A feasibility, randomised controlled trial of Club Connect: a group-based healthy brain ageing cognitive training program for older adults with major depression within an older people's mental health service

BACKGROUND

Using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, we outline steps taken to implement an evidence-based cognitive training program, Club Connect, in older adults with major depressive disorder in an Older People's Mental Health Service in Sydney, Australia. The primary aim was to explore feasibility (or 'reach'), tolerability (or 'implementation'), and acceptability (or 'adoption'). The secondary aim was to explore the most sensitive clinical outcomes and measurement tools (i.e. 'effectiveness') to inform a formal randomised controlled trial, and to explore the healthcare resources used (i.e. costs) to assist decision-making by health care managers and policy-makers in relation to future resource allocation.

METHODS

Using a single blinded feasibility design, 40 participants (mean age: 76.13 years, SD: 7.45, range: 65-95 years) were randomised to either (a) Club Connect, a 10-week group-based multifaceted program, comprising psychoeducation and computer-based cognitive training, or (b) a waitlist control group.

RESULTS

Implementing group-based cognitive training within a clinical setting was feasible, well tolerated and accepted by participants. Further, cognitive training, in comparison to the waiting list control, was associated with moderate to very large effect size improvements in depression, stress and inhibition (ηp2 = 0.115-0.209). We also found moderate effect size improvements on measures of daily functioning, wellbeing and cognitive flexibility. Small effect size improvements for other cognitive and psychosocial outcomes were also observed. The average cost per person participating in in the intervention was AU$607.50.

CONCLUSIONS

Our findings support the feasibility of implementing group-based cognitive training into a specialised clinical (public health) setting. This trial was registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12619000195156, 12/02/2019).

Communicating Personal Risk Profiles of Alzheimer's Disease to Older Adults: A Pilot Trial

Communicating personal Alzheimer's disease risk profiles based on validated risk algorithms may improve public knowledge about risk reduction, and initiate action. This proof of concept pilot trial aimed to test whether this is feasible and potentially effective and/or harmful. Older at-risk adults (N=24) were provided with their personal Alzheimer's disease risk profile online, which contained information on their personal risk level, scores and tailored recommendations to manage modifiable risk factors. After receiving the risk profile, participants were significantly more accurate in identifying risk and protective factors, and revised their perceived risk to be lower than their initial estimate. There was no apparent harm seen in psychological distress or dementia-related worry. This shows preliminary support for the feasibility of delivering personal dementia risk profiles to low risk, help-seeking older adults in an online format. A definitive trial examining behavioural outcomes and testing in groups with higher risk profiles is now warranted.

A Systematic Review and Meta-Analysis of Cognitive Training in Adults with Major Depressive Disorder

Major Depressive Disorder (MDD) is common and disabling, and is linked to functional impairment and increased mortality. While current treatments for MDD are moderately effective, ultimately, up to one third of patients do not achieve full remission. Interestingly, while affective symptoms of major depression typically resolve with the depressive episode, cognitive impairment frequently persists, and has been identified as one of the most prominent predictors of illness recurrence. Additionally, MDD is well-recognised as a key risk factor for further cognitive decline and dementia. Yet, available treatments for MDD do not typically address cognitive impairment. Cognitive training, represents a promising and novel therapeutic intervention in this regard. This review systematically identified and evaluated the evidence for cognitive training in adults with MDD. Following PRISMA guidelines, eligible studies were selected according to pre-defined criteria delineating our target population (adults with clinically defined MDD), parameters for cognitive training interventions (computer-or strategy-based, clinician-facilitated), and study design (controlled trials including pre-post cognitive and psychological or functional outcome data). Of 448 studies identified, nine studies met inclusion criteria. These studies were evaluated for methodological quality and risk of bias. Despite heterogeneity, qualitative and meta-analytic synthesis of study findings revealed significant improvements in cognitive and affective outcomes following cognitive training, with moderate pooled effect sizes. Unfortunately, very few studies investigated 'far transfer' to broader domains of everyday functioning. Overall, given the strong evidence for the efficacy and value of cognitive training in this context, cognitive training should be considered as a primary therapeutic intervention in the treatment of MDD.

A transdiagnostic examination of anxiety and stress on executive function outcomes in disorders with social impairment

BACKGROUND

Executive function (EF) difficulties characterise a number of psychiatric conditions and EF impairment may be a predisposing factor and/or consequence of anxiety and stress. The aim of the study was to examine EF factors in a mixed clinical cohort (Autism Spectrum Disorder and Social Anxiety Disorder) characterised by social impairment and investigate the influence of trait anxiety and state-based depression, anxiety and stress.

METHODS

In Study 1, a factor analysis identified EF and non-EF latent factor structures (N=205). In Study 2, (N=137) multiple regression analyses investigated the association between trait anxiety and state based depression, anxiety and stress, on EF and non-EF cognitive domains and on the two composite indices of the Behavioural Rating Inventory of Executive Function (BRIEF).

RESULTS

Trait anxiety was associated with better performance on neuropsychological measures of EF while state-based stress was associated with lower EF performance. A dissociation was observed between trait anxiety and state stress on the two behavioural indices of the BRIEF. Depression, anxiety and stress did not predict performance on non-EF cognitive domains.

LIMITATIONS

The cross-sectional design precludes cause-effect conclusions, further only self-report measures of affect were utilised and our performance measures of EF did not include a working memory test.

CONCLUSIONS

The results demonstrate that trait anxiety and state-based stress influence EF processes across disorders with social impairment. The transdiagnostic efficacy of this finding can facilitate remediation strategies, it may also contribute to individuals with Autism Spectrum Disorder gaining better access to mental health services.

0669 The Effects Of Continuous Positive Airway Pressure Therapy In Moderate To Severe Obstructive Sleep Apnea: A High-density EEG Study

Introduction

A previous high-density electroencephalography (EEG) investigation in asymptomatic OSA showed regional deficits in sleep EEG power particularly slow wave activity (SWA) during NREM sleep in the parietal region. It is unclear whether treatment with CPAP can reverse local sleep EEG abnormalities in OSA, and whether any recovery is related to improvement in sleep-dependent memory consolidation.

Methods

Fifteen male participants (age 50.4±6.5yrs, AHI 51.7±23.5/h) with moderate-severe OSA (AHI>15/h) underwent overnight polysomnography with 256-channel high-density EEG at baseline and following 3 months of CPAP therapy. A word paired associates declarative memory task was administered before and after sleep. After artefact removal, spectral analysis was performed for all channels. Topographical power maps were calculated for standard frequency ranges for NREM sleep (164 channels within a 0.57 radius from the vertex). Maps were compared using both absolute and normalized power (z-scores computed for each subject) and differences between baseline and treatment were determined by statistical nonparametric mapping.

Results

In 11 CPAP compliant patients (intolerant of CPAP [n=3]/high-density EEG [n=1]), analysis of polysomnographic variables showed that total sleep time did not differ but N1 (baseline vs. treatment: 66.9 vs. 39.5 mins,p=0.008) and N2 (195.0 vs. 150.6 mins,p=0.002) sleep was lower and N3 (89.8 vs. 128.7 mins,p=0.003) was higher after CPAP. Topographic analysis of high-density EEG data revealed a regional increase in SWA (1-4.5Hz) EEG power during N3 sleep in a cluster of electrodes overlying the centro-parietal cortex (cluster mean t-value=2.87,p=0.02). The change in overnight declarative memory consolidation (% recognition) after CPAP was significantly correlated with the change in slow spindle frequency activity in frontal regions (cluster mean r=0.875,p=0.003).

Conclusion

CPAP treatment may enhance localised deficits in sleep EEG activity in OSA, and specific regional recovery may translate to memory improvements in the short-term. These data also highlight the potential for long-term therapeutic effects on cognitive outcomes in OSA.

Support

 

The role of rumination in illness trajectories in youth: linking trans-diagnostic processes with clinical staging models

Research in developmental psychopathology and clinical staging models has increasingly sought to identify trans-diagnostic biomarkers or neurocognitive deficits that may play a role in the onset and trajectory of mental disorders and could represent modifiable treatment targets. Less attention has been directed at the potential role of cognitive-emotional regulation processes such as ruminative response style. Maladaptive rumination (toxic brooding) is a known mediator of the association between gender and internalizing disorders in adolescents and is increased in individuals with a history of early adversity. Furthermore, rumination shows moderate levels of genetic heritability and is linked to abnormalities in neural networks associated with emotional regulation and executive functioning. This review explores the potential role of rumination in exacerbating the symptoms of alcohol and substance misuse, and bipolar and psychotic disorders during the peak age range for illness onset. Evidence shows that rumination not only amplifies levels of distress and suicidal ideation, but also extends physiological responses to stress, which may partly explain the high prevalence of physical and mental co-morbidity in youth presenting to mental health services. In summary, the normative developmental trajectory of rumination and its role in the evolution of mental disorders and physical illness demonstrates that rumination presents a detectable, modifiable trans-diagnostic risk factor in youth.

Episodic memory in depression: the unique contribution of the anterior caudate and hippocampus

BACKGROUND

Learning and memory impairments in older adults with depression are linked to hippocampal atrophy. However, other subcortical regions may also be contributing to these deficits. We aimed to examine whether anterior caudate nucleus volume is significantly reduced in older adults with depression compared to controls; whether anterior caudate volume is associated with performance on tasks of episodic learning and memory, and if so, whether this association is independent of the effects of the hippocampus.

METHOD

Eighty-four health-seeking participants meeting criteria for lifetime major depressive disorder (mean age = 64.2, s.d. = 9.1 years) and 27 never-depressed control participants (mean age = 63.9, s.d. = 8.0 years) underwent neuropsychological assessment including verbal episodic memory tests [Rey Auditory Verbal Learning Test and Logical Memory (WMS-III)]. Magnetic resonance imaging was conducted, from which subregions of the caudate nucleus were manually demarcated bilaterally and hippocampal volume was calculated using semi-automated methods.

RESULTS

Depressed subjects had smaller right anterior caudate (RAC) (t = 2.3, p = 0.026) and poorer memory compared to controls (t = 2.5, p < 0.001). For depressed subjects only, smaller RAC was associated with poorer verbal memory (r = 0.3, p = 0.003) and older age (r = -0.46, p < 0.001). Multivariable regression showed that the RAC and hippocampus volume uniquely accounted for 5% and 3% of the variance in memory, respectively (β = 0.25, t = 2.16, p = 0.033; β = 0.19, t = 1.71, p = 0.091).

CONCLUSIONS

In older people with depression, the anterior caudate nucleus and the hippocampus play independent roles in mediating memory. While future studies examining this structure should include larger sample sizes and adjust for multiple comparisons, these findings support the critical role of the striatum in depression.

Early phenotypic differences between Parkinson's disease patients with and without freezing of gait

BACKGROUND

Previous studies have associated freezing of gait in Parkinson's disease with the presence of specific phenotypic features such as mood disturbances, REM sleep behavior disorder and selective cognitive impairments. However, it is not clear whether these features are present in the earlier stages of disease or simply represent a more general pattern of progression. To investigate this issue, the current study evaluated motor, cognitive, affective and autonomic features as well as REM sleep behavior disorder in Parkinson's disease patients in the early stages of the condition.

METHODS

Thirty-eight freezers and fifty-three non-freezers with disease duration of less than five years and a Hoehn and Yahr stage of less than three were included in this study. The groups were matched on a number of key disease features including age, disease duration, motor severity and dopamine dose equivalence. Furthermore, patients were assessed on measures of motor, cognitive, affective and autonomic features, as well as REM sleep behavior disorder.

RESULTS

Compared to non-freezers, patients with freezing of gait had significantly more non-tremor symptoms and a selective impairment on executive functions, such as set-shifting ability and working memory. Freezers and non-freezers did not differ on measures of tremor, autonomic function, REM sleep behavior disorder, mood or more general cognition.

CONCLUSION

These results suggest the pathophysiological mechanisms underlying freezing of gait in the early clinical stages of Parkinson's disease are likely to be related to specific changes in the frontostriatal pathways rather than being due to brainstem or more diffuse neuropathology.

Abnormal patterns of theta frequency oscillations during the temporal evolution of freezing of gait in Parkinson's disease

OBJECTIVE

We sought to characterize the electrophysiological signature of Freezing of gait in Parkinson's disease.

METHODS

We examined 24 patients with idiopathic Parkinson's disease and significant freezing of gait as they performed a series of timed up-and-go tasks in their 'off' state while electroencephalographic data was collected from four scalp leads. Fast Fourier Transformation was utilized to explore the power spectral density between periods of normal walking and periods of freezing, as well as during the transition between the two states. In addition, Cross Spectrum and Cross Frequency analyses were used to explore the role of impaired temporal and spatial connectivity.

RESULTS

When compared to walking, episodes of freezing were associated with a significant increase in theta band power within the central and frontal leads. The transition from normal walking to freezing of gait was also associated with increased theta frequency coupling between the central and frontal leads, along with an increase in cross-frequency coupling in the central lead.

CONCLUSIONS

Episodes of freezing of gait in Parkinson's disease are associated with abnormal oscillatory activity in the brain.

SIGNIFICANCE

These results provide novel insights into the pattern of spatiotemporal dynamics underlying freezing of gait and may provide a potential means for therapeutic prediction and alleviation of freezing episodes in susceptible patients.

Cognitive remediation improves memory and psychosocial functioning in first-episode psychiatric out-patients

BACKGROUND

Cognitive remediation (CR) is an effective treatment for several psychiatric disorders. To date, there have been no published studies examining solely first-episode psychiatric cohorts, despite the merits demonstrated by early intervention CR studies. The current study aimed to assess the effectiveness of CR in patients with a first-episode of either major depression or psychosis. Method Fifty-five patients (mean age = 22.8 years, s.d. = 4.3) were randomly assigned to either CR (n = 28) or treatment as usual (TAU; n = 27). CR involved once-weekly 2-h sessions for a total of 10 weeks. Patients were comprehensively assessed before and after treatment. Thirty-six patients completed the study, and analyses were conducted using an intent-to-treat (ITT) approach with all available data.

RESULTS

In comparison to TAU, CR was associated with improved immediate learning and memory controlling for diagnosis and baseline differences. Similarly, CR patients demonstrated greater improvements than TAU patients in psychosocial functioning irrespective of diagnosis. Delayed learning and memory improvements mediated the effect of treatment on psychosocial functioning at a marginal level.

CONCLUSIONS

CR improves memory and psychosocial outcome in first-episode psychiatric out-patients for both depression and psychosis. Memory potentially mediated the functional gains observed. Future studies need to build on the current findings in larger samples using blinded allocation and should incorporate longitudinal follow-up and assessment of potential moderators (e.g. social cognition, self-efficacy) to examine sustainability and the precise mechanisms of CR effects respectively.

In vivo glutathione levels in young persons with bipolar disorder: a magnetic resonance spectroscopy study

Oxidative stress has recently been reported to assume a significant role in the pathophysiology of bipolar disorder. Several studies have demonstrated the replenishment of glutathione (GSH) diminishes oxidative cellular damage and ameliorates depressive symptoms in this disorder. Whilst the mechanism by which GSH exerts any clinical effect is unknown it has been proposed that it involves the bolstering of antioxidant defences by increasing the bioavailability of GSH, which in turn reverses clinical symptoms of depression. Such a proposal is predicated on the implicit assumption that GSH is diminished in these patients prior to GSH supplementation. However hitherto no study has reported in vivo measures of GSH in patients with bipolar disorder. Using magnetic resonance spectroscopy we obtained in vivo measures of GSH in young people with bipolar disorder and contrasted these with matched healthy controls. Young people with bipolar disorder were found to have no diminution in baseline GSH concentration and, furthermore, no significant correlations were found between GSH and clinical scores of depression or mania. The results do not support the hypothesis that oxidative stress is involved in the primary pathophysiology of bipolar disorder.

The differential yet concurrent contributions of motor, cognitive and affective disturbance to freezing of gait in Parkinson's disease

OBJECTIVES

We sought to concurrently examine the specific motor, cognitive and affective contributions to self-reported FOG symptoms.

PATIENTS AND METHODS

Ninety-six patients with Parkinson's disease completed the validated freezing of gait questionnaire and had their motor function scored on section three of the Unified Parkinson's Disease Rating Scale questionnaire. A 5-choice reaction time task was administered in order to measure cognitive processing speed and the Beck Depression Inventory was utilised to assess affective disturbance.

RESULTS

The results showed that after controlling disease duration and dopaminergic medication dose, the triad of motor disability, cognitive processing speed and affective symptoms were all significant independent predictors of scores on the freezing of gait questionnaire.

CONCLUSIONS

These findings suggest the need to consider the interplay between distinct motor, cognitive and affective domains in aetiological studies of freezing and the development of future therapies.

Circadian profiles in young people during the early stages of affective disorder

Although disturbances of the circadian system are strongly linked to affective disorders, no known studies have examined melatonin profiles in young people in early stages of illness. In this study, 44 patients with an affective disorder underwent clinical and neuropsychological assessments. They were then rated by a psychiatrist according to a clinical staging model and were categorized as having an 'attenuated syndrome' or an 'established disorder'. During the evening, salivary melatonin was sampled under dim light conditions over an 8-h interval and for each patient, the time of melatonin onset, total area under the curve and phase angle (difference between time of melatonin onset and time of habitual sleep onset) were computed. Results showed that there was no difference in the timing of melatonin onset across illness stages. However, area under the curve analyses showed that those patients with 'established disorders' had markedly reduced levels of melatonin secretion, and shorter phase angles, relative to those with 'attenuated syndromes'. These lower levels, in turn, were related to lower subjective sleepiness, and poorer performance on neuropsychological tests of verbal memory. Overall, these results suggest that for patients with established illness, dysfunction of the circadian system relates clearly to functional features and markers of underlying neurobiological change. Although the interpretation of these results would be greatly enhanced by control data, this work has important implications for the early delivery of chronobiological interventions in young people with affective disorders.

Distinct neurometabolic profiles are evident in the anterior cingulate of young people with major psychiatric disorders

Currently, there are no validated neurobiological methods for distinguishing different pathophysiological pathways in young patients presenting in the early phases of major psychiatric disorders. Hence, treatments are delivered simply on the basis of their possible effects on nonspecific symptom constructs such as depression, cognitive change or psychotic symptoms. In this study, the ratios (relative to creatine) of key metabolites (N-acetyl aspartate, myoinositol, glutamate and glutathione) were measured with proton magnetic resonance spectroscopy ((1)H-MRS) within the anterior cingulate cortex of 88 young persons presenting with major mood or psychotic symptoms. We derived empirically (using a cluster analytical technique) three subgroups of subjects on the basis of their patterns of in vivo brain biochemistry. The three subgroups were distinguished (from each other) by all the four metabolites, in particular, glutathione and glutamate. By contrast, the groups could not be distinguished by differences in terms of other demographic, functional or clinical measures. We propose that this (1)H-MRS-based subclassification system could be used as the basis for much more specific tests of novel intervention strategies (notably, antioxidant and glutamatergic therapies) early in the course of major psychiatric disorders.

Assessing the utility of Freezing of Gait Questionnaires in Parkinson's Disease

There are currently two validated questionnaires, the Freezing of Gait Questionnaire and the New Freezing of Gait Questionnaire, that are intended to assess the degree of freezing of gait in patients with Parkinson's disease. However, to date no study has attempted to determine whether ratings on these questionnaires accurately reflect the severity (frequency and duration) of actual freezing episodes experienced by patients. We studied twenty-four patients with Parkinson's disease who self-reported significant freezing while in their practically-defined 'off' state. Prior to clinical assessment they completed both freezing of gait questionnaires before being video-recorded while performing a series of timed up-and-go tasks, which incorporated turning, rotating and passing through narrow gaps. The rating of video recordings by two independent observers identified a total of 530 freezing events. The frequency and duration of freezing episodes for each patient were calculated and correlated with questionnaire ratings. Scores on either questionnaire did not correlate with either the frequency or duration of freezing episodes experienced by patients during objective assessment. These results suggest the need to re-evaluate the utility of questionnaires in the assessment of freezing of gait. Furthermore, these results highlight the need for accurate objective methods of identifying freezing events when assessing future clinical interventions aimed at reducing this potentially disabling symptom of Parkinson's disease.

Variability and predictors of mental disorder rates and medical practitioner responses across Australian general practices

OBJECTIVE

To determine the variation in prevalence of common mental disorders and general practitioner (GP) responses across Australian general practices, and to identify practice characteristics that predict these rates.

DESIGN

Cross-sectional national audit of general practices throughout Australia in 1998-1999.

PARTICIPANTS

46515 ambulatory care patients attending 386 GPs.

MAIN OUTCOME MEASURES

Practice-based prevalence of mental disorders (based on patient-reported symptoms) and GP-reported rates of psychological diagnoses and treatment (median and range, excluding the upper and lower 10% of practices); practice characteristics (patient, doctor and organisational) that predict prevalences and rates, determined by multiple regression analysis.

RESULTS

Even after omitting the upper and lower 10% of practices, there were large variations between practices in prevalence of common mental disorders (range, 39% to 59% of patients; median, 48%), and substance misuse (range, 3%-13%; median, 7%). There were also large variations between practices in rates at which GPs made psychological diagnoses in each practice (range, 12%-51%; median, 27%), judged patients to be at risk to self or others (range, 6%-54%; median, 23%), provided psychological treatments (range, 8%-41%; median, 22%) and referred patients to specialist services (range, 1%-10%; median, 4%). Practice-based rates of disorders and GP responses were predicted not only by sociodemographic characteristics of patients in each practice (eg, mean age or proportion of unemployed people), but also by doctor characteristics (eg, age and sex) and practice organisation characteristics (eg, urban versus regional or rural location).

CONCLUSION

We identified patient, GP and practice characteristics that predict rates of mental disorder and treatments provided. These could be used to guide mental health service reform in general practice and assist with targeting relevant education and practice support programs.

Development of a simple screening tool for common mental disorders in general practice

OBJECTIVE

To develop and validate a self-report screening tool for common mental disorders.

DESIGN AND SETTING

Sequential development and validation studies in three cohorts of patients in general practice and one cohort of patients in a specialist psychiatry clinic.

PARTICIPANTS

1585 patients in general practice examined cross-sectionally and longitudinally; 46515 patients attending 386 general practitioners nationwide; 364 patients participating in a longitudinal study of psychiatric disorders in general practice; and 522 patients attending a specialist psychiatry clinic.

MAIN OUTCOME MEASURES

Performance of the 12 items from the 34-item SPHERE questionnaire against DSM-III-R and DSM-IV diagnoses of psychiatric disorder, self-reported Brief Disability Questionnaire findings, GPs' ratings of patients' needs for psychological care and degree of risk resulting from mental disorder, and patients' and GPs' reports of reasons for presentation.

RESULTS

Six somatic and six psychological questions identify two levels (and three types) of mental disorder: patients reporting both characteristic psychological and somatic symptoms (Level 1, Type 1), and patients reporting either psychological symptoms (Level 2, Type 2) or somatic symptoms (Level 2, Type 3). This classification system predicts disability ratings (Level 1, 8.2 "days out of role in the last month" and Level 2, 4.1 and 5.4 "days out of role in the last month" for Types 2 and 3, respectively), rates of lifetime psychiatric diagnoses (Level 1, 63% and Level 2, 59% and 48%, respectively), both patients' and GPs' report of reasons for presentation, and doctors' ratings of risk as a result of mental disorder. There are important and differing sociodemographic correlates for the three types of mental disorders.

CONCLUSION

A classification system based on the 12 items from the 34-item SPHERE questionnaire can be used to identify common mental disorders. This system has acceptable validity and reliability, and is suited specifically for general practice settings.

Unmet need for recognition of common mental disorders in Australian general practice

OBJECTIVE

To determine the rate and predictors of unmet need for recognition of common mental disorders in Australian general practice.

DESIGN AND SETTING

Cross-sectional national audit of general practices throughout Australia in 1998-1999.

PARTICIPANTS

46 515 ambulatory care patients attending 386 GPs.

SCREENING TOOLS

Prevalence of common mental disorders--12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of recognition of mental disorders by GPs--GPs reporting whether patients had depression, anxiety, mixed depression/anxiety, somatoform, or other psychological disorder; predictors of unmet need for recognition of mental disorders--self-report questions about demography for patients and GPs, and about practice organisation for GPs.

MAIN OUTCOME MEASURES

Reported recognition of psychological disorders by GPs; actual prevalence of disorders; and patient, GP and practice characteristics predicting the failure to recognise disorders.

RESULTS

GPs did not recognise mental disorder in 56% (11922/21210) of patients. These comprised 46% (5134/11060) of patients in the higher level of mental disorders, and (in the second level of disorders) 58% (2906/5036) of patients with predominantly psychological symptoms, and 76% (3882/5114) of those with predominantly somatic symptoms. Patients more likely to have their need for psychological assessment met had the following characteristics: middle-aged (odds ratio [OR], 1.76; 95% CI, 1.59-1.96), female (OR, 1.19; 95% CI, 1.12-1.27), Australian-born (OR, 1.16; 95% CI, 1.08-1.24), unemployed (OR, 1.75; 95% CI, 1.64-1.89), single (OR, 1.52; 95% CI, 1.41-1.61), presenting with mainly psychological symptoms (OR, 3.54; 95% CI, 3.28-3.81), and presenting for psychological reasons (OR, 4.20; 95% CI, 3.02-5.82). Characteristics of doctors associated with meeting patients' need for assessment were being aged over 35 years (OR, 1.51; 95% CI, 1.09-2.08), having an interest in mental health (OR, 1.27; 95% CI, 1.15-1.41), having had previous mental health training (OR, 1.29; 95% CI, 1.15-1.45), being in part-time practice (OR, 1.23; 95% CI, 1.09-1.39), seeing fewer than 100 patients per week (OR, 1.29; 95% CI, 1.13-1.47), working in practices with fewer than 2000 patients (OR, 1.28; 95% CI, 1.13-1.45) and working in regional centres (OR, 1.16; 95% CI, 1.05-1.28).

CONCLUSION

Unmet need for recognition of common mental disorders remains high. Predictors of unmet need include a somatic symptom profile and practitioner and organisational characteristics which impede the provision of high quality mental health services.

Treatment of common mental disorders in Australian general practice

OBJECTIVE

To determine the rates and predictors of treatments for patients with common mental disorders in Australian general practice.

DESIGN AND SETTING

Cross-sectional national audit of general practices throughout Australia in 1998-1999.

PARTICIPANTS

46 515 ambulatory care patients attending 386 GPs.

SCREENING TOOLS

Prevalence of common mental disorders--12 items from the 34-item SPHERE self-report questionnaire and associated classification system; pharmacological and non-pharmacological treatment provided, as reported by the GPs--questions relating to treatments provided; predictors of treatments--self-report questions about demography for patients and GPs, and about practice organisation for GPs.

MAIN OUTCOME MEASURES

GPs' reported provision of pharmacological and nonpharmacological treatments; and patient, GP and practice characteristics predicting treatment provision.

RESULTS

There were complete data on treatment for 39 983 patients. 27% (10752) of all patients received some form of intervention; 21% (8304) received non-pharmacological and 12% (4765) received pharmacological treatments. Non-pharmacological treatments were mostly non-specific counselling and support (83%; 6892/8304). Among the 10303 patients with the most severe level of psychological disorders, only 50% (5152) received any intervention (38% [3872] received non-pharmacological and 27% [2766] pharmacological treatments). Evidence-based treatments were provided to only 12% (4961) of all patients (and only 27% [2802] of the 10303 with the most severe disorders). Although the newer antidepressant agents were commonly prescribed, older medications (mainly tricyclic antidepressants) were prescribed to older (OR, 1.29; 95% CI, 1.07-1.56), less educated (OR, 1.41; 95% CI, 1.12-1.79) and female (OR, 1.44; 95% CI, 1.23-1.70) patients. Among the 8304 patients receiving non-pharmacological treatments, specific (evidence-based) treatments were provided to only 17% (1412); these patients were typically middle-aged (OR, 2.94; 95% CI, 2.32-3.73) and the providing GPs were typically not in full-time practice (OR, 3.34; 95% CI, 2.56-4.17).

CONCLUSION

Practitioners largely provide non-specific, non-pharmacological interventions for patients with common mental disorders. Even among those with the most severe disorders, only a minority receive pharmacological or specific evidence-based non-pharmacological treatments.

Comorbidity of common mental disorders and alcohol or other substance misuse in Australian general practice

OBJECTIVE

To determine in patients attending general practice 1) the extent of comorbidity of mental disorders and alcohol or other substance misuse, and consequent disability; and 2) GPs' diagnosis and management of patients with comorbidity.

DESIGN AND SETTING

Cross-sectional national audit of general practices throughout Australia in 1998-1999.

PARTICIPANTS

46 515 ambulatory care patients attending 386 GPs.

SCREENING TOOLS

Prevalence of common mental disorders--12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of alcohol or other substance misuse--two self-report screening questions, defining "probable" misuse (a positive response to both questions) and "possible" misuse (a positive response to one of the questions); disability--four items from the Brief Disability Questionnaire, and self-reported "days out of role" and "days in bed" in the past month; and rates of psychological diagnosis, treatment and referral by GPs, and GPs' rating of patients' psychological risk.

MAIN OUTCOME MEASURES

Comorbidity of mental disorders and alcohol or other substance misuse; disability; and correlation with GPs' diagnosis and management.

RESULTS

The screening questions revealed possible alcohol or other substance misuse in 11% of patients (5171/46515), and probable misuse in an additional 8% of patients (3593/46515). Comorbidity of mental disorders and substance misuse occurred in 12% (5672/46515) of patients. Patients with comorbidity (compared with those with alcohol or other substance misuse alone) were: more disabled--mean "days out of role in the last month", 8.4 (95% CI, 7.7-9.1) v 3.6 (95% CI, 2.9-4.3); at greater psychological risk (as rated by GPs)--22% v 7%, respectively; more frequently given psychological diagnoses by GPs--51% v 21%; more frequently treated for a psychological condition by GPs--47% v 17%; and more frequently referred to mental health specialists by GPs--9% v 2%.

CONCLUSION

Comorbidity of mental disorders and alcohol or other substance misuse is common in patients attending general practice, and results in considerable disability. Such patients receive inadequate attention (diagnosis and management) from GPs. GPs identifying one of these two types of behaviour disorder in a patient should ascertain whether the other type is also present.

Effects of mental health training and clinical audit on general practitioners' management of common mental disorders

OBJECTIVE

To evaluate the effects of a seminar-based training program and clinical practice audit on general practitioners' (GPs') knowledge and management of common mental disorders.

DESIGN

Survey of GPs' knowledge before and after training, and clinical practice audit and re-audit after feedback.

PARTICIPANTS AND SETTING

GP volunteers from around Australia in 1998-1999: 1008 completed the pre-training test, 190 the post-training test, 386 the first audit (33235 patients), and 157 of these the re-audit (13280 patients), with 57 undertaking both audit and training.

INTERVENTIONS

Four-seminar, 12-hour training program focused on improving GPs' capacity to identify and manage patients with depression and anxiety; practice audit with patient- and practice-based feedback on diagnosis and treatment of common mental disorders.

MAIN OUTCOME MEASURES

Scores on pre- and post-training knowledge tests; self-rated improvements in confidence in managing patients with mental disorders after training; rates of psychological diagnoses and treatment by GPs on first audit and re-audit.

RESULTS

GPs' knowledge of pharmacological treatments and clinical management improved after the training program (P<0.001), and 97% of GPs reported increased confidence in their management skills. GPs who undertook training had higher diagnosis rates for common mental disorders in the first audit than those who did not undertake training (36% versus 29%; P<0.001), and their diagnosis rates increased over time (36% to 39%; P<0.01), while those of GPs who did not undertake training were unchanged. Similarly, GPs who undertook training provided more mental health treatments than those who did not (30% versus 27% in the first audit [P<0.001], and 31% versus 24% at reaudit [P<0.001]). They also place greater emphasis on use of nonpharmacological treatments (24% versus 21% at first audit [P<0.001], and 25% versus 19% at re-audit [P<0.001]).

CONCLUSION

Clinical audits may heighten awareness of mental disorders, but, on their own, they do not improve mental health practice. A relatively brief but skills-based training program may contribute to better management of patients with common mental disorders by increasing GPs' confidence and competence.