule. The sample was stratified into two cohorts according to mental health status at baseline.

RESULTS

None of the socio-economic indicators studied was significantly associated with an episode of common mental disorder at follow-up after adjusting for baseline psychiatric morbidity. The analysis of separate diagnostic categories showed that subjective financial difficulties at baseline were independently associated with depression at follow-up in both cohorts.

CONCLUSIONS

These findings support the view that apart from objective measures of socio-economic position, more subjective measures might be equally important from an aetiological or clinical perspective.

Relationship between anxiety and agitation in dementia

Anxiety and agitation are common in people with dementia. Their consequences can be severe, including increased mortality rates and institutionalization. Despite the importance of these symptoms there is little literature in this area. Some studies have assumed that agitation is the outward manifestation of anxiety, while others have attempted to differentiate between them. The aim of this study was to investigate the relationship between anxiety and agitation in people with mild-to-moderate dementia. A secondary aim was to compare two measures of anxiety which have been used in people with dementia. A cross-sectional correlation design was used. Participants were 40 older adults with dementia. Agitation, anxiety, depression, and level of cognitive impairment were measured. The main finding from the study was that anxiety and agitation are associated in dementia. The degree of correlation did not support the use of agitation as a measure of anxiety. Anxiety symptoms of autonomic sensitivity were not correlated with agitation and could be used to differentiate between the two if this was required. The use of the Rating for Anxiety in Dementia (RAID) was supported as a measure of anxiety in people with dementia.

Differentiation of somatizing patients in primary care: why the effects of treatment are always moderate

The heterogeneity of somatizing patients influences outcomes, especially in unselected samples in primary care. A cluster analysis was performed as secondary analysis on an existing data set of 127 somatizing patients included in a randomized controlled clinical trial. Anxiety and depression (HADS), number and intensity of physical symptoms (SOMS), physical and emotional functioning (short form of the SF-36 Health Survey), health beliefs (KKU-G), and psychological distress (General Health Questionnaire) were used for clustering. Outcome, treatment satisfaction, and diagnosis were calculated and compared for the clusters. We differentiated three groups from this analysis: one with elevated emotional and physical stress, one in which emotional stress dominated, and one with low emotional and physical stress. The three groups did not differ in diagnoses of somatoform disorders. The high-stress groups improved over time, whereas the depression and emotional-functioning scores in the low-stress group deteriorated. All patients were satisfied with the treatment provided. Deterioration in the scores of the low-stress group may be a result of a clinically valuable change process, in that patients who were initially in denial were able to open up and admit their problems. The increased satisfaction with treatment supports this interpretation. This so-called response shift must be taken into account in the planning of studies.

Parent-child relationships and health problems in adulthood in three UK national birth cohort studies

BACKGROUND

Event-based measures suggest that emotional adversity in childhood has a long-term health impact, but less attention has been paid to chronic emotional stressors such as family conflict, harsh discipline or lack of affection. This study aimed to assess the impact of the latter on health problems and illness in adulthood.

METHODS

Logistic regression and multinomial logistic regression analyses of data collected in three UK national birth cohort studies at ages 43 and 16 years covering subjective report of relationship quality from the 'child', and number of health problems and illnesses reported in adulthood at ages 43, 33 and 26 years adjusted for social class, sex and, in 1946 and 1970 cohorts, for symptoms of mental illness.

RESULTS

Reports of abuse and neglect (1946 cohort), poor quality relationship with mother and father (1958 cohort), and a range of negative relationship descriptors (1970 cohort) predicted reports of three or more illnesses or health problems in adulthood. Results were inconsistent with respect to one or two illnesses or health problems. Adjustment for sex, social class and poor mental health attenuated the odds of poor health, but measures of relationship quality retained a significant independent effect.

CONCLUSIONS

Poor quality parent-child relationships could be a remediable risk factor for poor health in adulthood.

Help-seeking behaviour in men and women with common mental health problems: cross-sectional study

BACKGROUND

Many people with mental health problems do not seek professional help but their use of other sources of help is unclear.

AIMS

To investigate patterns of lay and professional help-seeking in men and women aged 16-64 years in relation to severity of symptoms and socio-demographic variables.

METHOD

Postal questionnaire survey, including the 12-item General Health Questionnaire (GHQ-12), sent to a stratified random sample (n=15,222) of the population of Somerset.

RESULTS

The response rate was 76%. Only 28% of people with extremely high GHQ-12 scores (> or = 8) had sought help from their general practitioner but most (78%) had sought some form of help. Males, young people and people living in affluent areas were the least likely to seek help.

CONCLUSIONS

Health promotion interventions to encourage appropriate help-seeking behaviour in young people, particularly in men, may lead to improvements in the mental health of this group of the population.

Thirty-six month outcome data from a trial of counselling with chronically depressed patients in a general practice setting

Counsellors have been employed in general practice with little evidence of effectiveness in this setting. This randomized controlled trial examined long-term effectiveness of short-term counselling in general practice for patients with chronic depression, either alone or combined with anxiety. Participants were 181 patients recruited from nine general practitioners' (GP) practices in Derbyshire by screening consecutive attenders using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression and social adjustment were measured at baseline, 6, 12, and 36 months. There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6, 12, or 36 months. Although fewer experimental group patients were still 'cases' on the BDI than controls at 6 and 12 months, this difference disappeared at 36 months. There was no evidence to demonstrate a long-term effect of improved outcomes in those referred to counselling.

[Guidelines of the Brazilian Medical Association for the treatment of depression (complete version)]

OBJECTIVE

Depression is a frequent and chronic condition with high levels of functional disability. Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present the original document that originated the abbreviated version available at the electronic address of Brazilian Medical Association.

METHODS

This paper was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. Brazilian Medical Association proposed this methodology for the whole project.

RESULTS

The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Planning of different phases of treatment is22 also discussed.

CONCLUSIONS

Guidelines are a good tool helping clinical decisions and are a reference for an attitude based on levels of evidence.

Psychological distress as a predictor of frequent attendance in family practice: a cohort study

In cross-sectional studies, psychological distress has been associated with frequent health care utilization. However, there is a need for prospective studies to confirm these findings. This cohort study evaluated whether psychological distress predicted frequent attendance in family practice. In 1990, 185 consecutive adults who consulted their primary care physician (PCP) about an illness were rated on two psychometric scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7), and their annual number of face-to-face contacts with a family practice was followed until 1996. Frequent attenders (FAs) were defined as the top 10%. A logistic regression analysis showed a significantly increased risk of becoming an FA with an increase of 1 point (odds ratio [OR] 1.17 [1.03-1.33]) on SCL and 1.28 (1.06-1.53) on Whiteley). An association was found between score and number of years as an FA (OR 1.16 [0.99-1.36] for SCL and OR 1.31 [1.05-1.65] for Whiteley). Psychological distress involved an increased risk of future frequent attendance among adult patients consulting family practice in the daytime about an illness.

The association between daytime attendance and out-of-hours frequent attendance among adult patients in general practice

BACKGROUND

Frequent attenders (FAs) account for a large proportion of daytime consultations in general practice. However, no studies have so far been conducted to establish whether daytime FAs are also out-of-hours FAs.

AIM

To analyse the association between daytime attendance and out-of-hours frequent attendance.

DESIGN OF STUDY

A registry-based study of individual face-to-face contacts with general practice during daytime and out of hours, based on National Health Insurance files.

SETTING

General practices in Aarhus County, Denmark (630,000 inhabitants).

METHOD

A total of 416,172 adults, i.e. all adults registered with a general practice during a 12-month period from November 1997 to October 1998 were included. Odds ratios (OR) for frequent attendance out of hours were stratified for age, sex, and frequency of contacts during daytime were calculated.

RESULTS

A strong association was observed between daytime level of attendance and out-of-hours level of attendance (OR = 2.9-6.3 among patients with low daytime attendance, OR = 33.7-99.8 among daytime FAs). Daytime FAs accounted for one-third of the daytime contacts, one-third of the out-of-hours contacts, and 42% of out-of-hours FAs. More than half of the daytime FAs did not attend out of hours. Two per cent of the out-of-hours FAs had no contacts during the daytime.

CONCLUSION

Frequent attendance in daytime was very strongly associated with frequent attendance out of hours, and daytime FAs accounted for a large proportion of all contacts with general practice.

Prevalence of enduring and disabling mental illness in the inner city

Previous research identifying the long-term mentally ill in primary care has been outside areas of deprivation. We used a case finding approach by a primary care group to identify the prevalence and characteristics of people with enduring and disabling mental ill health in a disadvantaged inner-city community. We found a high point prevalence (12.9 per 1000 patients) of enduring psychotic and non-psychotic illness (36.1% and 63.9% respectively). This contributed to considerable workload and disability, and included a significant proportion of older people (24.6% aged over 65 years). The approach may be useful for local needs assessment. It highlights a need to consider disability as well as diagnosis for service development.

The long-term perspective: a study of psychopathology and health status of patients with a history of depression more than 15 years after the first episode

This article examines psychopathology, functioning, well-being, social support, and coping-behavior of family practice patients with a history of depressive illness, both with and without recurrences. Results of depressive patients were compared with each other and with those of "normal" controls. The patients belonged to the four practices of the Continuous Morbidity Registry of the University of Nijmegen, Netherlands. Their first episode of depression for each patient was more than 15 years ago. Data were collected with the Symptom Checklist (SCL-90) the RAND-36, the Social Support List (SSL-12), and the short Utrecht Coping List (UCL-k). Psychopathology scores of patients without recurrences were higher than "normal" controls and lower than patients with recurrences. The same pattern was found concerning health status. No significant differences were found between the groups in social support but patients with recurrences had a lower score of emotional coping than patients without recurrences or normal patients. That even a long time after an episode of depression, patients have higher levels of a variety of psychopathology than controls has implications for every-day practice as it calls for a longer and more critical follow-up of depression by clinicians.

Counselling: filling a gap in general practice

A counsellor worked for 1 year in three practices in a rural area where there was previously no practice-based counselling. The service was evaluated, using a range of methods, in order to inform general practitioners and policy-makers about the demand for counselling, where it fits with other services, its potential value and how to organise and audit the service efficiently. Five kinds of information were collected: administrative data; patients' views; well-being scores; GPs' perceptions of individual patients; and interviews with the counsellor, GPs and other primary care staff by an independent researcher. All the GPs used the service, referring 131 people. The most common reason for referral was 'relationship difficulties'. There were improvements in patients' well-being, self-awareness and coping skills, and high satisfaction among GPs and patients. Communication with other services was seen to improve. The counselling service was found to fill a gap by addressing the needs of a substantial group of patients for whom psychiatric care was inappropriate.

General practitioner psychological management of common emotional problems (I): Definitions and literature review

General practitioners' (GPs') treatment of patients with common emotional problems often includes some form of psychological management within the consultation. Such psychological management may be limited to listening and discussion or may also include more specific psychological approaches, such as use of counselling, problem-solving, or cognitive-behavioural techniques. This paper defines GP psychological management and reviews what is known about its frequency and effectiveness. MEDLINE and PsychLIT searches were undertaken of empirical studies of the psychological management of emotional problems by GPs in routine consultations published up to 1998. Thirty-six studies were identified. Most lacked details of the nature of the psychological management reported, making it difficult to compare studies. The frequency of use of psychological management by GPs was found to be generally less when rated by external observers than when assessed by GP self-report. There is preliminary evidence from a few studies of the clinical effectiveness of GP psychological management in routine consultations.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology

A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.

Stigma of anxiety

Some 15% of the population suffer from pathological anxiety, making it the most common of all psychiatric conditions (Costa E Silva, 1998). Anxiety disorders are poorly conceptualized, rarely diagnosed and inadequately treated (Hale, 1997). They are taken for granted, yet remain a major source of emotional distress, chronic morbidity and high health-care resource utilization. Greater awareness, earlier recognition and more aggressive treatments would improve the prognosis, and overcome the stigmatization and undervaluation of patients with these disorders (Lloyd et al, 1996).

Primary care options to prevent mental illness

The common mental disorders, mainly anxiety and depression, constitute a major public health problem, incurring considerable costs in terms of use of health services and time lost from work. Risk factors include low socioeconomic status, poverty and poor housing, as well as stressful life events and difficulties such as demanding child care, separation or divorce, bereavement, loss of employment and caring for a dependant relative. Population approaches are probably necessary to reduce significantly the burden of such mental health problems, but health care measures are far from negligible. Primary care professionals have regular opportunities to identify people at risk of mental health problems and refer them to welfare and social support services (primary prevention). A number of interventions among high-risk groups have been shown to be effective, including problem-solving training and cognitive-behavioural approaches. The most important tasks in primary care are to identify people with depression, alcohol and drug misuse and eating disorders as early as possible in the course of their illness and to institute effective treatment (secondary prevention). Primary care teams should also join in shared care arrangements for patients with chronic disabling mental illnesses, in order to prevent recurrences and relapses (tertiary prevention).

Collaborative care in the United Kingdom

Counselors now work in about half of all family medical practices in the United Kingdom. This article discusses the reasons for the rapid growth of this new service. Increasing collaboration between counselors and family physicians is already having major effects on health care costs and on existing mental health services. Current problems that hinder further development are identified. Solutions are proposed to help counselors who work collaboratively with family physicians and other members of the primary health care team deliver effective and efficient interventions.

Sex and attitude: a randomized vignette study of the management of depression by general practitioners

BACKGROUND

The management and detection of depression varies widely, and the causes of variation are incompletely understood.

AIMS

To describe and explain general practitioners' (GPs') current practice in the recognition and management of depression in young adults, their attitudes towards depression, and to investigate associations of GP characteristics and patient sex with management.

METHOD

All GP principals in the Greater Glasgow Health Board were randomized to receive questionnaires with vignettes describing increasingly severe symptoms of depression in either male or female patients, and asked to indicate which clinical options they would be likely to take. The Depression Attitude Questionnaire was used to elicit GP attitudes.

RESULTS

As the severity of vignette symptoms increased, GPs responded by changing their prescribing and referral patterns. For the most severe vignette, the majority of GPs would prescribe drugs (76.4%) and refer the patient for further help (73.7%). Male and female patients were treated differently: GPs were less likely to ask female patients than male patients to attend a follow-up consultation (odds ratio [OR] = 0.55), and female GPs were less likely to refer female patients (OR = 0.33). GPs with a pessimistic view of depression, measured using the 'inevitable course of depression' attitude scale, were less willing to be actively involved in its treatment, being less likely to discuss a non-physical cause of symptoms (OR = 0.77) or to explore social factors in moderately severe cases (OR = 0.68).

CONCLUSIONS

Accepting the limitations of the method, GPs appear to respond appropriately to increasingly severe symptoms of depression, although variation in management exists. Educational programmes should be developed with the aim of enhancing GP attitudes towards depression, and the effects on detection and management of depression should be rigorously evaluated.

Poverty, unemployment, and common mental disorders: population based cohort study

OBJECTIVE

To determine whether poverty and unemployment increase the likelihood of or delay recovery from common mental disorders, and whether these associations could be explained by subjective financial strain.

DESIGN

Prospective cohort study.

SETTING

England, Wales, and Scotland.

SUBJECTS

7726 adults aged 16-75 living in private households.

MAIN OUTCOME MEASURES

Common mental disorders were assessed using the general health questionnaire, a self assessed measure of psychiatric morbidity.

RESULTS

Poverty and unemployment (odds ratio 1.86, 95% confidence interval 1.18 to 2.94) were associated with the maintenance but not onset of episodes of common mental disorders. Associations between poverty and employment and maintenance of common mental disorders, however, were much smaller than those of cross sectional studies. Financial strain at baseline was independently associated with both onset (1.57, 1.19 to 2.07) and maintenance (1.86, 1.36 to 2.53) even after adjusting for objective indices of standard of living.

CONCLUSIONS

Poverty and unemployment increased the duration of episodes of common mental disorders but not the likelihood of their onset. Financial strain was a better predictor of future psychiatric morbidity than either of these more objective risk factors though the nature of this risk factor and its relation with poverty and unemployment remain unclear.

Feelings of anxiety and associated variables in a very elderly population

OBJECTIVE

Anxiety disorders have been reported to decrease with age, while anxiety feelings have been reported to be as common as in younger age groups. In order to further explore this relationship and variables associated with anxiety, a population of very elderly persons was examined.

METHODS

966 persons, aged 78 years and over, underwent an examination by a physician including a structured psychiatric interview.

RESULTS

Anxiety feelings are strongly associated with psychiatric disturbances (anxiety disorders and depressive disorders). Moreover, the feelings were associated with dementia, a history of psychiatric disorders (most often depression), being female and being dissatisfied with social network. Few of those with a psychiatric disorder were adequately treated, in spite of the fact that most of them had seen a physician during the past month.

CONCLUSIONS

After excluding an anxiety disorder, one of the most important things to consider in a very old person with anxiety is whether depression is present or not. Generally, there is a need for more education of physicians concerning the common mental disorders in the elderly in order to improve their management.

Material standard of living, social class, and the prevalence of the common mental disorders in Great Britain

STUDY OBJECTIVE

To test the hypothesis that poor material standard of living is independently associated with the prevalence of the common mental disorders after adjusting for occupational social class, and to estimate the population impact of poor material standard of living on the prevalence of these disorders.

DESIGN

Cross sectional survey. Prevalence of the common mental disorders was assessed using the General Health Questionnaire, a self administered measure of psychiatric morbidity.

PARTICIPANTS

9064 adults aged 16-75 living in private households in England, Wales, and Scotland.

MAIN RESULTS

The common mental disorders were significantly associated with poor material standard of living, including low household income (OR 1.24, 95% CI 1.00, 1.54) and not saving from income (OR 1.29, 95% CI 1.15, 1.45), after adjusting for occupational social class and other potential confounders. An independent association was also found with occupational social class of the head of household among women, but not men, after adjusting for material standard of living. The adjusted population attributable fraction for poor material standard of living (using a five item index) was 24.0%.

CONCLUSIONS

Like mortality and physical morbidity, common mental disorders are associated with a poor material standard of living, independent of occupational social class. These findings support the view that recent widening of inequalities in material standards of living in the United Kingdom pose a substantial threat to health.

Benzodiazepine dependence: Avoidance and withdrawal

Benzodiazepine dependence remains a shadowy concept. Dependence undoubtedly exists but also acts as an umbrella concept for the underlying chronic morbidity associated with neurosis. Treatment should be directed at early detection and vigorous treatment of anxiety disorders; and an acceptance that long-term treatment may be necessary. Once benzodiazepine dependence is established, each patient requires careful evaluation to establish their unique problem and to institute individual treatment plans. Strategies for benzodiazepine withdrawal are documented but each has its own problems and success can only be achieved if underlying problems are dealt with as well as simply providing tranquilliser withdrawal.