Janez Rifel

Prevalence of common mental disorders in general practice attendees across Europe.

BACKGROUND There is evidence that the prevalence of common mental disorders varies across Europe. AIMS To compare prevalence of common mental disorders in general practice attendees in six European countries. METHOD Unselected attendees to general practices in the UK, Spain, Portugal, Slovenia, Estonia and The Netherlands were assessed for major depression, panic syndrome and other anxiety syndrome. Prevalence of DSM-IV major depression, other anxiety syndrome and panic syndrome was compared between the UK and other countries after taking account of differences in demographic factors and practice consultation rates. RESULTS Prevalence was estimated in 2,344 men and 4,865 women. The highest prevalence for all disorders occurred in the UK and Spain, and lowest in Slovenia and The Netherlands. Men aged 30-50 and women aged 18-30 had the highest prevalence of major depression; men aged 40-60 had the highest prevalence of anxiety, and men and women aged 40-50 had the highest prevalence of panic syndrome. Demographic factors accounted for the variance between the UK and Spain but otherwise had little impact on the significance of observed country differences. CONCLUSIONS These results add to the evidence for real differences between European countries in prevalence of psychological disorders and show that the burden of care on general practitioners varies markedly between countries.

Development and Validation of an International Risk Prediction Algorithm for Episodes of Major Depression in General Practice Attendees The PredictD Study

CONTEXT Strategies for prevention of depression are hindered by lack of evidence about the combined predictive effect of known risk factors. OBJECTIVES To develop a risk algorithm for onset of major depression. DESIGN Cohort of adult general practice attendees followed up at 6 and 12 months. We measured 39 known risk factors to construct a risk model for onset of major depression using stepwise logistic regression. We corrected the model for overfitting and tested it in an external population. SETTING General practices in 6 European countries and in Chile. PARTICIPANTS In Europe and Chile, 10 045 attendees were recruited April 2003 to February 2005. The algorithm was developed in 5216 European attendees who were not depressed at recruitment and had follow-up data on depression status. It was tested in 1732 patients in Chile who were not depressed at recruitment. Main Outcome Measure DSM-IV major depression. RESULTS Sixty-six percent of people approached participated, of whom 89.5% participated again at 6 months and 85.9%, at 12 months. Nine of the 10 factors in the risk algorithm were age, sex, educational level achieved, results of lifetime screen for depression, family history of psychological difficulties, physical health and mental health subscale scores on the Short Form 12, unsupported difficulties in paid or unpaid work, and experiences of discrimination. Country was the tenth factor. The algorithms average C index across countries was 0.790 (95% confidence interval [CI], 0.767-0.813). Effect size for difference in predicted log odds of depression between European attendees who became depressed and those who did not was 1.28 (95% CI, 1.17-1.40). Application of the algorithm in Chilean attendees resulted in a C index of 0.710 (95% CI, 0.670-0.749). CONCLUSION This first risk algorithm for onset of major depression functions as well as similar risk algorithms for cardiovascular events and may be useful in prevention of depression.

Prediction of depression in European general practice attendees: the PREDICT study

BackgroundPrevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation.Methods/designThis is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent.DiscussionResponse rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.

An international risk prediction algorithm for the onset of generalized anxiety and panic syndromes in general practice attendees: predictA

BACKGROUND There are no risk models for the prediction of anxiety that may help in prevention. We aimed to develop a risk algorithm for the onset of generalized anxiety and panic syndromes. METHOD Family practice attendees were recruited between April 2003 and February 2005 and followed over 24 months in the UK, Spain, Portugal and Slovenia (Europe4 countries) and over 6 months in The Netherlands, Estonia and Chile. Our main outcome was generalized anxiety and panic syndromes as measured by the Patient Health Questionnaire. We entered 38 variables into a risk model using stepwise logistic regression in Europe4 data, corrected for over-fitting and tested it in The Netherlands, Estonia and Chile. RESULTS There were 4905 attendees in Europe4, 1094 in Estonia, 1221 in The Netherlands and 2825 in Chile. In the algorithm four variables were fixed characteristics (sex, age, lifetime depression screen, family history of psychological difficulties); three current status (Short Form 12 physical health subscale and mental health subscale scores, and unsupported difficulties in paid and/or unpaid work); one concerned country; and one time of follow-up. The overall C-index in Europe4 was 0.752 [95% confidence interval (CI) 0.724-0.780]. The effect size for difference in predicted log odds between developing and not developing anxiety was 0.972 (95% CI 0.837-1.107). The validation of predictA resulted in C-indices of 0.731 (95% CI 0.654-0.809) in Estonia, 0.811 (95% CI 0.736-0.886) in The Netherlands and 0.707 (95% CI 0.671-0.742) in Chile. CONCLUSIONS PredictA accurately predicts the risk of anxiety syndromes. The algorithm is strikingly similar to the predictD algorithm for major depression, suggesting considerable overlap in the concepts of anxiety and depression.

Association of Common Mental Disorders and Quality of Life with the Frequency of Attendance in Slovenian Family Medicine Practices: Longitudinal Study

Background Most research on frequent attendance has been cross-sectional and restricted to one year attendance rates. A few longitudinal studies suggest that frequent attendance is self-limiting. Frequent attenders are more likely to have social and psychiatric problems, medically unexplained physical symptoms, chronic somatic diseases (especially diabetes) and are prescribed more psychotropic medication and analgesics. Research Question To describe the attendance rates in a longitudinal study and to test if depression, panic syndrome, other anxiety syndrome, alcohol misuse and general quality of life are associated with frequent attendance in next two consecutive years. Methods 1118 consecutive family practice attendees, aged 18 to 75 years from randomly selected family medicine practices were recruited at baseline and followed up at 12 and 24 months. We identified frequent attenders in the top 10 centile within one year. Using a multivariate model, we ascertained if presence of common mental disorders and quality of life assessed at baseline in 2003 predict frequent attendance in 2004 and 2005. Results 40% of frequent attenders continue to be frequent attenders in the following year and 20% of the frequent attenders were so for the 24 month period. Lower physical scores on the SF-12 questionnaire were strongly associated with future frequent attendance at 12 and 24 months. There was a trend for people with greater than elementary school education to be less likely to become frequent attenders at both 12 and 24 months. For other variables these effects were less consistent. Presence of major depression, panic syndrome, other anxiety syndrome and alcohol misuse were not predictive of frequent attendance in the following two years. Conclusion Low physical quality of life is strongly predictive of higher frequent attendance and similar finding was observed for people with lower educational level but further confirmatory research is required to establish this association.

Longstanding disease, disability or infirmity and depression in primary care

ZusammenfassungINHALT: Allgemein anerkannte Ergebnisse weisen darauf hin, dass Depression bei Personen mit chronischen Leiden häufiger auftritt als allgemein in der Bevölkerung. Depression wird als weltweite Ursache für Behinderung bis zum Jahr 2020 an zweiter Stelle nach Herz-Kreislauf-Erkrankungen rangieren. Ärzte sind aufgrund des Alterns der Bevölkerung gefordert, einen höheren Anteil an chronisch erkrankt Patienten zu behandeln. ZIEL: Beurteilung des Vorherrschens und Auftretens von Depression und der Wahrscheinlichkeit für neu ausbrechende Depression bei Patienten mit selbst berichteter langjähriger Erkrankung, Behinderung oder Gebrechlichkeit in der Teilnehmerprobe der medizinischen Grundversorgung. METHODE: Besucher einer Allgemeinmedizinpraxis im Alter von 18 bis 75 Jahren wurden einer nach dem anderen aufgenommen und über sechs Monate (erste Etappe) untersucht. Langjährige Erkrankung, Behinderung oder Gebrechlichkeit wurden festgestellt. ERGEBNISSE: Starke Depression herrscht bei 8.9% der Patienten in der Gruppe mit langjähriger Erkrankung vor, im Vergleich zu 3.1% in der Gruppe ohne langjährige Erkrankung. Starke Depression tritt nach sechs Monaten bei 2.7% in der Gruppe mit langjähriger Erkrankung und bei 0.9% in der Gruppe ohne langjährige Erkrankung auf. Bei Patienten mit langjähriger Erkrankung in der ersten Etappe war die Wahrscheinlichkeit für starke Depression nach sechs Monaten viermal so hoch wie bei Patienten, die über keine langjährige Erkrankung in der ersten Etappe berichteten. SCHLUSSFOLGERUNG: Die Zusammenhänge zwischen langjähriger Erkrankung und Depression sind im Rahmen der medizinischen Grundversorgung wichtig.SummaryCONTEXT: Current evidence suggests that depression is much more prevalent among those with chronic medical conditions compared to the general population. Depression will rank second to cardiovascular disease as a global cause of disability by 2020. With ageing of the population physicians are called upon to treat a higher percentage of patients with chronic medical illness. OBJECTIVE: To assess the prevalence and incidence of depression and likelihood for new-onset depression in patients with self-reported longstanding disease, disability or infirmity in the sample of primary care attendees. METHODE: Consecutive family medicine practice attendees aged 18 to 75 years were recruited and followed up after six months. Presence of longstanding disease, disability or infirmity was recorded. RESULTS: Prevalence of major depression was 8.9% in the group of patients reporting longstanding disease compared to 3.1% in the group without longstanding disease. Incidence of major depression after 6 months was 2.7% in the group with longstanding disease and 0.9% in the group without longstanding disease. For the patients with longstanding disease at the baseline it was almost 4 times more likely to have major depression after 6 months than for patients who did not report any longstanding disease at the baseline. CONCLUSION: The associations between longstanding disease and depression are important in primary care setting.

Thermal conductivity of the porcine heart tissue

Abstract The porcine heart was used as a model for studying the thermal changes in myocardium at cooling and re-warming during open heart surgery. A section of the heart septum was excised and tissue was cut into two similar square slices. The same shape of the tissue, cut from the surface from the upper lateral wall of the left ventricle, covered with epicardium and fat, was taken for another measurement. A thin (<0.5 mm) square thermal source of the same length of the side as the tissue samples was put between the two slices of tissue. This set was placed in the middle of two identical copper cylinders (2r=50 mm, height=55 mm) used to keep the outer side of the specimen at controlled room temperature. Thermal conductivity of the heart tissue was determined at controlled thermal power, and known difference of the temperature at the edge of the tissue and at the middle of the heater, when steady state was reached. Thermal conductivity calculated from the temperature difference and the geometry of heater and samples was 0.75 W/m.K for septal heart tissue, and 0.60 W/m.K for the lateral wall ventricle tissue with epicardium and fat.

The Effects of a Web Application and Medical Monitoring on the Quality of Medication, Adverse Drug Events and Adherence in the Elderly Living at Home: a Protocol of the Study -

Background: In more than half of elderly chronically-ill family clinic attendees, drug prescribing deviates from the internationally acknowledged STOPP/START recommendations. Our study will determine whether it is possible to improve the quality of drug prescriptions in chronically-ill elderly people living at home by regularly monitoring the prescribed drugs according to STOPP/START criteria. Methods: The project started in 2014 and will run until 2017. Forty general practitioners (GPs) are participating in a pragmatic randomized controlled trial. From the patient register, GPs randomly selected 20 patients older than 65 years who regularly receive at least one drug and invited them to participate in the study. We will use the START/STOPP criteria to determine the (in)adequacy of drug prescribing in the elderly by a web application (WA). Expected Results: The use of the WA will be the basis of the implementation of the final version of the application into the regular family medicine practice, thereby reducing the problems of inappropriate prescribing, correct medication, polypharmacy and adherence; we will identify the stability of the factors of drug prescribing in the elderly. By comparing the test and control groups, it will be possible to distinguish which are related to the WA and which act independently.

Problems of mental health at primary care level – how to recognise a depresive episode

Each and every mental health program has to include primary care. No single service setting can meet all mental health needs of the population. Support, supervision, collaboration, information- sharing and education across different levels of care are essential to any system. People with mental disability need to be involved in their own recovery and this must be reinforced at each level of care. Family physicians treat the majority of depressed patients, only one fifth of the patients are referred to the secondary care. Physicians fail to recognize most of the patients with mild symptoms at their first visit. Good physical accessibility and continuity of care ensure that the majority of disorders that require a formal form of treatment are recognized ant treated.

Anticholinergic burden and most common anticholinergic-acting medicines in older general practice patients

Abstract Introduction Anticholinergic burden in older adults has been correlated with cognitive decline, delirium, dizziness and confusion, falls and hospitalisations. Nevertheless, anticholinergic-acting medications remain commonly prescribed in up to a third of older adults in primary care population. Our aim was to study the anticholinergic burden in older adults in Slovenian ambulatory setting and explore the most commonly involved medications which could be avoided by the physicians. Methods A cross-sectional study was conducted in 30 general practices in Slovenia as part of a larger trial. Data on prescribed medications were collected for randomly chosen adults of over 65 years of age visiting general practice, who were taking at least one regularly prescribed medication. Anticholinergic burden was calculated using Duran’s scale and Drug Burden Index. Results Altogether, 622 patients were included, 356 (57.2%) female, average age of 77.2 (±6.2), with an average of 5.6 medications. At least one anticholinergic medication was present in 78 (12.5 %) patients. More than half (N=41, 52.6%) of anticholinergic prescriptions were psychotropic medications. Most common individual medications were diazepam (N=10, 1.6%), quetiapine (N=9, 1.4%) and ranitidine (N=8, 1.3%). Conclusions Though the prevalence of anticholinergic medications was low compared to international research, the most commonly registered anticholinergic prescriptions were medications that should be avoided according to guidelines of elderly prescriptions. It would be probably clinically feasible to further decrease the anticholinergic burden of older adults in Slovenian primary care setting by avoiding or replacing these medications with safer alternatives.