Felicity Goodyear-Smith

Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population

PURPOSE Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9. METHODS Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed. RESULTS There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999. CONCLUSIONS We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

Corticosteroid injections for osteoarthritis of the knee: meta-analysis

Abstract Objectives To determine the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee and to identify numbers needed to treat. Data sources Cochrane controlled trials register, Medline (1966 to 2003), Embase (1980 to 2003), hand searches, and contact with authors. Inclusion criteria Randomised controlled trial in which the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee could be ascertained. Results In high quality studies, the pooled relative risk for improvement in symptoms of osteoarthritis of the knee at 16-24 weeks after intra-articular corticosteroid injections was 2.09 (95% confidence interval 1.2 to 3.7) and the number needed to treat was 4.4. The pooled relative risk for improvement up to two weeks after injections was 1.66 (1.37 to 2.0). The numbers needed to treat to get one improvement in the statistically significant studies was 1.3 to 3.5 patients. Conclusion Evidence supports short term (up to two weeks) improvement in symptoms of osteoarthritis of the knee after intra-articular corticosteroid injection. Significant improvement was also shown in the only methodologically sound studies addressing longer term response (16-24 weeks). A dose equivalent to 50 mg of prednisone may be needed to show benefit at 16-24 weeks.

What Can Family Physicians Offer Patients With Carpal Tunnel Syndrome Other Than Surgery? A Systematic Review of Nonsurgical Management

BACKGROUND We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS). METHODS Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS. RESULTS We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal ant-iinflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment. CONCLUSIONS For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.

Patients Prefer Pictures to Numbers to Express Cardiovascular Benefit From Treatment

PURPOSE This study aimed to determine which methods of expressing a preventive medication’s benefit encourage patients with known cardiovascular disease to decide to take the medication and which methods patients prefer. METHODS We identified patients in Auckland, New Zealand, family practices located in areas of differing socioeconomic status who had preexisting heart disease (myocardial infarction, angina, or both) and were taking statins. The patients were interviewed about their preference for methods of expressing the benefit of a hypothetical medication. Benefits were expressed numerically (relative risk, absolute risk, number needed to treat, odds ratio, natural frequency) and graphically. Statistical testing was adjusted for practice. RESULTS We interviewed 100 eligible patients, representing a 53% response rate. No matter how the risk was expressed, the majority of patients indicated they would be encouraged to take the medication. Two-thirds (68) of the patients preferred 1 method of expressing benefit over others. Of this group, 57% preferred the information presented graphically. This value was significantly greater (P <.001) than the 19% who chose the next most preferred option, relative risk. Few patients preferred absolute risk (13%) or natural frequencies (9%). Only a single patient (1%) preferred the odds ratio. None preferred number needed to treat. Ninety percent of patients responding to a question about framing preferred positive framing (description of the benefit of treatment) over negative framing (description of the harm of not being treated). CONCLUSIONS Although number needed to treat is a useful tool for communicating risk and benefit to clinicians, this format was the least likely to encourage patients to take medication. As graphical representation of benefit was the method patients preferred most, consideration should be given to developing visual aids to support shared clinical decision making.

Primary care patients reporting concerns about their gambling frequently have other co-occurring lifestyle and mental health issues

BackgroundProblem gambling often goes undetected by family physicians but may be associated with stress-related medical problems as well as mental disorders and substance abuse. Family physicians are often first in line to identify these problems and to provide a proper referral. The aim of this study was to compare a group of primary care patients who identified concerns with their gambling behavior with the total population of screened patients in relation to co-morbidity of other lifestyle risk factors or mental health issues.MethodsThis is a cross sectional study comparing patients identified as worrying about their gambling behavior with the total screened patient population for co morbidity. The setting was 51 urban and rural New Zealand practices. Participants were consecutive adult patients per practice (N = 2,536) who completed a brief multi-item tool screening primary care patients for lifestyle risk factors and mental health problems (smoking, alcohol and drug misuse, problem gambling, depression, anxiety, abuse, anger). Data analysis used descriptive statistics and non-parametric binomial tests with adjusting for clustering by practitioner using STATA survey analysis.ResultsApproximately 3/100 (3%) answered yes to the gambling question. Those worried about gambling more likely to be male OR 1.85 (95% CI 1.1 to 3.1). Increasing age reduced likelihood of gambling concerns – logistic regression for complex survey data OR = 0.99 (CI 95% 0.97 to 0.99) p = 0.04 for each year older. Patients concerned about gambling were significantly more likely (all p < 0.0001) to have concerns about their smoking, use of recreational drugs, and alcohol. Similarly there were more likely to indicate problems with depression, anxiety and anger control. No significant relationship with gambling worries was found for abuse, physical inactivity or weight concerns. Patients expressing concerns about gambling were significantly more likely to want help with smoking, other drug use, depression and anxiety.ConclusionOur questionnaire identifies patients who express a need for help with gambling and other lifestyle and mental health issues. Screening for gambling in primary care has the potential to identify individuals with multiple co-occurring disorders.

Anticonvulsants for neuropathic pain: gaps in the evidence.

ObjectiveTo summarize the available evidence on the use of anticonvulsant drugs for the treatment of various conditions of neuropathic pain. MethodsThis is a systematic review on quantity and quality of evidence for using anticonvulsants in the management of neuropathic pain. Medical Subject Heading terms searched were “anticonvulsants” and “pain.” Data sources used were the Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, Medline 1966 to May 2006, Embase 1980 to May 2006, and CINAHL 1982 to May 2006. Additional studies were identified by hand searching the reference lists of retrieved papers and by autoalerts subsequent to May 2006. Randomized controlled trials, systematic reviews, and meta-analyses included. Non-English papers excluded. Evidence and evidence gaps with regard to specific conditions and drugs identified. ResultsConcise summary of all existing evidence or lack thereof was produced. A succinct table is presented of the efficacy of specific drugs for specific conditions and the nature and quality of evidence. The paper outlines the incidence of specific neuropathic pain conditions within various population groups and assesses the quantity of available evidence in regard to the frequency that those conditions are likely to occur. DiscussionGaps in the evidence are striking. Recommendations directly supported by the evidence by drug and by condition are made.

Recruitment of practices in primary care research: the long and the short of it

OBJECTIVE To determine factors that facilitated or hindered recruitment of general practices into a large New Zealand primary care project that aimed to determine general practice characteristics of immunization coverage. METHODS The project had a multi-level recruitment strategy requiring recruitment of randomly selected practices before randomly selecting GPs, practice nurses and caregivers of children enrolled at those practices. Detailed quantitative and qualitative recruitment data were recorded on an access database. Post-recruitment, recruiters underwent semi-structured interviews. Analysis was mixed method, with triangulation of descriptive statistics of the number of calls and time course to recruitment and general inductive thematic analysis of qualitative data. RESULTS Identifying key decision makers and how individual practice processes work can save significant recruitment time. Factors identified as assisting practice recruitment included using a personal approach from doctor to doctor, getting buy-in from all practice staff, streamlining the research process to minimize disruption to the practice and flexibility to accommodate practices. CONCLUSIONS The task of recruiting should not be underestimated. Adequate time and resource need to be allocated from the onset. Long periods where practices have no added burdens such as audits, mass vaccination programmes or influenza season are unlikely, therefore there are always considerable challenges in recruiting practices for research. Remaining flexible to individual practice styles and influences and acknowledging the commitment of participants is important.

eCHAT for Lifestyle and Mental Health Screening in Primary Care

PURPOSE Early detection and management of unhealthy behaviors and mental health issues in primary care has the potential to prevent or ameliorate many chronic diseases and increase patients’ well-being. This study aimed to assess the feasibility and acceptability of the systematic use of a Web-based eCHAT (electronic Case-finding and Help Assessment Tool) screening patients for problematic drinking, smoking, and other drug use, gambling, exposure to abuse, anxiety, depression, anger control, and physical inactivity, and whether they want help with these issues. Patients self-administered eCHAT on an iPad in the waiting room and received summarized results, including relevant scores and interpretations, which could be by a family physician on the website and in the electronic health record (EHR) at the point of care. METHODS We conducted a mixed method feasibility and acceptability study in 2 general practices in Auckland, New Zealand. Participants were consecutive adult patients attending the practice during a 2-week period, as well as all practice staff. Patients completed eCHAT, doctors accessed the summarized reports. Outcome measures were patients’ responses to eCHAT, and patients’ written and staff recorded interview feedback. RESULTS Of the 233 invited patients, 196 (84%) completed eCHAT and received feedback. Domains where patients wanted immediate help were anxiety (9%), depression (7%), physical activity (6%), and smoking (5%), which was not overwhelming for physicians to address. Most patients found the iPad easy to use, and the questions easy to understand and appropriate; they did not object to questions. Feedback from 7 doctors, 2 practice managers, 4 nurses, and 5 receptionists was generally positive. Practices continue to use eCHAT regularly since the research was completed. CONCLUSIONS eCHAT is an acceptable and feasible means of systemic screening patients for unhealthy behaviors and negative mood states and is easily integrated into the primary care electronic health record.

Prevalence of causes of insomnia in primary care: a cross-sectional study.

BACKGROUND As a result of a research interest in primary insomnia, the prevalence of other causes of insomnia in primary care must be ascertained. No source was found in the literature. It is also essential to know the epidemiology of the common causes of a condition to make an accurate diagnosis in primary care. AIM To determine the prevalence of causes of insomnia in primary care, as part of a method of identifying patients with primary insomnia. DESIGN AND SETTING Cross-sectional study in three general practices in Auckland, New Zealand. METHOD Consecutive patients from the waiting room were asked to complete a nine-page questionnaire on possible causes of insomnia. RESULTS In total, 1517 patients were approached and 955 completed the nine-page questionnaire (63%). Of the 41% (388) who reported difficulty with sleeping, primary insomnia occurred in 12% (45) of the population (95% confidence interval = 9% to 15%); 50% (195) had depression, 48% (185) had anxiety and 43% (165) had general (physical) health problems. Obstructive sleep apnoea occurred in 9% (34) and delayed sleep phase disorder in 2% (7). Only primary insomnia and delayed sleep phase disorder are mutually exclusive; the others can co-exist. CONCLUSION This is the first description of the prevalence of causes of insomnia in primary care. It is hoped that the focus on primary insomnia will result in more behavioural treatments and lower the use of hypnotics in primary care; it should also assist in the appropriate detection and treatment of other causes of insomnia in primary care.

Case finding of lifestyle and mental health disorders in primary care: validation of the ‘CHAT’ tool

BACKGROUND Primary care is accessible and ideally placed for case finding of patients with lifestyle and mental health risk factors and subsequent intervention. The short self-administered Case-finding and Help Assessment Tool (CHAT) was developed for lifestyle and mental health assessment of adult patients in primary health care. This tool checks for tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse, anger problems, inactivity, and eating disorders. It is well accepted by patients, GPs and nurses. AIM To assess criterion-based validity of CHAT against a composite gold standard. DESIGN OF STUDY Conducted according to the Standards for Reporting of Diagnostic Accuracy statement for diagnostic tests. SETTING Primary care practices in Auckland, New Zealand. METHOD One thousand consecutive adult patients completed CHAT and a composite gold standard. Sensitivities, specificities, positive and negative predictive values, and likelihood ratios were calculated. RESULTS Response rates for each item ranged from 79.6 to 99.8%. CHAT was sensitive and specific for almost all issues screened, except exercise and eating disorders. Sensitivity ranged from 96% (95% confidence interval [CI] = 87 to 99%) for major depression to 26% (95% CI = 22 to 30%) for exercise. Specificity ranged from 97% (95% CI = 96 to 98%) for problem gambling and problem drug use to 40% (95% CI = 36 to 45%) for exercise. All had high likelihood ratios (3-30), except exercise and eating disorders. CONCLUSION CHAT is a valid and acceptable case-finding tool for most common lifestyle and mental health conditions.