APRAND programme: an intervention to prevent relapses of anxiety and depressive disorders. First results of a medical health promotion intervention in a population of employees.

OBJECTIVE: The study sought to determine whether an organized health promotion intervention during medical consultations improves the outcome for patients who meet the ICD10 criteria for anxiety or depressive disorders. METHODS: In 2001, physicians used the MINI to screen 9743 employees on sick leave and consulting physicians in 21 medical centres of a large company. A health promotion intervention was implemented in eight "active" centres. It took place immediately after diagnosis and consisted of explaining the disorders, delivering the test results and leaflets based on WHO recommendations, and advising patients to consult their personal physician, psychiatrist or occupational physician, if necessary. Its effectiveness, evaluated by symptom severity and outcome over 1 year, was assessed by comparing the eight active centres to 13 control centres (without the intervention). RESULTS: Disorders were detected among 10.6% of the subjects, 29.4% of whom had no previous diagnosis of anxiety or depressive disorder. The intervention was associated with a positive effect on the 6-week and 6-month HAD scores. Total absence of disorders at 1 year was associated with age, sex, and intervention, among all identified cases (OR=1.53), among those with at least one anxiety disorder (OR=1.45), and among those with at least one depressive disorder (OR=1.40). CONCLUSION: Combining detection with organized provision of information including printed material improves patients' outcome and physicians' diagnostic abilities.

Consensus statement on transcultural issues in depression and anxiety from the International Consensus Group on Depression and Anxiety.

OBJECTIVE: To provide primary care physicians with a better understanding of transcultural issues in depression and anxiety. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Five faculty invited by the chair also participated: Laurence J. Kirmayer, Jean-Pierre Lepine, Keh-Ming Lin, Osamu Tajima, and Yutaka Ono. EVIDENCE: The consensus statement is based on the 5 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles, and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSION: The consensus statement underlines the prevalence of depression and anxiety disorders across all cultures and nations while recognizing that cultural differences exist in symptom presentation and prevalence estimates. In all countries, the recognition of depression by clinicians in the primary care setting is low (generally less than 50%), and the consensus group recommends a 2-step process to aid the recognition and diagnosis of depression. In line with the low recognition of depression and anxiety disorders is the finding that only a small proportion of patients with depression or anxiety are receiving appropriate treatments for their condition. Biological diversity across ethnic groups may account for the differential sensitivity of some groups to psychotropic medication, but this area requires further investigation.

The burden of depression and anxiety in general medicine.

Psychological illness is responsible for considerable disability worldwide. The World Health Organization Global Burden of Disease Survey estimates that by the year 2020, major depression will be second only to ischemic heart disease in the amount of disability experienced by sufferers. Although different measures of disability have been used in different studies, they have consistently demonstrated that individuals with depression and anxiety disorders experience impaired physical and role functioning, more days in bed due to illness, more work days lost, increased impairment at work, and high use of health services. The disability caused by depression and anxiety is just as great as that caused by other common medical conditions, such as hypertension, diabetes, and arthritis. Comorbidity of depression with anxiety or medical illness further increases the disability experienced by sufferers. Recognition and treatment, however, relieve the burden imposed by untreated depression on the individual, society, and health services.

Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety.

OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in posttraumatic stress disorder (PTSD) and guide clinical practice with recommendations on the appropriate management strategy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty invited by the chair were Edna B. Foa, Ronald C. Kessler, Alexander C. McFarlane, and Arieh Y. Shalev. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSION: PTSD is often a chronic and recurring condition associated with an increased risk of developing secondary comorbid disorders, such as depression. Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed.

A European perspective on social anxiety disorder.

Epidemiologic surveys conducted across Europe indicate that the lifetime prevalence of social anxiety disorder in the general population is close to 7%. The disorder in adulthood rarely presents in its 'pure' form and 70-80% of patients have at least one other psychiatric disorder, most commonly depression. Social anxiety disorder is a risk factor for the development of depression and alcohol/substance use or dependence, especially in cases with an early onset (< 15 years). Individuals with social anxiety disorder have significant functional impairment, notably in the areas of initiation and maintenance of social/romantic relationships and educational and work achievement. The economic consequences of social anxiety disorder are considerable, with a high level of diminished work productivity, unemployment and an increased utilisation of medical services amongst sufferers. Effective treatment of social anxiety disorder would improve its course and its health and economic consequences.

The prescribing of psychotropic drugs by primary care physicians: an international collaborative study.

Psychotropic drugs play a major role in primary care management of mental disorders. This study expands the existing data on prescribing practices using data from a 15-center, primary care epidemiologic survey. Questions to be addressed include the following: Which clinical and nonclinical factors are related to the prescribing of psychotropic drugs by primary care physicians? How do prescribing patterns vary across primary care centers? At each center, primary care patients were screened using the General Health Questionnaire, and a stratified random sample completed a standardized diagnostic assessment. For each patient completing the diagnostic assessment, the treating primary care physician provided data on clinical diagnosis and medications prescribed. Study results indicated that 11.5% of all practice attenders, 51.7% of cases who received a diagnosis of mental disorders by a physician, and 27.6% of cases who received a diagnosis using the Composite International Diagnostic Interview were treated with psychotropic medication because of their psychologic problems. Anxiolytics, hypnotics, and antidepressants each accounted for approximately 20% of all prescriptions. Prescription rates increased with the prominence of psychologic complaints, severity of mental disorder, severity of social disability, female gender, age older than 40 years, lower education, unemployment, and marital separation. Rates and type of drugs also varied among specific mental disorders; 19.3% of patients with brief recurrent depression but 55.0% with agoraphobia got any psychotropic drug. Antidepressant drugs were prescribed in 7.7% of anxiety disorders compared with 31.9% of depressive disorders. There were large differences between international centers. When comparing client-type centers with clinic-type centers, overall prescription rates were similar (51.2 vs. 52.9%), but significant differences were observed with respect to psychotropic polypharmacy (12.6% client, 6.3% clinic), tranquilizer medication (24.2 client, 32.9% clinic), and antidepressant medication (17.3 client, 8.9% clinic). Psychotropic drugs have an important role in the treatment of mental disorders by general practitioners. Prescription is associated with a number of clinical but also nonclinical factors that must be recognized when guidelines for international use are to be published. Recognition of mental disorders and selection of specific drug classes are important areas in which medical practice needs improvement.

Comorbidity in social anxiety disorder: impact on disease burden and management.

Social anxiety disorder is a chronic, disabling disorder in which patients suffer with considerable morbidity that, more often than not, precedes the development of other psychiatric disorders. The development of comorbidity adds to the severity of the disorder, increases the risk of suicide attempts, and increases the overall burden of the disease for both the patient (greater disability) and the health care service (greater use of medical services). Comorbidity in social anxiety disorder may result in one good thing: increased recognition and treatment, because in the absence of comorbidity the level of recognition of the disorder is very low. However, the disorder is rarely recognized correctly and, consequently, patients are often offered inappropriate treatments. Given the degree of disability caused by social anxiety disorder, whether "pure" or comorbid, there is a need for improved education of both doctors and patients regarding its status as a disorder and its treatment.

Prevalence and recognition of anxiety syndromes in five European primary care settings. A report from the WHO study on Psychological Problems in General Health Care.

BACKGROUND: This study explored the prevalence, socio-demographic characteristics and severity of different anxiety syndromes in five European primary care settings, as well as medical help-seeking, recognition by general practitioners (GPs) and treatment prescribed. METHOD: The data were collected as part of the WHO study on Psychological Problems in General Health Care. Among 9714 consecutive primary care patients, 1973 were interviewed using the Composite International Diagnostic Interview. Reason for contact, ICD-10 diagnoses, severity and disability were assessed. Recognition rates and treatment prescribed were obtained from the GPs. RESULTS: Anxiety syndromes, whether corresponding to well-defined disorders or to subthreshold conditions, are frequent in primary care and are associated with a clinically significant degree of severity and substantial psychosocial disability. Their recognition by GPs as well as the proportion treated are low. CONCLUSIONS: Since people with subthreshold anxiety show a substantial degree of disability and suffering, GPs may consider diagnostic criteria to be insufficient. However, their awareness of specific definitions and treatment patterns for anxiety disorders still needs a lot of improvement both for patients' well-being and for the cost resulting from non-treatment.

Differences between prescription and consumption of antidepressants and anxiolytics.

The rate of detection of depressed patients by general practitioners (GPs) is generally reported to be lower than 50%, with some studies giving a value as low as 14%. In addition, GPs tend to overdiagnose anxiety and underdiagnose depression. Patients are not necessarily aware of the psychological nature of the disorder and only one-fifth list psychological complaints as the reason for contact. We collected information on the prescription and consumption of drugs in order to assess the influence of recognition of depression by GPs and of other factors on the treatment received by patients. Our results, which are particularly important in the context of current discussions on the cost of mental healthcare treatments, indicate not only a need for GPs to improve their identification rates but also a need to make patients more aware of the nature of their psychological diagnoses. When spontaneous psychological complaints are presented, the identification rate increases very substantially, and when patients are well aware of their conditions, compliance increases. It is clear from our results that greater specific recognition of psychiatric patients accompanied by the prescription of a specific treatment would not substantially alter the direct costs of drug prescription. On the contrary, it would very probably lower many costs, since the proportion of specific treatment given to properly identified patients is very low at present.

Depression comorbid with anxiety: results from the WHO study on psychological disorders in primary health care.

The World Health Organization collaborative study on "Psychological Problems in General Health Care" investigated the form, frequency, course and outcome of common psychological problems in primary care settings at 15 international sites. The research employed a two-stage case-finding procedure. GHQ-12 was administered to 25916 adults who consulted health-care services. The second-stage assessment (n = 5438) consisted of the Composite international Diagnostic Interview (CIDI), the Social Disability Schedule, and questionnaires. Possible cases or borderline cases of mental disorder, and a sample of known cases, were followed up at three months and one year. Using standard diagnostic algorithms (ICD-10), prevalence rates were calculated for current disorder (one-month) and lifetime experience disorder. Well-defined psychological problems are frequent in all the general health-care settings examined (median 24.0%). Among the most common were depression anxiety, alcohol misuse, somatoform disorders, and neurasthenia. Nine per cent of patients suffered from a "subthreshold condition" that did not meet diagnostic criteria but had clinically significant symptoms and functional impairment. The most common co-occurrence was depression and anxiety. Comorbidity increases the likelihood of recognition of mental disorders in general health care, and the likelihood of receiving treatment.

Risk-benefit assessment of newer versus older monoamine oxidase (MAO) inhibitors.

The first generation of monoamine oxidase (MAO) inhibitors fell into disuse because of poor efficacy in major depression with melancholia and/or endogenous depression, and because of poor tolerability (drug interactions and the 'cheese' effect). New MAO inhibitors, reversible inhibitors of MAO-A (RIMAs), are able to induce a reversible and specific inhibition of MAO-A. Consequently, the inhibition of MAO is quicker and the dose-response relationship improved, such that dosage adjustment is easier. Also, no carry-over effect once treatment is terminated is observed. The frequency and severity of drug interactions with RIMAs is reduced, although coadministration with pethidine (meperidine) or dextromethorphan should still be avoided. No specific subgroup of patients with depression has shown a better or worse response to RIMAs. The presence of melancholia in major depression, or the existence of endogenous depression, are not predictive of reduced efficacy compared with tricyclic antidepressant (TCA) reference compounds. Dysthymic patients have shown a good response to both RIMAs and TCAs independent of the co-existence of a major depressive episode. Older MAO inhibitors are more effective than TCAs in the treatment of atypical depression, and further studies are needed to confirm if this is true for RIMAs. Long term studies to evaluate the effects of RIMAs on disease recurrence are also required. RIMAs are better tolerated than older MAO inhibitors, including use in subgroups particularly at risk of adverse effects such as the elderly. Overall, RIMAs appear to represent therapeutic progress in the treatment of depression in terms of both efficacy and tolerability.