Wolfgang Rutz

Long‐term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression

In 1983‐1984 the Swedish Committee for the Prevention and Treatment of Depression offered an educational program on diagnosis and treatment of depressive disorders to all general practitioners on the island of Gotland. The program has been carefully evaluated; 1982 was used as the baseline and the main evaluation was carried out in 1985. After the educational programs, the frequency of sick leave for depressive disorders decreased, the frequency of inpatient care for depressive disorders decreased to 30% of that at the baseline; the prescription of antidepressants increased, but prescription of major tranquilizers, sedatives and hypnotics decreased. The frequency of suicide on the island decreased significantly. This study describes the long‐term effects. In 1988, 3 years after the project ended, the inpatient care for depressive disorders increased, the suicidal rate returned almost to baseline values and the prescription of antidepressants stabilized. Thus, the effects were strictly related in time to the educational programs, indicating that the effects were real and not only a coincidence with local trends on Gotland. Furthermore, the results indicate that educational programs that can have pronounced effects on the health care system have to be repeated approximately every 2 years if long‐term effects are to be expected.

Frequency of suicide on Gotland after systematic postgraduate education of general practitioners

In 1983–1984 the Swedish Committee for Prevention and Treatment of Depression (PTD Committee) introduced an educational program for all general practitioners (GPs) on the Swedish island of Gotland. The primary goal was to increase knowledge about diagnosis and treatment of patients with affective disorders. The effects of the educational programs were evaluated in detail; GPs identified more patients with depressive disorders and treated them more accurately. The suicide rate on Gotland was followed, primarily to ensure that the new treatment strategies did not include a risk for the individual patients. However, it was also hoped that increased awareness of patients with affective disorders and better treatment routines could reduce the suicide rale. The suicide rate dropped the year after the educational programs were introduced. This was a statistically significant deviation both from the long‐term trend on Gotland and from the trends in Sweden as a whole. Programs aiming at giving GPs increased capacity and responsibility to treat patients with affective disorders do not increase the frequency of suicide. Better primary treatment of patients with depressive disorders may reduce the suicide rate in a given area.

An educational program on depressive disorders for general practitioners on Gotland: background and evaluation

ABSTRACT General practitioners are the psychiatrists’ most important co‐workers in the treatment of depressive disorders. A high degree of knowledge about this illness in this group of doctors is of decisive importance. However, the value of postgraduate educational programs for general practitioners has been questioned. The Swedish Committee for the Prevention and Treatment of Depression (PTD) offered an educational program on symptoms, etiology, diagnosis, prevention and treatment of depression to all general practitioners on the Swedish island of Gotland. Lectures on suicide, depressive illness in childhood and in old age and psychotherapy of depressive states were also given. In several control periods data were collected on suicides, referrals to the local psychiatric department, emergency admissions, the quantity of sick leave used and the quantity of inpatient care due to depression. Even the prescription of psychopharmacological drugs on the island was investigated. Overall, the results indicated that general practitioners gratefully accepted the educational program and achieved increasing competence and stringency in treating and preventing depressive states. The program was associated with decreases in the use of psychiatric inpatient care and the sick leave frequency of depressed patients. The possibility of preventing suicides was positively influenced.

The Gotland Male Depression Scale: A validity study in patients with alcohol use disorder

The Gotland Male Depression Scale has been developed to improve the recognition of major depression in males. The Gotland Male Depression Scale was compared to the Major Depression Inventory in a population of male patients treated for alcohol dependency at the Alcohol Outpatients Clinic of Copenhagen University Hospital. The prevalence of depression as well as the prescription of antidepressants were used as indices of validation. The Gotland Male Depression Scale was shown to have an adequate internal validity. The prevalence of depression according to the Major Depression Inventory was 17% and according to the Gotland Male Depression Scale 39% of the patients had a probable or definite depression and should be considered for treatment with antidepressants. The Gotland Depression Subscale was found to be better than the Gotland Distress Subscale at discriminating between patients treated and not treated with antidepressants.

Male depression and suicide.

Based on the experiences of the Gotland Study that education of general practitioners about depressive illness resulted in a statistically significant reduction in the number of female suicides, leaving the rate of male suicides almost unaffected, we propose the concept of a male depressive syndrome. This syndrome comprises a low stress tolerance, an acting-out behavior, a low impulse control, substance abuse and a hereditary loading of depressive illness, alcoholism and suicide. This notion is supported by data from The Amish study as well as the concept of van Praag of a stress-precipitated, cortisol-induced, serotonin-related and anxiety-driven depressive illness most often seen in males. In order to identify depressed males, the Gotland Male Depression Scale has been developed. Some preliminary data using the scale in a group of alcohol-dependant patients are presented.

Cost-benefit analysis of an educational program for general practitioners by the Swedish Committee for the Prevention and Treatment of Depression

In 1983–1984 the Swedish Committee for the Prevention and Treatment of Depression launched an educational program on the diagnosis and treatment of depressive disorders for all general practitioners on the island of Gotland. The baseline year chosen was 1982 and the immediate effects were evaluated in 1985. In 1988 the long‐term effects were evaluated. These two evaluations indicated strictly time‐related beneficial effects on the frequency of sick leave and inpatient care for depressive disorders, the pattern of prescription of psychopharmacologic drugs and the frequency of suicide. This article describes a cost‐benefit analysis of the program. The cost of the educational program, changes in drug prescription and inpatient care were calculated as well as indirect costs concerning changes in morbidity and mortality. The calculation of the savings to society was subject to a sensitivity analysis. This shows that the educational program resulted in savings to society on the order of about SEK 155 million (USD 26 million). It is concluded that educational programs of this kind should be repeated every second to third year.

Effect of an educational program for general practitioners on Gotland on the pattern of prescription of psychotropic drugs

During the years 1983–1984, an educational program was given to all general practitioners on the island of Gotland. This report evaluates changes in prescription habits from 1982 to 1985. To correct for general trends that occurred simultaneously, the prescription habits were compared to the habits in the rest of Sweden. Both on Gotland and in Sweden as a whole, the use of antidepressants increased from 1982–1985, but significantly more on Gotland. In 1982, the use of antidepressants was low on Gotland, 54% of that in the rest of Sweden. After the educational programs, Gotland reached 77% of the use in the rest of Sweden. In 1982, the use of lithium was 123% of that in the rest of Sweden. After the educational programs, the use of lithium was unchanged, and a small increase of 5.6% was seen in the rest of Sweden. After the educational programs, the prescription of sedatives on Gotland decreased (– 8.2%), and an increase of 4.5% was seen in the rest of Sweden. The use of major tranquilizers also decreased significantly (– 23%) on Gotland. Even in the rest of Sweden, a significant but much smaller decrease was seen: – 13%. On Gotland the frequency of hypnotics remained stable from 1982–1985, and a significant increase was seen in the rest of Sweden.

Prevention of suicide and depression

In the years 1983–84, the Swedish Committee for the Prevention and Treatment of Depression (PTD) offered an educational programme to all general practitioners (GP:s) on the Swedish island of Gotland. The education has been shown to lead to a significant decrease in inpatient care, morbidity, mortality and costs caused by depressive illness on the island. Unspecific medication decreased and specific anti-depressive medication increased. A scrutiny of all suicides on Gotland during the 1980s revealed that the overall decrease in suicides as a result of the educational programme was caused mainly by the decrease in suicides committed by female suicidants with recognized major depression and in contact with general practitioners. This was expected. However, the number of male suicides was almost unaffected by the educational programme, as well as improvement in the GPs ability to diagnose and treat depression. This was unexpected.We believe that the reason for this is that male depressive suicidants are possi...

Evaluation of postgraduate medical education given by the Swedish PTD Committee

The Swedish Committee for the Prevention and Treatment of Depression (the Swedish PTD committee) has created a series of educational programmes to be used in post-graduate education of general practitioners; they deal with the etiology, pathogenesis, diagnosis and treatment of depression. The separate chapters were presented to general practitioners on the island of Gotland in two separate educational programmes with one year in between. Before, in between and after the last educational programme, information was collected regarding number of suicides, number of attempted suicides, number of referrals to the Dept. of Psychiatry, number of emergency admissions, number of subjects on sickleave due to depression and number of prescriptions for antidepressants and minor tranquillizers. The general practitioners completed a questionnaire concerning knowledge about etiology, pathogenesis, diagnosis and treatment of depression, attitudes towards depressed patients and their treatment, current practice and person...

The need for psychiatric professionalism - an integrative view

Some decades ago a diagnosis of schizophrenia meant being condemned to long-term institutional life. Today the situation is incomparably more positive but new problems have appeared that need to be tackled by the professional. The professionalism required today is different from that of the 1970s, which was the product of opportunistic modish ideologies. What is needed today is that facts about schizophrenia, its prognosis and treatability are presented to both patients and relatives - in order to replace anxiety with knowledge and to lay the basis for mandate and mutual trust. We need professionalism to be realistic about the rehabilitation goals concerning the effect of the disease on judgement, will and insight. Research today shows that psychotherapy and family therapy are in no way in contradiction to pharmacological treatment, but are mostly complements of each other. The best way to improve professionality is to focus on the interaction between biological vulnerability and psychosocial stress and i...