Ruth Kalda

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.

Structure and duration of consultations in Estonian family practice.

Duration of the consultation is dependent on patient-related factors as well as on factors related to the health care system. Video-recording allows direct evaluation of the consultation and is acceptable to patients. Length of time of consultation is dependent on the patients age and on the number and nature of the problems, but is not influenced by gender. Objective - r To study the influence of age, gender and the nature of the patients problems on length of time of consultation in the practices of newly trained family doctors in a recently reconstructed health care system. Design r - r Video-recordings of consultations with consecutive patients in family practice were studied for duration of consultation in relation to age, gender and nature of the problem(s). Setting r - r Primary health care. Subjects r - r 405 consecutive consultations were video-taped in the practices of 27 family doctors. Main outcome measures r - r Length of time of consultation and its segments was analysed using the Statistical Package for the Social Sciences. The problems were classified according to the ICPC. Results r - r The average consultation lasted 9.0 min ( - 4.9). Physical examination was 2.0 min ( - 1.9) and was performed in 79% of all consultations. Respiratory and circulatory problems were the most common. More than one reason for the encounter was given in one-fourth of cases. Consultation time was longer for older age groups and for patients with psychological problems. Conclusion r - r Video-recording allows consultations to be evaluated directly and is acceptable to patients. The high participation rate of patients in our study can be explained by the individual approach and by the family doctor system. The period of consultation was dependent on patient age and on the number and nature of the problems, but was not influenced by gender.

Factors associated with recurrent depression: a prospective study in family practice

BACKGROUND Depression has a high rate of recurrence. Finding the variables that predict which patients are at higher risk of experiencing a recurrent episode of depression would benefit an individual patient. OBJECTIVE To determine the factors associated with recurrent depression >12 months. METHODS Consecutive patients (N = 1094), aged 18-75 years, were recruited from 23 family practices across Estonia. The patients were followed up at 6- and 12-month intervals as suggested in the PredictD study. Depression was assessed using the Composite International Diagnostic Interview. Each participant filled in a questionnaire to assess their risk factors for depression. RESULTS Major depression was diagnosed in 13% of the patients. Twenty-eight per cent of the depressed patients had a recurrent episode of depression 12 months later. The odds of having recurrent depression were significantly higher for patients who had a history of drug abuse, odds ratio (OR) 7.48 [95% confidence interval (CI) = 1.42-39.43), for patients who had experienced discrimination, OR 2.92 (95% CI = 1.05-8.11) and for patients with a history of childhood abuse, OR 1.58 (95% CI = 1.05-2.38). CONCLUSIONS One-third of the patients developed recurrent depression. Drug abuse, discrimination and childhood abuse predicted recurrent depression. These factors should be taken into consideration by family doctors when managing patients with depression.

Depression and musculoskeletal problems

A recent study by Mallen et al ,1 published in the October issue of the BJGP , concluded that older patients consulting their GP due to musculoskeletal pain have frequently comorbid depressive symptoms, and that brief depression screening during the consultation can miss a large number of persons with depressive symptoms. The authors found that a total of 51.4% of the study participants had depressive symptoms, according to a …

Meeting targets in type 2 diabetes care contributing to good glycaemic control. A cross-sectional study from a primary care setting in Estonia

Abstract Objective: To assess glycaemic control among Estonian patients with type 2 diabetes mellitus (DM2) and to find patient and disease related factors associated with adequate glycaemic control. Methods: A cross-sectional study of 200 randomly selected DM2 patients from a primary care setting. Data on each patients glycosylated haemoglobin (HbA1c), body mass index, blood pressure, and medications for treatment of DM2 were provided by family doctors. A structured patient questionnaire was administered as a telephone interview (n = 166). The patients’ self-management behaviour, awareness of the HbA1c test and its recent value were inquired. Results: The mean HbA1c of the DM2 patients was 7.5%. The targets of DM2 treatment were achieved as follows: 39% of the patients had HbA1c below 6.5% and half the patients had HbA1c below 7%. More than third of the patients had systolic blood pressure below 140 mmHg and in 51% of the patients diastolic blood pressure was below 85 mmHg. Six per cent of the patients were in normal weight (<25 kg/m2). Fifty-two per cent of the patients were aware of the HbA1c test and 36% of them knew its recent value. In multivariate regression analysis, awareness of the HbA1c test but not the HbA1c value, longer duration of diabetes and not having a self-monitoring device were independently associated with adequate glycaemic control (HbA1c< 6.5%). Conclusion: The studied DM2 patients often did not reach the clinical targets suggested in the guidelines. Awareness of the HbA1c test was related to better glycaemic control. However, advanced stage of the disease had a negative effect on HbA1c.

The Role of General Practitioners in Cancer Care: A Mixed Method Design

The aims of this study were to identify the current role of general practitioners (GP) and the unmet needs of cancer patients in primary care. First, we conducted individual interviews with 10 cancer patients. Next, we developed a questionnaire, which was distributed among cancer patients across Estonia. Altogether, 113 questionnaires were returned. We observed that while the patients were satisfied with their GP’s work, they mostly preferred to discuss cancer-related problems with oncologists. The role of GPs in regard to other diseases was perceived as very important, also patients found it relevant to consult all investigations with their primary health care physician. The main problems experienced by the patients were a lack of proper accessible information about their disease and its inadequate presentation by doctors, as well as problems with coordination between primary and secondary health care providers. In conclusion, we can say that even treatment of cancer is centralised to oncology clinics, patients also contact their GPs during cancer care. Therefore, GPs should be aware of patients’ general health and comorbid medical problems. Better communication between primary and secondary health care doctors as well as more integration of GPs in cancer care is needed.

Family medicine in the Baltic countries

In this journal, we regularly publish national editorials from the five Nordic colleges of general practitioners [1–5], as an important way of learning from each other. Just as important, is, of course, to learn from other countries, and the aim of this editorial is to give an overview of family medicine in Estonia, Latvia, and Lithuania.

Patients’ experience with cancer care: A qualitative study in family practice

Abstract Background: Continuity is an important aspect of cancer care that is often a challenge owing to the movement of patients between family practice, cancer clinics, and hospitals. Objectives: To investigate the experiences of cancer patients in relation to continuity of care. Methods: A qualitative study was conducted in a family practice setting. Semi-structured interviews were used for data collection. 10 cancer patients with a wide variation in their disease duration and experiences with medical care were interviewed. Open questions were used to encourage patients to express their personal experiences with cancer care. The interviews were recorded, transcribed and analysed by three researchers using thematic analysis. Results: Cancer patients experienced a lack of information concerning cancer and its treatment. They also perceived that the cancer treatment made them suffer. In the patients’ opinion, the family doctor has a limited role in cancer care. However, the patients felt that the family doctor should be aware of their health. The patients’ satisfaction with the oncologists care was high. They considered that their role in cancer care was to mediate an exchange of information between the oncologist and the family doctor. Conclusion: Cancer patients experience continuity of care in several ways: continuity in cancer care should be implemented by co-ordinating activities, such as regular check-ups, a clear timeframe and provision of adequate information. In addition, communication between the primary and secondary sector could be improved.