GPs' experiences with enhanced collaboration between psychiatry and general practice for children with ADHD.

BACKGROUND: Most general practitioners (GPs) do not feel comfortable with diagnosing and treating children with attention deficit hyperactivity disorder (ADHD). This is problematic since ADHD is a prevalent disorder and an active role of GPs is desired. In the Netherlands a collaborative ADHD programme was established, comprising of shortened diagnostic assessment in specialized mental healthcare followed by psycho-education in mental healthcare and pharmacological treatment by pre-trained GPs. OBJECTIVES: To explore the experiences of GPs regarding the diagnosis and treatment of children with uncomplicated ADHD within this programme. METHODS: Semi-structured interviews with 15 GPs were conducted. The GPs participated in an evaluation of the collaborative ADHD programme. Data was analysed using the principles of constant comparative analysis. RESULTS: Most participating GPs expressed reluctance to diagnose ADHD themselves. The reluctance was due to a lack of time, knowledge and experience. The GPs welcomed the collaborative programme because it met their need for both quick and adequate diagnosis by a specialist. Furthermore, an online ADHD course, offered by the programme, gave them the confidence to start and monitor ADHD medication. Finally, they appreciated the possibility of consulting a specialist when necessary. CONCLUSION: GPs preferred that ADHD was diagnosed by a specialist. In the context of the ADHD collaborative programme, they felt competent and comfortable to start and monitor medication in children with uncomplicated ADHD. Key Messages Within a collaborative ADHD programme for children, participating GPs were positive about a quick and specialist diagnostic process within secondary care. After an online course, GPs felt confident to start and monitor ADHD medication in children with uncomplicated ADHD. GPs were content about the collaboration between primary and secondary care.

[Summary of the Dutch College of General Practitioners' (NHG) practice guideline 'ADHD in children']. / Samenvatting van de NHG-standaard 'ADHD bij kinderen'.

The diagnosis of ADHD may be considered if a child is hyperactive, impulsive or inattentive, and if this behaviour results in evidently impaired functioning in multiple settings. Children with behavioural problems and slightly impaired functioning may benefit from patient information, education and parenting advice. From the age of 6 years, children can be offered diagnostic testing and professional support within the primary care setting, provided sufficient knowledge and expertise is available and there is collaboration with other health care providers. Management of a child with ADHD but no comorbid psychiatric disorder, consists of a step-by-step plan including education, parent and teacher guidance and, optionally, behavioural therapy for the child. In consultation with parents, child and other therapists, methylphenidate can be prescribed if behavioural interventions are not sufficiently effective. Children taking medication for ADHD should be monitored periodically, including assessment of the effectiveness and side effects.

[Proactive monitoring of sickness absence for psychosocial problems]. / Wees proactief bij verzuim door psychische problemen.

Psychosocial problems are common in daily practice. These problems are the cause of 30% of absence from work due to sickness. Almost one third of workers with common mental disorders experience recurrent sickness absence. Although general practitioner (GP) and occupational physician (OP) guidelines have suggested monitoring these patients, these doctors are not used to doing this. Dutch researchers studied a problem-solving intervention (SHARP-at work) for evaluating the effectiveness of preventing recurrent sickness absence. Although the researchers found a decrease in recurrent sickness absence, it is not clear whether this effect was caused by the intervention or by the extra contacts between doctor and employee. Support and empathy are non-specific factors which could explain these positive findings in themselves. Given the findings in this study, GPs and OPs should be more aware of the importance of proactive monitoring of patients with common mental disorders after they have returned to work.

[Summarisation of the NHG practice guideline 'Anxiety']. / Samenvatting van de NHG-standaard 'Angst'.

Anxiety and anxiety disorders are addressed in the practice guideline of the Dutch College of General Practitioners (NHG). It is important to distinguish anxiety and anxiety disorders because of differences in prognosis and treatment. Several visits may be needed before the diagnosis is established. Treatment is based on a stepped-care model. For anxiety, psychoeducation and follow-up visits are often sufficient. For anxiety disorders with relatively low levels of distress or social dysfunctioning, self-help with supervision in addition to psychoeducation is helpful. If this is not effective or if there is severe distress or social dysfunctioning, cognitive behavioural therapy is the first choice treatment. An antidepressant could be started after or in addition to cognitive behavioural therapy. If an antidepressant is prescribed, SSRIs are preferred above tricyclic antidepressants because of the lesser risk of severe adverse effects.

Problem-solving treatment in general practice residency: a focus group study of registrars' views.

OBJECTIVE: General practitioner (GP) registrars often express the need for more expertise of non-pharmacological treatments for patients with mental health problems. Problem-solving treatment (PST) could be an attractive option. We aimed to explore GP registrars' views on PST-training during residency and on the actual use of PST in general practice. METHODS: We performed a qualitative study with four focus groups, interviewing 18 Dutch registrars who had been trained in PST during residency. Data were analysed according to the principles of constant comparative analysis. RESULTS: Registrars thought that PST-training during residency was feasible, interesting and helpful, but found that it took too much time in everyday practice and was not a GP's task. All registrars, however, said they would use specific elements in a variety of consultations, for instance concretising problems, brainstorming about practical solutions, and activating patients. CONCLUSION: Registrars regarded PST-training during residency feasible and helpful. In daily practice they would apply specific elements of the treatment. PRACTICE IMPLICATIONS: We recommend residency programmes to offer training in PST or another psychological treatment with comparable elements. Training should fit in with the registrars' needs and level of training and experience.

Effectiveness of problem-solving treatment by general practice registrars for patients with emotional symptoms.

INTRODUCTION: In general practice many patients present with emotional symptoms. Both patients and physicians desire effective non-pharmacological treatments. AIM: To study the effectiveness of problem-solving treatment (PST) delivered by trained general practice registrars (GP registrars) for patients with emotional symptoms. METHODS: In a controlled clinical trial we compared the effectiveness of PST versus usual care for patients with emotional symptoms. Dutch GP registrars provided either PST or usual care, according to their own preference. Patients were included if they (a) had presented for three or more consultations with emotional symptoms in the past six months; and (b) scored four or more on the 12-item General Health Questionnaire. Outcomes at three- and nine-month follow-up were standard measures of depression, anxiety and quality of life. RESULTS: Thirty-eight GP registrars provided PST and included 98 patients; 43 provided usual care and included 104 patients. PST patients improved significantly more than usual care patients: at nine-month follow-up, recovery rates for somatoform disorder and anxiety were higher in the PST group (OR 6.50, p=0.01 respectively OR 11.25, p=0.03). PST patients had improved significantly more on the domains social functioning, role limitation due to emotional problems and general health perception. DISCUSSION: Patients with emotional symptoms improved significantly more after PST delivered by motivated GP registrars than after usual care by GP registrars. Further research, with randomisation of interested registrars or interested GPs, is needed.