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Two of the authors were general practitioners (GPs) in the 1980s, when there was much interest in consultation, stimulated by the psychoanalyst Michael Balint. Around one in five psychiatrists worked in consultation liaison in general practice at that time, but in the 1990s this was stopped to increase the focus on psychosis. However, the Royal College of Psychiatrists and Royal College of General Practitioners have a strong history of collaboration, and many psychiatrists, nurses and GPs trained together in the national Trailblazers programme, focusing on service delivery in all areas of mental health. Recent proposals for mental health community collaborative networks from the NHS provide an opportunity for psychiatrists to work with GPs and a range of other professionals once more, for complex non-psychotic illness that cannot be helped by Improving Access to Psychological Therapies services. The circle is closing for GPs like us, who were working in the 1980s.
Depression is a well-known risk factor for recurrent cardiac events (RCEs) but findings are less consistent for anxiety, not previously reported on using a time-dependent approach. We aimed to study the prognostic effect of anxiety and depression symptom levels on RCEs.
Data (N = 595) were drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Hospital Anxiety and Depression Scale symptoms were grouped into: agitation (three items), anxiety (four items), and depression (seven items) subscales. We performed two types of multivariate analyses using Cox proportional hazard models with delayed entry: with baseline variables (long-term analysis), and with variables measured 12-to-18 months prior to the event (short-term time-dependent analysis), as RCE risk factors.
In the baseline analysis, both anxiety and depression, but not agitation, were separate RCE risk factors, with a moderating effect when considered jointly. In the short-term time-dependent analysis, elevated scores on the anxiety subscale were associated with increased RCE risk even when adjusted for depression [hazard ratio (95% confidence interval) 1.22 (1.05–1.41), p = 0.009]. Depression was no longer a significant predictor when adjusted for anxiety [1.05 (0.87–1.27), p = 0.61]. For anxiety, individual items associated with RCEs differed between the two approaches: item 5 ‘worrying thoughts’ was the most significant long-term risk factor [1.52 (1.21–1.91), p = 0.0004] whereas item 13 ‘feelings of panic’ was the most significant time-dependent short-term risk factor [1.52 (1.18–1.95), p = 0.001].
Anxiety is an important short-term preventable and potentially causal risk factor for RCEs, to be targeted in secondary cardiac disease prevention programmes.
Antidepressant prescribing patterns and factors influencing the choice of antidepressant for the treatment of depression were examined in the Factors Influencing Depression Endpoints Research (FINDER) study, a prospective, observational study in 12 European countries of 3468 adults about to start antidepressant medication for their first episode of depression or a new episode of recurrent depression. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed antidepressant (63.3% patients), followed by serotonin-norepinephrine reuptake inhibitors (SNRIs, 13.6%), but there was considerable variation across countries. Notably, tricyclic and tetracyclic antidepressants (TCAs) were prescribed for 26.5% patients in Germany. The choice of the antidepressant prescribed was strongly influenced by the previous use of antidepressants, which was significantly associated with the prescription of a SSRI (OR 0.64; 95% CI 0.54, 0.76), a SNRI (OR 1.49; 95% CI 1.18, 1.88) or a combination of antidepressants (OR 2.78; 95% CI 1.96, 3.96). Physician factors (age, gender, speciality) and patient factors (severity of depression, age, education, smoking, number of current physical conditions and functional syndromes) were associated with initial antidepressant choice in some models. In conclusion, the prescribing of antidepressants varies by country, and the type of antidepressant chosen is influenced by physician- as well as patient-related factors.
Factors influencing outcomes of depression in clinical practice, especially health-related quality of life (HRQoL), are poorly understood. The Factors Influencing Depression Endpoints Research (FINDER) study is a European prospective, observational study designed to estimate the HRQoL of adults with a clinically diagnosed depressive episode at baseline, and 3 and 6 months after commencing antidepressant medication. We report here the study design and baseline patient characteristics.
HRQoL was assessed by the 36-item Short-Form Health Survey (SF-36) and European Quality of Life-5 Dimensions (EQ-5D). Patient ratings on Hospital Anxiety and Depression Scale (HADS) and pain Visual Analogue Scale (VAS) were also obtained. Results (n = 3468) showed that SF-36 mental component summary (mean 22.2) was more than two SDs below general population norms (mean 50.0) and one SD below clinical depression norms (mean 34.8); the physical component summary (mean 46.1) was similar to general population (mean 50.0) and clinical depression norms (mean 45.0). Mean EQ-5D scores were also lower than general population norms. Mean HADS-Depression and -Anxiety subscores were 12.3 and 13.0, respectively. Fifty-six percent of patients reported an overall pain VAS score of at least 30 mm and 70% of these patients had no physical explanation for their pain.
Further investigation into factors associated with HRQoL in depression after treatment initiation is warranted.
Third-wave psychological interventions have gained relevance in mental health service provision but their application to people with psychosis is in its infancy and interventions targeting wellbeing in psychosis are scarce. This study tested the feasibility and preliminary effectiveness of positive psychotherapy adapted for people with psychosis (WELLFOCUS PPT) to improve wellbeing.
WELLFOCUS PPT was tested as an 11-week group intervention in a convenience sample of people with psychosis in a single centre randomised controlled trial (ISRCTN04199273) involving 94 people with psychosis. Patients were individually randomised in blocks to receive either WELLFOCUS PPT in addition to treatment as usual (TAU), or TAU only. Assessments took place before randomisation and after the therapy. The primary outcome was wellbeing (Warwick-Edinburgh Mental Well-Being Scale, WEMWBS). Secondary outcomes included symptoms (Brief Psychiatric Rating Scale), depression (Short Depression-Happiness Scale), self-esteem, empowerment, hope, sense of coherence, savouring beliefs and functioning, as well as two alternative measures of wellbeing (the Positive Psychotherapy Inventory and Quality of Life). Intention-to-treat analysis was performed. This involved calculating crude changes and paired-sample t-tests for all variables, as well as ANCOVA and Complier Average Causal Effect (CACE) Analysis to estimate the main effect of group on all outcomes.
The intervention and trial procedures proved feasible and well accepted. Crude changes between baseline and follow-up showed a significant improvement in the intervention group for wellbeing according to all three concepts assessed (i.e., WEMWBS, Positive Psychotherapy Inventory and Quality of Life), as well as for symptoms, depression, hope, self-esteem and sense of coherence. No significant changes were observed in the control group. ANCOVA showed no main effect on wellbeing according to the primary outcome scale (WEMWBS) but significant effects on symptoms (p = 0.006, ES = 0.42), depression (p = 0.03, ES = 0.38) and wellbeing according to the Positive Psychotherapy Inventory (p = 0.02, ES = 0.30). Secondary analysis adapting for therapy group further improved the results for symptom reduction (p = 0.004, ES = 0.43) and depression (p = 0.03, ES = 0.41) but did not lead to any more outcomes falling below the p = 0.05 significance level. CACE analysis showed a non-significant positive association between the intervention and WEMWBS scores at follow-up (b = 0.21, z = 0.9, p = 0.4).
This study provides initial evidence on the feasibility of WELLFOCUS PPT in people with psychosis, positively affecting symptoms and depression. However, more work is needed to optimise its effectiveness. Future research might evaluate positive psychotherapy as a treatment for comorbid depression in psychosis, and consider alternative measurements of wellbeing.
Depression is one of the most prevalent disorders in the general population, causing personal and social disability and impairment. Major studies assessing the diagnosis and management of depression have shown that it is often underdiagnosed and undertreated. A pan-European study aimed at assessing the extent and consequences of depression in six different countries is reported in this article. Different types of depressive profiles are analyzed and their respective management has been compared. The importance of improving diagnosis and treatment of depression is underlined. Appropriate management of depression depends on the recognition of depressive symptoms by patients, their possibility of seeking care, and the ability of the primary care physician to recognize the disorder and prescribe the appropriate medicines. Improvement in all of these fields is necessary.
Despite its high prevalence, help-seeking for depression is low.
To assess the effectiveness and cost-effectiveness of 1-day
cognitive–behavioural therapy (CBT) self-confidence workshops in reducing
depression. Anxiety, self-esteem, prognostic indicators as well as access
were also assessed.
An open randomised controlled trial (RCT) waiting list control design
with 12-week follow-up was used (trial registration: ISRCTN26634837). A
total of 459 adult participants with depression (Beck Depression
Inventory (BDI) scores of 14) self-referred and 382 participants (83%)
were followed up.
At follow-up, experimental and control participants differed
significantly on the BDI, with an effect size of 0.55. Anxiety and
self-esteem also differed. Of those who participated, 25% were GP
non-consulters and 32% were from Black and minority ethnic groups. Women
benefited more than men on depression scores. The intervention has a 90%
chance of being considered cost-effective if a depression-free day is
valued at £14.
Self-confidence workshops appear promising in terms of clinical
effectiveness, cost-effectiveness and access by difficult-to-engage
In this edition of the Journal, findings presented by Jokela and colleagues suggest some improvements in the equity of service provision of psychotherapies in the UK. This is encouraging, however, further work would be necessary to exclude other forms of inequity. For instance, people with equivalent need in different areas might find their needs are responded to with different durations of treatment.
Aims – This paper aims to describe current trends in the UK primary care management of common mental disorders and explore the appropriateness of differing management approaches in light of the course and common complications of these disorders. Methods – It highlights key findings concerning the course and comorbidity of depression to indicate that depression and associated mental illnesses may often form part of more complex patterns of ill health and that these conditions have a clear potential for chronicity. A narrative review of studies providing detail of depression prevalence in selected comorbid conditions is presented for this purpose. Conclusion – The presentation and course of common mental disorders indicate organizational changes in health service delivery, and - for a sizeable patient group – the use of chronic disease management strategies.
Child and adolescent mental health problems are common in primary care. However, few parents of children with mental health problems express concerns about these problems during consultations.
To explore the factors influencing parental help-seeking for children with emotional or behavioural difficulties.
Focus group discussions with 34 parents from non-specialist community settings who had concerns about their child's mental health. All groups were followed by validation groups or semi-structured interviews.
Most children had clinically significant mental health symptoms or associated impairment in function. Appointment systems were a key barrier, as many parents felt that short appointments did not allow sufficient time to address their child's difficulties. Continuity of care and trusting relationships with general practitioners (GPs) who validated their concerns were perceived to facilitate help-seeking. Parents valued GPs who showed an interest in their child and family situation. Barriers to seeking help included embarrassment, stigma of mental health problems, and concerns about being labelled or receiving a diagnosis. Some parents were concerned about being judged a poor parent and their child being removed from the family should they seek help.
Primary healthcare is a key resource for children and young people with emotional and behavioural difficulties and their families. Primary care services should be able to provide ready access to health professionals with an interest in children and families and appointments of sufficient length so that parents feel able to discuss their mental health concerns.
Depressive symptoms range along a continuum from everyday sadness to suicidal depression, and any cut-off between a ‘normal’ and a ‘depressed’ person is to an extent arbitrary, but categorical diagnoses are necessary in clinical practice to make decisions about intervening. Psychiatric classification systems identify a category of ‘major depression’ which predicts the need for active treatment, irrespective of environmental factors, except for bereavement (American Psychiatric Association, 2000).
Around three times as many depressed patients have symptom levels below the cut-off for major depression, which, though relatively mild, are still associated with significant distress and impairment of social functioning (Rapaport et al, 2002). Depression very commonly occurs with anxiety (see Chapter 10).
The multi-country survey of 2000–2001 undertaken by the World Health Organization (WHO) found that major depression affected around 5% of women and 3% of men per year. Depression was the fourth leading cause of disease burden among all diseases, responsible for, on average, 4.4% of total disability-adjusted life-years lost (ranging from 1.2% in Africa to 8.0% in the Americas), which had increased from 3.7% in 1990. Depression caused the largest amount of non-fatal burden among all diseases: 12.1% of total years lived with disability on average, which had increased from 10.7% in 1990 (Üstün et al, 2004).
Cross-sectional surveys have shown an increasing prevalence of depression, prompting talk of an epidemic of depression. The prevalence of major depression doubled among US adults between 1992 and 2002 (Compton et al, 2006). Depression is now the second (for women) or third (for men) biggest cause of long-term sickness benefits in the UK (Moncrieff & Pomerleau, 2000) and all high-income countries have seen year-on-year increases in antidepressant prescribing in primary care since the selective serotonin reuptake inhibitors (SSRIs) were introduced in 1990 (Middleton et al, 2001). Depression is predicted to be second after ischaemic heart disease in global health burden by 2020 (Murray & Lopez, 1997).
Andre Tylee, Head of the Section of Primary Care Mental Health in the Department of Health Services,
Annie Wallace, Project Director for Public Health Curriculum Development for the North East Teaching Public Health Network
Attempting a definition of mental health promotion
Defining mental health promotion (MHP) is at least as difficult a task as defining health promotion. In order to define it you need to be clear about where you sit in terms of how you define mental health. Confusingly, as with health generally, we define our mental health services as a place where we treat mental ill health. Unsurprisingly, the public still tend to think of mental health in terms of schizophrenia and depression. The World Health Organization (WHO), in defining ‘health’ in 1947, included mental health as part of an attempt at a holistic vision of health. In 2001, the WHO published the following definition of positive mental health:
a state of well-being in which the individual realises his or her own abilities, can cope with normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her own community. (WHO, 2001)
This definition, while capturing what many may view as good mental health, reflects the same arguments as physical well-being versus disability and leaves the survivors of mental health issues, to some extent, outside of the definition. Health and illness, however, can coexist. They are mutually exclusive only if health is defined in a restrictive way as the absence of disease (Sartorius, 1990). Lay beliefs about health vary across culture, gender, age and social circumstance; for example, young people in high-income countries tend to think in terms of fitness or healthy diet, older people in terms of inner strength and coping with life's challenges. However, the definitions of mental health we routinely use are culturally skewed, individualised and expert-led versions of what it means to be mentally healthy. For example, what these Westernised definitions fail to take account of might be the reliance on fate or a deity, or on some other belief system present in other cultural representations.
This chapter outlines the historical background of alcohol problems, current classificatory systems for diagnosis, psychological and physical related disorders, and the epidemiology of alcohol disorders. A variety of research methodologies have been adopted to examine the relative contribution of genetic and environmental factors to alcohol dependence. Explanatory models for age and sex differences in adolescent drug use can be derived from a variety of theories, including social learning theory and social control theory. The general protocol is adapted from that developed for nicotine dependence and is a useful way to formulate the assessment process, because it translates into specific management plans. Psychological treatments are pivotal to treatment effectiveness, even when pharmacological treatments are administered. The relationships between alcoholism and other psychiatric disorders are some times complex, and it is not always easy to achieve abstinence from alcohol to make an adequate assessment of the nature of the relationship.
Antidepressant prescribing should reflect need. The Quality and Outcomes Framework has provided an opportunity to explore factors affecting antidepressant prescribing in UK general practice.
To explore the relationship between physical illness, social deprivation, ethnicity, practice characteristics and the volume of antidepressants prescribed in primary care.
This was an ecological study using data derived from the Quality and Outcomes Framework, the Informatics Collaboratory of the Social Sciences, and Prescribing Analyses and CosT data for 2004-2005. Associations were examined using linear regression modelling.
Socio-economic status, ethnic density, asthma, chronic obstructive pulmonary disease and epilepsy explained 44% of the variance in the volume of antidepressants prescribed.
Lower volumes of antidepressants are prescribed in areas with high densities of Black or Asian people. This may suggest disparities in provision of care. Chronic respiratory disease and epilepsy may have a more important association with depression in primary care than previously thought.
Los modelos de prescripción de antidepresivos y los factores que influyen en la elección del antidepresivo para el tratamiento de la depresión se estudiaron en el estudio de los Factores que Influyen en la Investigación de los Criterios de Valoración de la Depresión (FINDER), un estudio prospectivo de observación realizado en 12 países europeos con 3.468 adultos sobre el comienzo de la medicación antidepresiva en el primer episodio de depresión o en un nuevo episodio de depresión recurrente. Los inhibidores selectivos de la recaptación de serotonina (ISRS) son los antidepresivos más prescritos más frecuentemente (63,3% de los pacientes), seguidos de los inhibidores de la recaptación de serotonina-noradrenalina (IRSN, 13,6%), pero hubo una variación considerable entre los distintos países. Debemos destacar que se prescribieron antidepresivos tricíclicos y tetracíclicos (ATC) al 26,5% de los pacientes en Alemania. La elección del antidepresivo prescrito estaba bajo una influencia muy fuerte del uso anterior de antidepresivos, que se asoció considerablemente con la prescripción de un ISRS (CP 0,64; IC 95% 0,54, 0,76), un IRSN (CP 1,49; 1C 95% 1,18, 1,88) o una combinación de antidepresivos (CP 2,78; IC 95% 1,96, 3,96). Los factores del médico (edad, sexo, especialidad) y de los pacientes (gravedad de la depresión, edad, educación, tabaquismo, número de enfermedades físicas y síndromes funcionales actuales) se asociaron con la eleccción del antidepresivo inicial en algunos casos. Para concluir, la prescripción de antidepresivos varía en función del país, y el tipo de antidepresivo escogido está bajo la influencia de factores relacionados con el médico y con el paciente.
Los factores que influyen en los resultados de depresión en la práctica clínica, sobre todo, la calidad de vida relacionada con la salud (CVRS), son relativamente desconocidos. El estudio de los Factores que Influyen en la Investigación de los Criterios de Valoración de la Depresión (FINDER) es un estudio europeo prospectivo de observación diseñado para estimar la CVRS de adultos con un episodio depresivo diagnosticado en la clínica inicialmente, y 3 y 6 meses después del comienzo del tratamiento antidepresivo. Describimos aquí el diseño del estudio y las características iniciales de los pacientes.
La CVRS se evaluó con el Cuestionario de Salud de 36 apartados (SF-36) y en el Cuestionario Europeo de Calidad de Vida de 5 Dimensiones (EQ-5D). También se determinaron las Puntuaciones de los pacientes en la Escala de Depresión, y Ansiedad Hospitalaria (HADS) y en la Escala Analógica Visual (EAV). Los resultados (n=3.468) demostraron que el resumen del componente mental del custionario SF-36 (media 22,2) estaba más de dos DE por debajo de la norma de la población general (media 50) y una DE por debajo de la norma de la depresión clínica (media 34,8); el resumen del componente físico (media 46,1) fue similar a la población general (media 50) y a la norma de depresión clínica (media 45). Las puntuaciones medias de EQ-5D eran tambien inferiores que la norma de la población general. Las puntuaciones medias de depresión y ansiedad de HADS eran 12,3 y 13, respectivamente. El 56% de los pacientes describió una puntuación total del dolor en la EAV de, al menos, 30 mm y el 70% de estos pacientes no tenía ninguna explicación física de su dolor.
Deben realizarse más investigaciones sobre los factores asociados con la CVRS en pacientes con depresión después de la iniciación del tratamiento.
Cognitive-behavioural therapy (CBT) is effective for treating anxiety and depression in primary care, but there is a shortage of therapists. Computer-delivered treatment may be a viable alternative.
To assess the cost-effectiveness of computer-delivered CBT.
A sample of people with depression or anxiety were randomised to usual care (n = 128) or computer-delivered CBT (n = 146). Costs were available for 123 and 138 participants, respectively. Costs and depression scores were combined using the net benefit approach.
Service costs were £40 (90% CI-£28 to £148) higher over 8 months for computer-delivered CBT. Lost-employment costs were £407 (90% CI £196 to £586) less for this group. Valuing a 1-unit improvement on the Beck Depression Inventory at £40, there is an 81% chance that computer-delivered CBT is cost-effective, and it revealed a highly competitive cost per quality-adjusted life year.
Computer-delivered CBT has a high probability of being cost-effective, even if a modest value is placed on unit improvements in depression.