Rates of depression among men attending high-HIV-caseload general practices in Australia

This paper compares rates of current depression among men attending high-HIV-caseload general practices in New South Wales and South Australia. Current depression was assessed by the treating general practitioner (GP), using the nine-item Patient Health Questionnaire (PHQ-9), and by patient self-reporting. The study found that GPs, the PHQ-9 screening tool and patients were equally likely to identify current depression. High rates of depression were observed among the men attending general practice, with the highest rates among men with HIV and men who did not identify as either heterosexual or homosexual.     

Patients' experiences of receiving collaborative care for the treatment of depression in the UK: a qualitative investigation

Objective We explored the experiences of patients who received treatment for depression during a 'phase II' platform trial of collaborative care in the UK.Method Semi-structured interviews were used to obtain information from 13 patients receiving collaborative care. Patients from a range of general practitioner (GP) practices within the trial were purposively sampled. The constant comparative approach within a framework analysis was used to identify emerging concepts and key themes.Results Three distinct themes in people's experience of collaborative care were identified: (1) the process of collaborative care; (2) the content of collaborative care; and (3) staying well. These themes were set against a backdrop in which patients described how they had been struggling with lowmood. Our central therapeutic ingredients of information giving, behavioural activation and medication management were supported by patients. Patients expressed reservations about the rigid inflexibility of telephone-based treatment.Conclusions While most of the protocol elements were supported by patients, we have been able to amend our protocol to allow for greater delivery flexibility and more attention to the therapeutic alliance and relapse prevention. We are now testing this in a multicentre randomised controlled trial.     

Depression remission after six months of collaborative care management: role of initial severity of depression in outcome

Aim The impact of initial severity of depression on the rate of remission has not been well studied. The hypothesis for this study was that increased depression severity would have an inverse relationship on clinical remission at six months while in collaborative care management.Participants The study cohort was 1128 primary care patients from a south-eastern Minnesota practice and was a longitudinal retrospective chart review analysis.Results Clinical remission at six months was less likely in the severe depression group at 29.6% compared with 36.9% in the moderately severe group and 45.6% in the moderate depression group (P < 0.001). Multivariate analysis of a sub-group demonstrated that increased initial anxiety symptoms (odds ratio [OR] 0.9645, 95% confidence interval [CI] 0.9345–0.9954, P = 0.0248) and an abnormal screening for bipolar disorder (OR 0.4856, 95% CI 0.2659–0.8868, P = 0.0187) predicted not achieving remission at six months. A patient with severe depression was significantly less likely to achieve remission at six months (OR 0.6040, 95% CI 0.3803–0.9592, P = 0.0327) compared with moderate depression, but not moderately severe depression (P = 0.2324). There was no statistical difference in the adjusted means of the PHQ-9 score for those patients who were in remission at six months. However, in the unremitted patients, the six-month PHQ-9 score was significantly increased by initial depression severity when controlling for all other variables.Conclusion Multivariate analysis in our study demonstrated that patients with severe depression have a decreased OR for remission at six months compared with moderate depression. Also, there was a significant increase in the six-month PHQ-9 score for those unremitted patients in the severe vs. moderate depression groups.     

Effects of an educational outreach campaign (IMPACT) on depression management delivered to general practitioners in one primary care trust

Objective An educational outreach initiative with general practitioners (GPs) within Walsall, led by pharmacists and aimed at delivering evidence-based guidance on stepped care management of clinical depression.Methods Standardised educational material was produced with key messages and contributions by experts on prescribing principles and management of clinical depression based on NICE guidance. The primary care pharmacists together with a psychiatrist or other professional delivered the training through initial face-to-face meetings with GP practices and carrying out follow-up visits.Evaluation Analysis of prescribing data (PACT) on antidepressants, which included prescribing of defined daily doses (DDD) and net ingredient cost (NIC) of commonly prescribed antidepressants for the whole of Walsall teaching Primary Care Trust (tPCT) and comparison with prescribing data for the West Midlands and for England during the period June 2000 to June 2006.Results The use of Fluoxetine increased slightly and the prescribing of Dosulepin continued to fall. The prescribing of Escitalopram, which had steadily increased prior to the launch of campaign, showed decline, resulting in savings of over ￡50K in the year 2005 to 2006. This was in comparison to a relative increase in the prescribing for Escitalopram for the same time period in the West Midlands and nationally. Prescribing of Dosulepin continued to fall. The total cost of prescribing for the four antidepressants fell and theses changes were sustained over the following year.Conclusions The educational outreach campaign successfully influenced prescribing behaviour in terms of adhering to NICE guidance and cost-effective prescribing, and also facilitated improved communication among clinicians at the primary-secondary care interface.     

A feasibility study of a telephone-supported self-care intervention for depression among adults with a comorbid chronic physical illness in primary care

Objective We assessed the feasibility and acceptability to patients of a telephone-supported self-care intervention for depression among adults aged 40 years or over with one of six targeted chronic physical illnesses and comorbid depressive symptoms in family practice settings.Methods An open, uncontrolled trial (feasibility study) was conducted among patients treated in Montreal family practices. Eligible patients were aged 40 years or over, had one or more of the targeted chronic physical illnesses for at least 6 months (arthritis, hypertension, diabetes, heart disease, asthma and chronic obstructive pulmonary disease) and were evaluated as having at least mild depressive symptoms (a score of ≥ 5 on the 9-item Patient Health Questionnaire, PHQ-9). Participants received a package of six self-care tools (information booklet, video, Internet programme, action plan, workbook and mood-monitoring tool) with telephone support by a lay coach for up to 6 months.Results In total, 63 eligible patients provided written consent and completed the baseline interview; 57 (90%) and 55 (87%) patients completed 2-month and 6-month follow-up interviews, respectively. The mean number of telephone calls made by coaches to participants was 10.5 (SD 4.0), and the average length of these calls was 10.6 minutes. At the 6-month follow-up, 83.6% of the participants reported that one or more of the tools were helpful. Clinically significant improvements were seen in depressive symptoms (as assessed by the PHQ-9) at 6 months, with an effect size of 0.88 (95% CI, 0.55, 1.14).Conclusion A telephone-supported self-care intervention for depression was feasible, was acceptable to patients, and was associated with a significant 6-month improvement in depressive symptoms. A randomised trial of this intervention is justified.     

Compiling a register of patients with moderate or severe learning disabilities: experience at one United Kingdom general practice

Background Identifying patients with learning disabilities within primary care is central to initiatives for improving the health of this population. UK general practitioners (GPs) receive additional income for maintaining registers of patients with learning disabilities as part of the Quality and Outcomes Framework (QOF), and may opt to provide Directed Enhanced Services (DES), which requires practices to maintain registers of patients with moderate or severe learning disabilities and offer them annual health checks.Objectives This paper describes the development of a register of patients with moderate or severe learning disabilities at one UK general practice.Methods A Read code search of one UK general practice's electronic medical records was conducted in order to identify patients with learning disabilities. Confirmation of diagnoses was sought by scrutinising records and GP verification. Cross-referencing with the practice QOF register of patients with learning disabilities of any severity, and the local authority's list of clients with learning disabilities, was performed.Results Of 15 001 patients, 229 (1.5%) were identified by the Read code search as possibly having learning disabilities. Scrutiny of records and GP verification confirmed 64 had learning disabilities and 24 did not, but the presence or absence of learning disability remained unclear in 141 cases. Cross-referencing with the QOF register (n=81) and local authority list (n=49) revealed little overlap.Conclusion Identifying learning disability and assessing its severity are tasks GPs may be unfamiliar with, and relying on Read code searches may result in under-detection. Further research is needed to define optimum strategies for identifying, cross-referencing and validating practice-based registers of patients with learning disabilities.     

Patient characteristics that may predict the likelihood of the presence of mental health problems in patients attending the general outpatient clinic of a tertiary hospital in South-South Nigeria

Background A considerable number of patients seen in general outpatient clinics (GOPC) are known to suffer from psychiatric rather than physical disorders. Studies have shown that doctors working in these clinics have difficulty in making accurate ratings of mental health problems in their patients and have poor knowledge of psychiatric diagnosis. Accurate recognition of psychiatric symptoms in a patient is essential for specific diagnosis and successful management. There is a need for the use of an easy tool such as the12-item General Health Questionnaire (GHQ-12) for screening and identification of psychopathologies especially in a busy clinic setting like the GOPC. Aside from psychometric screening tools, patients' sociodemographic characteristics such as gender, age, marital status, occupation, education etc. have been found to be of value in predicting those at risk.Objectives This study seeks to correlate GHQ 'caseness' with sociodemographic factors and to compare physician diagnosis with GHQ diagnosis.Subjects and method Three-hundred and twenty-two respondents were recruited for the study by a systematic random sampling method. Using a cut off score of three on both the English and Efik translation versions of the GHQ-12, 'cases' and 'non-cases' generated were compared with the same classification as identified by the GOPC doctors. Identification rates for both groups were calculated and the coefficients determined using a two-by-two contingency table. Sociodemographic correlates were determined by statistical comparison of the classifications in both groups.Results Statistically significant differences in sociodemographic characteristics of respondents were found for age (χ(2)=48.97; P <0.05) and education (χ(2)=45.64; P=0.05) using their GHQ-12 scores, and for occupation (χ(2)=37.90; P <0.05) among those seen by the GOPC doctors. A further comparison of identified 'cases' and 'non-cases' by doctors again revealed significant difference for age (χ(2)=7.151; P <0.05). Sex as a sociodemographic characteristic showed no statistically significant difference though a greater percentage of females (57.3%) were observed as 'high scorers' as compared to their male counterparts (42.7%). The GHQ-12 identified 46.6% 'cases' while the GOPC doctors identified 6.8% among the attendees with a diagnostic sensitivity of 8% and a specificity of 94%, respectively.Conclusion Belonging to the 18-39 years age group, being employed and having less than 12 years of education were the patients' characteristics that suggested the likelihood of the presence of mental health problems.This study also revealed that despite the high proportion of psychiatric morbidity (46.6%) in the GOPC of the University of Calabar Teaching Hospital (UCTH) rate of detection by the clinic doctors was low (6.8%).It is recommended that primary care doctors should be alerted to the possibility that clinically significant psychiatric morbidity may be present in GOPC attendees. The correlation between patients' sociodemographic parameters and presence of mental health problems could be informative and should be given adequate attention during consultation.     

Bereavement in the elderly: the role of primary care

Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members'' burden and suffering.     

Screening for suicidal thoughts in primary care: the views of patients and general practitioners

Background It has been argued that primary care practitioners have an important part to play in the prevention of suicide. However, levels of assessment of risk of suicide among patients treated in this setting are generally low.Methods Cross-sectional survey of general practitioners (GPs) and people being treated in primary care who had signs of depression. The study combined open and closed questions on attitudes to screening or being screened for suicidal ideation.Results One hundred and one of 132 patients took part in the survey and 103 of 300 GPs completed a questionnaire. A majority of both GPs and patients stated that people should be screened for suicidal ideation. However, an important minority of patients and GPs stated that asking or being asked such questions made them feel uncomfortable. Less than half of GPs had received formal training on the assessment of suicide risk. GPs told the researchers that barriers to screening included time pressures, culture and language, and concerns about the impact that screening could have on people's mental health. One-quarter of GPs and one-fifth of patients supported the notion that screening for suicidal ideation could induce a person to have thoughts of self-harm.Conclusions GPs and family doctors should screen for suicidal risk among depressed patients and should receive training on how to do this as part of their general training in the assessment and management of mental disorders. Research should be conducted to examine what, if any, effect screening for suicidal ideation has on mental health.     

Explanatory models of medically unexplained symptoms: a qualitative analysis of the literature

Background Medically unexplained symptoms (MUS) are common in primary health care. Both patients and doctors are burdened with the symptoms that negatively affect patients' quality of life. General practitioners (GPs) often face difficulties when giving patients legitimate and convincing explanations for their symptoms. This explanation is important for reassuring patients and for maintaining a good doctor-patient communication and relationship.Objective To provide an overview of explanatory models for MUS.Study design We performed a systematic search of reviews in PsycINFO and PubMed about explanatory models of MUS. We performed a qualitative analysis of the data according to the principles of constant comparative analysis to identify specific explanatory models.Results We distinguished nine specific explanatory models of MUS in the literature: somatosensory amplification, sensitisation, sensitivity, immune system sensitisation, endocrine dysregulation, signal filter model, illness behaviour model, autonomous nervous system dysfunction and abnormal proprioception. The nine different explanatory models focus on different domains, including somatic causes, perception, illness behaviour and predisposition. We also found one meta-model, which incorporates these four domains: the cognitive behavioural therapy model.Conclusion Although GPs often face difficulties when providing explanations to patients with MUS, there are multiple explanatory models in the scientific literature that may be of use in daily medical practice.     

Focus: Preventive Medicine: Pre-Participation Screening of Athletes: Primary Health Care Physicians’ Knowledge,Experience, and Approach in Turkey

Pre-participation screening (PPS) is crucial for assessing the competitive athletes since their risk of sudden death is higher than non-athletes. In Turkey, PPS is performed at the primary health care setting by primary care physicians (PCPs) who are family medicine specialists (FMSs) or general practitioners (GPs). Although there are national guidelines, there is no legal regulation for this process. This study aims to evaluate PCPs’ knowledge, experience, and approach about PPS. We prepared an online survey for PCPs and used non-probabilistic sampling. PPS attitudes and practices were analyzed and compared according to factors such as experience, education, and being GP or FMS. Of the 214 PCPs included in the study, 39.3% were female. The mean age was 44.9 years (SD:8.88). The average work experience was 7.9 years. Most participants were aware of their authorization to perform PPS (89.7%) and had previously prepared it (90.2%). However, 6.5% of them felt confident in performing PPS. Only 13.1% were aware of the guidelines. Almost 25% of the participants stated being informed about the subject at some part of their career, but this did not affect the confidence or referral decisions. In addition to medical history and physical examination, further testing was considered necessary by 96.3% of the participants. Significantly more tests were ordered by GPs than FMSs (p=0.026 and p=0.011, respectively). The accurate referral decision ratio was 59.3%, without difference between FMSs and GPs (p=0.216). We found that awareness of the guidelines was low among PCPs who lack confidence in PPS. These factors collectively increased the tendency for unnecessary further testing and referral. Therefore, the PPS implementation into medical school and residency curriculums and national legal regulation for the process is a necessity in Turkey.     

Making sense of medically unexplained symptoms in general practice: a grounded theory study

Background General practitioners often encounter patients with medically unexplained symptoms. These patients share many common features, but there is little agreement about the best diagnostic framework for describing them.Aims This study aimed to explore how GPs make sense of medically unexplained symptoms.Design Semi-structured interviews were conducted with 24 GPs. Each participant was asked to describe a patient with medically unexplained symptoms and discuss their assessment and management.Setting The study was conducted among GPs from teaching practices across Australia.Methods Participants were selected by purposive sampling and all interviews were transcribed. Iterative analysis was undertaken using constructivist grounded theory methodology.Results GPs used a variety of frameworks to understand and manage patients with medically unexplained symptoms. They used different frameworks to reason, to help patients make sense of their suffering, and to communicate with other health professionals. GPs tried to avoid using stigmatising labels such as ‘borderline personality disorder’, which were seen to apply a ‘layer of dismissal’ to patients. They worried about missing serious physical disease, but managed the risk by deliberately attending to physical cues during some consultations, and focusing on coping with medically unexplained symptoms in others. They also used referrals to exclude serious disease, but were wary of triggering a harmful cycle of uncoordinated care.Conclusion GPs were aware of the ethical relevance of psychiatric diagnoses, and attempted to protect their patients from stigma. They crafted helpful explanatory narratives for patients that shaped their experience of suffering. Disease surveillance remained an important role for GPs who were managing medically unexplained symptoms.     

The pattern of physical comorbidity and the psychosocial determinants of depression: a prospective cohort study on a representative sample of family practice attendees in Slovenia

Objectives This study aims to present the patterns of physical comorbidity in depressed patients and factors strongly associated with depression in a representative sample of Slovenian family practice attendees.Methods Medical data was obtained for 911 general practice attendees. Of them, 221 (24.3%) were diagnosed as depressed. The depressive states of the subjects were evaluated using the Composite International Diagnostic Interview (CIDI). Physical comorbidity was assessed with a questionnaire covering the most common health problems in the Slovenian adult population. Several psycho-social factors were also analysed.Results Those variables significantly related to ICD depression were included in multivariate binary logistic regression analysis, adjusted by age, gender and education. The calculation included the chi-square, odds ratio (OR) with confidence interval (95% CI) and P-value. A P-value < 0.05 was marked as statistically significant.Conclusions There was no significant difference in the number of concurrent chronic diseases in depressed and non-depressed subjects. The risk of depression was increased by the presence of several concomitant factors. The burden of somatic co-morbidity was shown to be smaller than the impact of psychosocial determinants, which also acted as protective factors: the feeling of safety at home and the absence of problems in intimate relationships. The abuse of alcohol and drugs by a family member and current poor financial situation were strongly associated with depression. The impact of concurrent incontinence and chronic bowel disease was also important, though somewhat weaker.     

Maternal adverse childhood experiences,child mental health,and the mediating effect of maternal depression: A cross-sectional,population-based study in rural,southwestern Uganda

Objectives

This study aimed to examine the intergenerational effects of maternal adverse childhood experiences (ACEs) and child mental health outcomes in rural Uganda, as well as the potentially mediating role of maternal depression in this pathway. Additionally, we sought to test the extent to which maternal social group membership attenuated the mediating effect of maternal depression on child mental health.

Methods

Data come from a population-based cohort of families living in the Nyakabare Parish, a rural district in southwestern Uganda. Between 2016 and 2018, mothers completed surveys about childhood adversity, depressive symptoms, social group membership, and their children's mental health. Survey data were analyzed using causal mediation and moderated-mediation analysis.

Results

Among 218 mother–child pairs, 61 mothers (28%) and 47 children (22%) showed symptoms meeting cutoffs for clinically significant psychological distress. In multivariable linear regression models, maternal ACEs had a statistically significant association with severity of child conduct problems, peer problems, and total child difficulty scores. Maternal depression mediated the relationship between maternal ACEs and conduct problems, peer problems, and total difficulty, but this mediating effect was not moderated by maternal group membership.

Conclusions

Maternal depression may act as a potential mechanism linking maternal childhood adversity with poor child mental health in the next generation. Within a context of elevated rates of psychiatric morbidity, high prevalence of childhood adversity, and limited healthcare and economic infrastructures across Uganda, these results emphasize the prioritization of social services and mental health resources for rural Ugandan families.     

Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability

Integration of mental health into primary care is essential to meet population needs yet faces many challenges if such projects are to achieve impact and be sustainable in low income countries alongside other competing priorities. This paper describes the rationale and progress of a collaborative project in Kenya to train primary care and community health workers about mental health and integrate mental health into their routine work, Within a health systems strengthening approach. So far 1877 health workers have been trained. The paper describes the multiple challenges faced by the project, and reviews the mechanisms deployed which have strengthened its impact and sustainability to date.     

Challenging the racialization of child sexual exploitation: Muslim men,racism and belonging in Rotherham

This paper presents findings from original research exploring the impact on Muslim men of a child sexual exploitation scandal that attracted significant attention to the northern English town where they live and contributed to a sustained detrimental effect on local community relations. It foregrounds men’s accounts to reveal their agency and resilience in responding to racism that they identified as resulting from the scandal. It reveals how their accounts disrupt dominant discourses foregrounding Muslim self-segregation and lack of integration, demonstrating positive attachments and claims to localized space, and commitment to belonging. In doing so, it shows how men’s responses to racism challenge racialized forms of knowledge about Muslims. The paper draws attention to the significance of localized forms of belonging in facilitating the inclusion of Muslim minorities. It also highlights the importance of centring Muslim men as historically speaking subjects in accounts of issues involving them.     

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool,GRiST

Aim To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care.Background Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients'' care pathways, within general practice and IAPT services.Methods Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants'' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis.Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems.Conclusions A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.     

The role of extracellular potassium dynamics in the different stages of ictal bursting and spreading depression: A computational study

Experimental evidences point out the participation of nonsynaptic mechanisms (e.g., fluctuations in extracellular ions) in epileptiform bursting and spreading depression (SD). During these abnormal oscillatory patterns, it is observed an increase of extracellular potassium concentration [K⁺]_o and a decrease of extracellular calcium concentration [Ca²⁺]_o which raises the neuronal excitability. However, whether the high [K⁺]_o triggers and propagates these abnormal neuronal activities or plays a secondary role into this process is unclear. To better understand the influence of extracellular potassium dynamics in these oscillatory patterns, the experimental conditions of high [K⁺]_o and zero [Ca²⁺]_o were replicated in an extended Golomb model where we added important regulatory mechanisms of ion concentration as Na⁺-K⁺ pump, ion diffusion and glial buffering. Within these conditions, simulations of the cell model exhibit seizure-like discharges (ictal bursting). The SD was elicited by the interruption of the Na⁺−K⁺ pump activity, mimicking the effect of cellular hypoxia (an experimental protocol to elicit SD, the hypoxia-induced SD). We used the bifurcation theory and the fast-slow method to analyze the interference of K⁺ dynamics in the cellular excitability. This analysis indicates that the system loses its stability at a high [K⁺]_o, transiting to an elevated state of neuronal excitability. Effects of high [K⁺]_o are observed in different stages of ictal bursting and SD. In the initial stage, the increase of [K⁺]_o creates favorable conditions to trigger both oscillatory patterns. During the neuronal activity, a continuous growth of [K⁺]_o by outward K⁺ flow depresses K⁺ currents in a positive feedback way. At the last stage, due to the depression of K⁺ currents, the Na⁺-K⁺ pump is the main mechanism in the end of neuronal activity. Thus, this work suggests that [K⁺]_o dynamics may play a fundamental role in these abnormal oscillatory patterns.