Challenges in communication during clerkships: a case report.

Patient-centered communication skills training is an integral part of the medical training of students of the Radboud University Nijmegen Medical Centre. During their clerkships, however, students are confronted with a variety of physicians, demonstrating communication skills which differ from what they have been taught. Some physicians have difficulty with patient-centered communication themselves. This may cause students to adopt inadequate communication behaviors. To prevent this, we suggest raising awareness in students and including supervising physicians in communication skills training.

Teaching and training in breaking bad news at the Dutch medical schools: a comparison.

BACKGROUND: Physicians consider breaking bad news (BBN) a difficult task, and training is therefore necessary. There is much variety in what schools consider to be best practice and best timing for such training. This article discusses BBN-programmes at the Dutch medical schools. We studied how students value their training and offer recommendations. METHODS: We developed two questionnaires to obtain programme information from course co-ordinators and student opinions about BBN-training. We compared student opinions right after BBN-training (T1) and towards the end of the medical curriculum (T2). RESULTS: BBN-programmes in Dutch medical schools vary in timing, models used and training methods. Overall, students are satisfied with the timing. They appreciate feedback by physicians and simulated patients most. At T2, some groups of students reported that BBN-training had given them slightly less guidance than was reported by T1-students at the same institution. DISCUSSION: T2-students perhaps realised they had not received the amount of support they needed and may have shifted from being unconsciously incompetent to being consciously incompetent. RECOMMENDATIONS: We recommend: (a) longitudinal programmes with experiential skills-training sessions and clinical practice, (b) to involve simulated patients, physicians and psychologists in training programmes as well as practising physicians who supervise students during clinical work and (c) to ensure ongoing support and feedback in the clinical phase.

[Research report 'the appropriate prescribing of antidepressants in general practice': who is better served by more diagnoses and more antidepressants?]. / Onderzoeksrapport 'doelmatig voorschrijven van antidepressiva in de huisartspraktijk': wie is er gebaat bij meer diagnosen en meer antidepressiva?

Recently a report entitled 'The appropriate prescribing of antidepressants in general practice' was published. The researchers conclude that depression and anxiety are still more under-diagnosed than over-diagnosed and that antidepressants are frequently prescribed even when they are not indicated. Why this is so remains unclear. Looking for better interventions to improve treatment and increase therapy compliance, this study reports that many types of intervention could help but it is not very specific on how this could be achieved. Improving communication and knowledge about prescribing and how and when to discontinue treatment, are among the suggestions made in the report. Many questions remain: (a) is under-diagnosis a problem in a condition that often resolves spontaneously with watchful waiting?, (b) why are antidepressants so widely prescribed when their effectiveness is controversial and they have major adverse reactions?, (c) why are other treatment options such as talking therapy and a short period psychological intervention, of which the effectiveness has been established, not more frequently applied?

[The practice guideline 'Anxiety disorders' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Angststoornissen' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The recommendations provided by the revised guideline 'Anxiety disorders' are well suited to every-day practice. The multidisciplinary approach reflects the increasing cooperation between primary and secondary care in the management of mental-health problems. The description of the various anxiety disorders and the questions that can be asked to elicit the symptoms will facilitate recognition. The indications for treatment with medication are clear: a limited number of antidepressants should be used. Although it is agreed that patient education is an important part of treatment, the guidelines could have described in more detail how this should be done. Cognitive-behavioural techniques may be used but this requires extra training; its effectiveness when used by general practitioners needs further study. This guideline will add to existing knowledge and improve the skills of general practitioners in dealing with anxiety.

The long-term perspective: a study of psychopathology and health status of patients with a history of depression more than 15 years after the first episode.

This article examines psychopathology, functioning, well-being, social support, and coping-behavior of family practice patients with a history of depressive illness, both with and without recurrences. Results of depressive patients were compared with each other and with those of "normal" controls. The patients belonged to the four practices of the Continuous Morbidity Registry of the University of Nijmegen, Netherlands. Their first episode of depression for each patient was more than 15 years ago. Data were collected with the Symptom Checklist (SCL-90) the RAND-36, the Social Support List (SSL-12), and the short Utrecht Coping List (UCL-k). Psychopathology scores of patients without recurrences were higher than "normal" controls and lower than patients with recurrences. The same pattern was found concerning health status. No significant differences were found between the groups in social support but patients with recurrences had a lower score of emotional coping than patients without recurrences or normal patients. That even a long time after an episode of depression, patients have higher levels of a variety of psychopathology than controls has implications for every-day practice as it calls for a longer and more critical follow-up of depression by clinicians.

The validity of the diagnosis of depression in general practice: is using criteria for diagnosis as a routine the answer?

BACKGROUND: In general practice, making a diagnosis does not follow the same lines as in secondary care because every new diagnosis is made against 'foreknowledge' and could be coloured by it. This could explain low accordance and differences in diagnoses between primary and secondary care, in particular when mental illness such as depression is concerned. When criteria are used for diagnosis there should be no differences. AIM: To establish the accordance with the Diagnostic and Statistical Manual of mental disorders, 4th edition (DSM-IV) criteria of major depressive disorder when the diagnosis of depression has been made by general practitioners (GPs) for whom coding and using criteria for diagnosis is a daily routine (ICHPPC-2 criteria). METHOD: Ninety-nine general practice patients from four general practices belonging to the Continuous Morbidity Registry (CMR) of the University of Nijmegen in The Netherlands were interviewed using the Composite International Diagnostic Interview (auto) 12-month version (DSM-IV criteria). Thirty-three patients had a code for depression; 33 patients a code for chronic nervous functional complaints (CNFC); and 33 had no code for mental illness (the depression and CNFC codes were given in the 12 months prior to the interview). Specificity and accordance with the DSM-IV criteria of major depressive disorder (MDD) were calculated with the results from the interviews. RESULTS: Of the 33 general practice depression cases (all matching ICHPPC-2 criteria), 28 matched DSM-IV criteria: 26 for MDD and 2 for dysthymia. No cases of DSM-IV MDD were found in the control group without a code for a mental disorder, and seven out of 33 were found in the control group with the code for CNFC. CONCLUSION: The specificity of diagnosis of depression made by GPs in a continuous morbidity registry and the accordance with DSM-IV criteria are high. Using criteria for diagnosis, which is a trend, could be one of the solutions towards a better diagnosis. As far as the sensitivity is concerned, GPs should not be distracted from using criteria for the diagnosis of depression when a large variety of complaints is presented.

[Depression: longer-lasting episode not an automatic indication for referral]. / Depressie: langer durende episode niet zonder meer een verwijsindicatie.

During episodes of depression, patients exhibit a low mood and a number of other emotional and/or physical symptoms for a certain period of time. Regarding depression as just the defined episode when patients meet the criteria for diagnosis, ignores the fluctuating character of the illness and the role of the patient. The patient is, after all, the one who decides if and when the symptoms experienced are important enough to seek medical assistance. How a patient with depression should be treated, and whether or not and to whom the patient should be referred, depends on more than just the severity of the depression. This is because severity involves more than just the number of symptoms when the depression was first diagnosed. Ineffective coping behaviour and lack of social support both negatively influence the course of depression and if the initial treatment is not effective enough, the episode will be prolonged. The interest and skills of the general practitioners as well as the expectations and former experiences of the patient play a major role in deciding whether to refer a patient to secondary care.

Long-term follow-up of depression among patients in the community and in family practice settings. A systematic review.

BACKGROUND: Current knowledge about the long-term outcome of depression is largely based on the results of studies performed with the small selection of patients who are referred to psychiatric professionals. However, because of the high prevalence of depression in the community and in primary care, information about the longterm outcome in these populations is indispensable if physicians are to offer the best possible care in these settings. METHODS: We performed a literature search to identify relevant papers published between 1970 and 1999 on original long-term follow-up studies of depression in community and primary care populations. The included studies were of adult populations with depression based on diagnostic criteria and a follow-up of at least 5 years. Data about recurrences, relapses, psychopathology, disability, or quality of life at follow-up were examined. RESULTS: We found 8 studies that fulfilled our criteria. The reported rates of recurrence or depression at follow-up were between 30% and 40%. Higher rates were found in the younger and older age groups. Data about other predictors of outcome, health status, and the relation between treatment and outcome did not justify any hard conclusions. CONCLUSIONS: The long-term outcome of depression in the community and in primary care is rarely studied. The results of available studies are difficult to compare because of the large differences in populations and methods. Nevertheless, these studies suggest that the longterm prognosis of depression in the community and in primary care is not as poor as in psychiatry.

Treatment of depression related to recurrence: 10-year follow-up in general practice.

OBJECTIVES: To study outcomes related to long-term treatment of depression and differences in treatments for first episodes of depression in patients with and without recurrences. METHODS: A historic cohort design study with 222 general practice patients who had been followed up for 10 years after being diagnosed of depression. Prescriptions for antidepressants, psychotropics and referrals over the period of 10 years following the first diagnosis of depression were studied. RESULTS: Over the 10-year period, the length of treatment with antidepressants and the doses prescribed were low compared to what is known to be efficacious in depression. This was also true for treatment during the first episode. Patients with a recurrent type of illness were more often treated with antidepressants and other psychotropics during their first episode than patients with only one episode of depression, but they were not referred any more often. CONCLUSION: Even though treatment was not as recommended for depression, the majority of the patients did not have recurrences. Future prospective research is needed to study causal relationships between treatment of depression and long-term outcome.