Robert Peveler

Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial.

BACKGROUND Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression. METHODS We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat. FINDINGS The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve. INTERPRETATION Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.

Frequency and impact of nonadherence to immunosuppressants after renal transplantation: A systematic review

Nonadherence to immunosuppressants is recognized to occur after renal transplantation, but the size of its impact on transplant survival is not known. A systematic literature search identified 325 studies (in 324 articles) published from 1980 to 2001 reporting the frequency and impact of nonadherence in adult renal transplant recipients. Thirty-six studies meeting the inclusion criteria for further review were grouped into cross-sectional and cohort studies and case series. Meta-analysis was used to estimate the size of the impact of nonadherence on graft failure. Only two studies measured adherence using electronic monitoring, which is currently thought to be the most accurate measure. Cross-sectional studies (n=15) tended to rely on self-report questionnaires, but these were poorly described; a median (interquartile range) of 22% (18%–26%) of recipients were nonadherent. Cohort studies (n=10) indicated that nonadherence contributes substantially to graft loss; a median (interquartile range) of 36% (14%–65%) of graft losses were associated with prior nonadherence. Meta-analysis of these studies showed that the odds of graft failure increased sevenfold (95% confidence interval, 4%–12%) in nonadherent subjects compared with adherent subjects. Standardized methods of assessing adherence in clinical populations need to be developed, and future studies should attempt to identify the level of adherence that increases the risk of graft failure. However, this review shows nonadherence to be common and to have a large impact on transplant survival. Therefore, significant improvements in graft survival could be expected from effective interventions to improve adherence.

The prevalence of co-morbid depression in adults with Type 1 diabetes: systematic literature review

Aim  To review the literature estimating the cross‐sectional prevalence of clinical depression in adults with Type 1 diabetes.

MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS IN PRIMARY CARE: A COMPARISON OF SELF- REPORT SCREENING QUESTIONNAIRES AND CLINICAL OPINION

This study was undertaken to assess recognition of medically unexplained physical symptoms by general practitioners (GPs), and the feasibility of using a screening procedure based on validated self-report questionnaires. GPs identified unexplained physical symptoms as the main clinical problem for 19% of attending patients. Screening instruments identified 35% of patients as having multiple unexplained physical symptoms, of whom 5% were probable cases of somatization disorder. Nine percent of attending patients reported high levels of health anxiety. Twenty percent were probable cases of mood disorder: in half of these, psychological symptoms were not documented in the casenotes. Patients with more somatic symptoms and higher health anxiety were more likely to be recognized by the GP: higher levels of mood symptoms did not predict recognition. The screening procedure used in this study shows promise and merits further investigation.

First- v. second-generation antipsychotics and risk for diabetes in schizophrenia: systematic review and meta-analysis

BACKGROUND The increased prevalence of diabetes in schizophrenia is partly attributed to antipsychotic treatment, in particular second-generation antipsychotics, but the evidence has not been systematically reviewed. AIMS Systematic review and meta-analysis comparing diabetes risk for different antipsychotics in people with schizophrenia. METHOD We searched MEDLINE, PsycINFO, EMBASE, International Pharmaceutical Abstracts, CINAHL and Web of Knowledge until September 2006. Studies were eligible for inclusion if the design was cross-sectional, case-control, cohort or a controlled trial in individuals with schizophrenia or related psychotic disorders, where second-generation antipsychotics (defined as clozapine, olanzapine, risperidone and quetiapine) were compared with first-generation antipsychotics and diabetes was an outcome. Data were pooled using random effects inverse variance weighted meta-analysis. RESULTS Of the studies that met the inclusion criteria (n=14), 11 had sufficient data to include in the meta-analysis. Four of these were retrospective cohort studies. The relative risk of diabetes in patients with schizophrenia prescribed one of the second-generation v. first-generation antipsychotics was 1.32 (95% CI 1.15-1.51). There were insufficient data to include aripiprazole, ziprasidone and amisulpride in this analysis. CONCLUSIONS There is tentative evidence that the second-generation antipsychotics included in this study are associated with a small increased risk for diabetes compared with first-generation antipsychotics in people with schizophrenia. Methodological limitations were found in most studies, leading to heterogeneity and difficulty interpreting data. Regardless of type of antipsychotic, screening for diabetes in all people with schizophrenia should be routine.

Eating disorders in young adults with insulin dependent diabetes mellitus: a controlled study.

OBJECTIVE--To determine the prevalence of clinical eating disorders and lesser degrees of disturbed eating in young adults with insulin dependent diabetes and a matched sample of non-diabetic female controls. DESIGN--Cross sectional survey of eating habits and attitudes in diabetic and non-diabetic subjects. SETTING--Outpatient clinic catering for young adults with diabetes; community sample of non-diabetic women drawn from the lists of two general practices. SUBJECTS--100 patients with insulin dependent diabetes (54 women and 46 men) aged 17-25 and 67 non-diabetic women of the same age. MAIN OUTCOME MEASURES--Eating habits and eating disorder psychopathology were assessed by standardised research interview adapted for the assessment of patients with diabetes (eating disorder examination). Glycaemic control was assessed by glycated haemoglobin assay. RESULTS--In both non-diabetic and diabetic women disturbed eating was common, and in diabetic women the degree of disturbance was related to control of glycaemia. Twenty of the diabetic women (37%) had omitted or underused insulin to influence their weight. This behaviour was not restricted to those with a clinical eating disorder. None of the men showed any features of eating disorders, and none had misused insulin to influence their weight. CONCLUSIONS--There was no evidence that clinical eating disorders are more prevalent in young women with diabetes than in non-diabetic women. Nevertheless, disturbed eating is common and is associated with poor control of glycaemia, and the misuse of insulin to influence body weight is also common in young women with diabetes.

Measuring compliance with drug regimens after renal transplantation: comparison of self-report and clinician rating with electronic monitoring.

Nonadherence to immunosuppressants in renal transplant recipients is a major factor affecting graft survival, but it is difficult to detect accurately in clinical practice. Adherence was measured in 153 adult renal transplant recipients using self-report questionnaires and interview, clinician rating, and cyclosporine levels. The sensitivity and specificity of these measures were determined by comparison with electronic monitoring in a randomly selected subsample of 58 subjects. Measures of adherence in current clinical use do not perform well when tested against electronic monitoring. Self-report at a confidential interview was the best measure of adherence for the detection of both missed doses and erratic timing of medication. However, the use of a confidential interview is not directly applicable to a clinical setting. Further research on how best to facilitate disclosure in clinical settings may be the best way to develop adherence measures for use in routine practice.

Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia.

People with schizophrenia are at greater risk of obesity, Type 2 diabetes, dyslipidaemia and hypertension than the general population. This results in an increased incidence of cardiovascuLar disease (CVD) and reduced Life expectancy, over and above that imposed by their mentaL illness through suicide. Several Levels of evidence from data Linkage analyses to clinical trials demonstrate that treatment-related metabolic disturbances are commonplace in this patient group, and that the use of certain second-generation antipsychotics may compound the risk of developing the metabolic syndrome and CVD. In addition, smoking, poor diet, reduced physical activity and alcohol or drug abuse are prevalent in people with schizophrenia and contribute to the overall CVD risk. Management and minimization of metaboLic risk factors are pertinent when providing optimal care to patients with schizophrenia. This review recommends a framework for the assessment, monitoring and management of patients with schizophrenia in the UK clinical setting.

Adherence to treatment in patients with epilepsy: associations with seizure control and illness beliefs

OBJECTIVE This study investigated non-adherence to antiepileptic drug treatment amongst patients with epilepsy in secondary care. The associations between adherence and seizure control, perceptions of illness and medication, anxiety and depression were also examined. METHODS A cross-sectional study of fifty-four patients with epilepsy were recruited from a hospital epilepsy clinic. RESULTS Fifty-nine percent were estimated to be non-adherent to medication. There was a negative correlation between adherence and frequency of seizures. Patients with poorly controlled epilepsy were more anxious, and expected a longer duration of their epilepsy. CONCLUSION Assessment of adherence should be a routine part of management of epilepsy. Further recognition and support should be given to patients who have poor seizure control since they are more likely to be more anxious and have unhelpful illness and treatment beliefs.

Depression in medical patients

Depressive illness is usually treatable. It is common and results in marked disability, diminished survival, and increased healthcare costs. As a result, it is essential that all doctors have a basic understanding of its diagnosis and management. In patients with physical illness depression may ![][1] Aretaeus of Cappadocia (circa 81–138 AD) is credited with the first clinical description of depression The term depression describes a spectrum of mood disturbance ranging from mild to severe and from transient to persistent. Depressive symptoms are continuously distributed in any population but are judged to be of clinical significance when they interfere with normal activities and persist for at least two weeks, in which case a diagnosis of a depressive illness or disorder may be made. The diagnosis depends on the presence of two cardinal symptoms of persistent and pervasive low mood and loss of interest or pleasure in usual activities. #### Criteria for major depression* Five or more of the following symptoms during the same two week period representing a change from normal View this table: Adjustment disorders are milder or more short lived episodes of depression and are thought to result from stressful experiences. Major depressive disorder refers to a syndrome that requires the presence of five or more symptoms of depression in the same two week period. “Neurotic” symptoms, including depression, are continuously distributed in the UK population The association between depression and mortality after myocardial infarction Dysthymia covers persistent symptoms of depression that may not be severe enough to meet the criteria for major depression, in which depressed mood is present for two or more years. Such chronic forms of depression are associated with an increased risk of subsequent major depression, considerable social disability, and unhealthy lifestyle choices … [1]: /embed/graphic-1.gif