W. van den Brink

Training primary-care physicians to recognize, diagnose and manage depression : does it improve patient outcomes?

BACKGROUND We developed a comprehensive, 20-hour training programme for primary-care physicians, that sought to improve their ability to detect, diagnose and manage depression. We evaluated the effects of physician training on patient outcomes, using a pre-post design. METHODS In the pre-training phase of the study, we sampled 1834 consecutive patients of 17 primary-care physicians and evaluated 518 of these patients for the presence of depression. We measured outcomes of all patients with depression at 3 months and 1 year. The outcome measures were: severity of psychopathology; duration of depressive episode; and level of daily functioning. After the 17 physicians completed the training, we drew a new sample from their practices (498 of 1785 consecutive patients were evaluated for depression) and measured outcomes for the depressed patients. RESULTS We found an effect of the training on short-term outcome, particularly for patients with a recent-onset depression. At 3-month follow-up depressed patients whose physicians had received training had less severe psychopathology and patients with recent-onset depression also showed higher levels of daily functioning than patients of the same physicians prior to the training. The patients with a recent-onset depression that was recognized by trained physicians had shorter depressive episodes, but this was not statistically significant. At 1-year follow-up, all training effects had faded away. CONCLUSIONS Training primary-care physicians to recognize, diagnose and manage depression can improve short-term patient outcomes, especially for patients with a recent onset of depression. Patients suffering from a recurrent or chronic depression may need more specific interventions, both for acute treatment and long-term management.

Detecting psychopathology in young adults: the Young Adult Self Report, the General Health Questionnaire and the Symptom Checklist as screening instruments

This study compares the screening capacity of an age‐adjusted child‐oriented questionnaire, the Young Adult Self Report (YASR) with two adult‐oriented questionnaires, the General Health Questionnaire‐28 (GHQ‐28) and Symptom Checklist‐90 (SCL‐90) in a sample of young adults (18–25 years). The YASR performed just as well as the SCL‐90 and both performed better than the GHQ‐28. The relatively poor performance of the GHQ‐28 compared with the YASR and SCL‐90 could not be attributed to instrument characteristics or to the use of referral status as indicator of psychopathology. In assessing psychopathology in young adults an age‐adjusted child‐oriented instrument might be a good alternative to the existing adult‐oriented instruments, especially when one takes into account the problem of data comparability over time in longitudinal studies in which children are followed into adulthood.

MENTAL-HEALTH INTERVENTION PROGRAMS IN PRIMARY CARE - THEIR SCIENTIFIC BASIS

This study examines the scientific basis for mental health intervention programs in primary care. The validity of five underlying assumptions is evaluated, using the results of a naturalistic study covering a representative sample of 25 Dutch family practices and data from the literature. Our findings corroborate the validity of the assumptions. Firstly, our study indicates that mental disorders are indeed very prevalent in primary care settings. Secondly, we find that a substantial proportion of mental disorders is not recognized by the general practitioner (GP). Thirdly, our data show that mental disorders in primary care are not transient or self-limiting. Fourthly, it is shown that only half of the GP attenders with a mental disorder receive some form of mental health treatment in the 14 months after their index consultation. Finally, our data suggest that mental disorders, when identified, can be treated effectively in primary care. These findings are in general agreement with the literature. In the discussion we underscore the need for public health intervention programs targeted at primary care providers. Training programs for general physicians must be directed at improving recognition and diagnosis and at enhancing the availability and quality of mental health interventions. The effectiveness of these programs has to be tested in randomized trials.

Concurrent validity of GHQ-28 and PSE as measures of change

Substantial cross-sectional correlations have been reported between the GHQ and PSE (and CIS) total scores. Although necessary, this is not a sufficient condition for assuming good validity of the GHQ as a severity measure in longitudinal and health care evaluation studies. For this purpose the GHQ should also accurately reflect changes in severity over time. To examine their concurrent validity, GHQ and PSE scores were compared, in a three-wave longitudinal study, among 175 new psychiatric out-patients. Using a longitudinal structural equation model that takes measurement error into account, the strength of both the cross-sectional and longitudinal relationship between GHQ and PSE were estimated. The GHQ performed remarkably well; changes in severity as defined by PSE-ID and PSE total score were clearly reflected by changes in GHQ scores. The revised scoring method of the GHQ proposed by Goodchild and Duncan-Jones did not yield superior results.

The relationship between depression and anxiety : construction of a prototypical anxiety and depression scale

The question of the relationship between anxiety and depression remains to be solved. The fact that clinical pictures show substantial overlap makes it difficult, using conventional instruments, to distinguish between the co-occurrence of anxiety and depression and overlap in definitions and measurement of the two syndromes. This calls for the construction of scales which exclude symptoms common to both syndromes and incorporate symptoms specific only to anxiety or only to depression; i.e. scales with maximum discriminant validity. This article describes the construction of two such scales based on PSE symptoms; a prototypical anxiety scale and a prototypical depression scale. In a sample of 134 non-psychotic psychiatric out-patients these scales show good reliability and validity, both as a measure of severity and as a screening device. Compared to the Hamilton anxiety and depression scales (HARS and HRSD), the correlation between the prototypical anxiety and depression scales is low.

Effect of Early Dysphoric Response and Cannabis Use on Discontinuation of Olanzapine or Risperidone in Patients With Early Psychosis

An early dysphoric response following treatment with antipsychotic medication may lead to discontinuation of antipsychotic medication and thereby to relapse and rehospitalisation. Also cannabis use has found to be related to non-adherence to therapy. In the present study we examined whether 1) an early dysphoric response to antipsychotic medication, 2) cannabis use were related to discontinuation of antipsychotic medication in patients with early psychosis, and 3) whether there were diff erences in discontinuation between olanzapine compared with risperidone. This study was a 1-year open extension of a previous doubleblind randomized controlled trial comparing olanzapine (n = 63) and risperidone (n = 65) in patients with early psychosis due to schizophrenia according to DSM IV criteria, performed in 4 centres in the Netherlands. In the previous trial [2] we found no diff erences between olanzapine and risperidone in early dysphoric response to study medication, nor in the use of cannabis. However, it was hypothesised that both these variables would lead to earlier discontinuation. Discontinuation of olanzapine and risperidone was assessed after 1 year when patients were interviewed with the Life Chart Schedule . Early subjective response was defi ned as the diff erence between the total score on the Subjective Well-being under Neuroleptics Scale (SWN) between start of treatment and after 6 weeks treatment. Early dysphoric response was defi ned as an SWN diff erence score less than the median. Cannabis use after 6 weeks treatment was assessed with self reports. 3 diff erent survival curves were executed; 1) ‘ early dysphoric response ’ vs. ‘ early non-dysphoric response ’ , 2) cannabis use vs. non use, and 3) olanzapine vs. risperidone. Diff erences between groups were tested with a log rank test. The mean doses of study medication were 11.0 mg per day for olanzapine and 3.0 mg per day for risperidone at the end of the double blind trial. After 1 year, 15 patients were lost to follow-up, and 75 of the 113 patients with follow-up data had discontinued the treatment: 39 / 58 patients stopped olanzapine and 36 / 55 patients stopped taking risperidone (P = 0.84). Discontinuation rates are comparable to those found in the CATIE study [1] . The mean time to discontinuation was 5.8 (SD 4.9) months for the total group. 1) Time to discontinuation due to any reason was signifi cantly longer for the group with an early non-dysphoric response (7.3 months, SD 4.8) compared to the group with an early dysphoric response (4.1 months, SD 4.4) (log-rank chi squared = 13.3, d. f. = 1, P = 0.0003). 2) Patients who did not use cannabis after 6 weeks treatment had a signifi cantly longer mean time on the study medication (mean 6.4 months, SD 5.0) compared to cannabis users (4.3 months, SD 4.2) (log-rank chi squared = 4.98, d. f. = 1, P = 0.03). 3) We found no statistical diff erence in discontinuation between olanzapine (mean 5.6 months, SD 4.9) and risperidone (mean 5.9 months, SD 4.9). Reasons for discontinuation were not signifi cantly diff erent for olanzapine (19 / 58 ineffi cacy, 5 / 58 weight gain, 2 / 58 extrapyramidal symptoms, 6 / 58 sedation, 7 / 58 other) vs. risperidone (14 / 55 ineffi cacy, 1 / 55 weight gain, 5 / 55 extrapyramidal symptoms, 9 / 55 sedation, 7 / 55 other). In conclusion, we have found that time on medication was associated with early dysphoric response and use of cannabis, whereas no signifi cant diff erence in time on medication was found between olanzapine and risperidone. Improving the subjective response to medication by adjusting dose or type of medication may increase time on medication.