Time-dependent depression and anxiety symptoms as risk factors for recurrent cardiac events: findings from the UPBEAT-UK study.

BACKGROUND: Depression is a well-known risk factor for recurrent cardiac events (RCEs) but findings are less consistent for anxiety, not previously reported on using a time-dependent approach. We aimed to study the prognostic effect of anxiety and depression symptom levels on RCEs. METHODS: Data (N = 595) were drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Hospital Anxiety and Depression Scale symptoms were grouped into: agitation (three items), anxiety (four items), and depression (seven items) subscales. We performed two types of multivariate analyses using Cox proportional hazard models with delayed entry: with baseline variables (long-term analysis), and with variables measured 12-to-18 months prior to the event (short-term time-dependent analysis), as RCE risk factors. RESULTS: In the baseline analysis, both anxiety and depression, but not agitation, were separate RCE risk factors, with a moderating effect when considered jointly. In the short-term time-dependent analysis, elevated scores on the anxiety subscale were associated with increased RCE risk even when adjusted for depression [hazard ratio (95% confidence interval) 1.22 (1.05-1.41), p = 0.009]. Depression was no longer a significant predictor when adjusted for anxiety [1.05 (0.87-1.27), p = 0.61]. For anxiety, individual items associated with RCEs differed between the two approaches: item 5 'worrying thoughts' was the most significant long-term risk factor [1.52 (1.21-1.91), p = 0.0004] whereas item 13 'feelings of panic' was the most significant time-dependent short-term risk factor [1.52 (1.18-1.95), p = 0.001]. CONCLUSIONS: Anxiety is an important short-term preventable and potentially causal risk factor for RCEs, to be targeted in secondary cardiac disease prevention programmes.

Depression and anxiety symptom trajectories in coronary heart disease: Associations with measures of disability and impact on 3-year health care costs.

BACKGROUND: As mortality from coronary heart disease (CHD) falls, years lived with disability increase. Depression and anxiety are known indicators of poor outcomes in CHD, but most research has measured distress symptoms at one time point, often following acute events. Here we consider the long-term trajectories of these symptoms in established CHD, and examine their association to distinct measures of disability and impact on costs. METHODS AND RESULTS: 803 patients with diagnosis of CHD were recruited from primary care, and completed detailed assessments every 6months for 3years. Latent class growth analysis (LCGA) was used to identify 5 distinct symptom trajectories based on the Hospital Anxiety and Depression Questionnaire (HADS): 'stable low', 'chronic high', 'improving', 'worsening', and 'fluctuating'. The 'chronic high' group had highest association with reporting of chest pain (RRR 5.8, CI 2.9 to 11.7), smoking (2.9, 1.1 to 6.3), and poorer physical (0.88, 0.83-0.93) and mental (0.78, 0.73-0.84) quality of life. The 'chronic high' and 'worsening' trajectories had significantly higher health-care costs over the 'stable low' trajectory (107.2% and 95.5% increase, respectively). In addition, our trajectories were the only significant variable associated with increased health-care costs across the 3years. CONCLUSIONS: Symptoms of depression and anxiety are highly prevalent in stable CHD patients, and their long-term trajectories are the single biggest driver of health care costs. Managing morbidity in these patients, in which depression and anxiety play a key role in, should become the primary focus of policy makers and future clinical trials.

Health Service Utilisation, Detection Rates by Family Practitioners, and Management of Patients with Common Mental Disorders in French Family Practice.

OBJECTIVE: Provide up-to-date detection rates for common mental disorders (CMD) and examine patient service-use since the Preferred Doctor scheme was introduced to France in 2005, with patients encouraged to register with and consult a family practitioner (FP) of their choice. METHODS: Study of 1133 consecutive patients consulting 38 FPs in the Montpellier region, replicating a study performed before the scheme. Patients in the waiting room completed the self-report Patient Health Questionnaire (PHQ) and Client Service-Receipt Inventory with questions on registration with a Preferred Doctor and doctor-shopping. CMD was defined as reaching PHQ criteria for depression, somatoform, panic or anxiety disorder. For each patient, FPs completed a questionnaire capturing psychiatric caseness. RESULTS: 81.2% of patients were seeing their Preferred Doctor on the survey-day. Of those with a CMD, 52.6% were detected by the FP. This increased with CMD severity and comorbidity. Detected cases were more likely to be consulting their Preferred Doctor (84.7% versus 79.4% for non-detected cases, p = 0.05) rather than another FP. They declared more visits to psychiatrists (17.2% versus 6.7%, p = 0.002). There was no association with consultation frequency or doctor-shopping, which both declined between the two studies. CONCLUSION: The CMD detection rate is relatively high, with no increase compared to our previous study, despite a decline in doctor-shopping. An explanation is the same high proportion of patients visiting their usual FP on the survey-day at both periods, suggesting a limited impact of the scheme on care continuity. FP action taken highlights the importance of improving detection for providing care to patients with CMDs.

The development and psychometric properties of a measure of clinicians' attitudes to depression: the revised Depression Attitude Questionnaire (R-DAQ).

BACKGROUND: Depression is a common mental disorder associated with substantial disability. It is inadequately recognised and managed, and clinicians' attitudes to this condition and its treatment may play a part in this. Most research in this area has used the Depression Attitude Questionnaire (DAQ), but analyses have shown this measure to exhibit problems in psychometric properties and suitability for the health professionals and settings where depression recognition may occur. METHODS: We revised the DAQ using a pooled review of findings from studies using this measure, together with a Delphi study which sought the opinions of a panel of relevant experts based in the UK, USA, Australia, and European countries (n = 24) using 3 rounds of questioning to consider attitude dimensions, content, and item wording. After item generation, revision and consensus (agreement >70%) using the Delphi panel, the revised DAQ (R-DAQ) was tested with 1193 health care providers to determine its psychometric properties. Finally the test-retest reliability of the R-DAQ was examined with 38 participants. RESULTS: The 22-item R-DAQ scale showed good internal consistency: Cronbach's alpha coefficient was 0.84; and satisfactory test-retest reliability: intraclass correlation coefficient was 0.62 (95% C.I. 0.37 to 0.78). Exploratory factor analysis favoured a three-factor structure (professional confidence, therapeutic optimism/pessimism, and a generalist perspective), which accounted for 45.3% of the variance. CONCLUSIONS: The R-DAQ provides a revised tool for examining clinicians' views and understanding of depression. It addresses important weaknesses in the original measure whilst retaining items and dimensions that appeared valid. This revised scale is likely to be useful in examining attitudes across the health professional workforce and beyond the confines of the UK, and may be valuable for the purpose of evaluating training that aims to address clinicians' attitudes to depression. It incorporates key dimensions of attitudes with a modest number of items making it applicable to use in busy clinical settings.

Depression in primary care patients with coronary heart disease: baseline findings from the UPBEAT UK study.

BACKGROUND: An association between depression and coronary heart disease is now accepted but there has been little primary care research on this topic. The UPBEAT-UK studies are centred on a cohort of primary patients with coronary heart disease assessed every six months for up to four years. The aim of this research was to determine the prevalence and associations of depression in this cohort at baseline. METHOD: Participants with coronary heart disease were recruited from general practice registers and assessed for cardiac symptoms, depression, quality of life and social problems. RESULTS: 803 people participated. 42% had a documented history of myocardial infarction, 54% a diagnosis of ischaemic heart disease or angina. 44% still experienced chest pain. 7% had an ICD-10 defined depressive disorder. Factors independently associated with this diagnosis were problems living alone (OR 5.49, 95% CI 2.11-13.30), problems carrying out usual activities (OR 3.71, 95% CI 1.93-7.14), experiencing chest pain (OR 3.27, 95% CI 1.58-6.76), other pains or discomfort (OR 3.39, 95% CI 1.42-8.10), younger age (OR 0.95 per year 95% CI 0.92-0.98). CONCLUSION: Problems living alone, chest pain and disability are important predictors of depression in this population.

The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study.

BACKGROUND: Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression. METHODS: Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables. RESULT: 1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000. CONCLUSIONS: Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN21615909.

UPBEAT study patients' perceptions of the effect of coronary heart disease on their lives: a cross-sectional sub-study.

BACKGROUND: Patients can report positive effects of myocardial infarction. It is unknown whether these effects are sustained or what factors influence adaptation. OBJECTIVES: To explore primary care patients' perceptions of the effect of coronary heart disease and to identify possible modifiable predictors of adaptation. DESIGN AND SETTING: Cross-sectional, sub-study of UPBEAT cohort participants. Patients were recruited from coronary heart disease Registers in South London General Practices. METHOD: 548 participants were asked "Has having heart disease changed your life? If so, was that change for the better, worse, both or neither?" Participants were asked to explain their response; explanations were subjected to content analysis. Associations between response and lifestyle, demographic, mood and coronary heart disease variables were tested. RESULTS: Respondents (394 male, 72%) were aged 27-98 years and had had heart disease for a mean of 12.4 SD ± 8.4 years. 120 (22%) reported that life was better and 200 (37%) said it was worse. The explanations of those who said 'better' were categorised as 'Healthier Living', 'Recognised Mortality' and 'Stress Reduction'. For those saying 'worse', categories were 'Restricted Lifestyle', 'Recognised Mortality', 'Loss and Burden'. More anxiety symptoms (RRR 1.56, 95% CI 1.12, 2.17), lower functional status (RRR 2.46, 95% CI 1.21, 4.98) and self-reported chest pain (RRR 2.24, 95% CI 1.34, 3.77) were associated with saying 'worse'. CONCLUSIONS: Many primary care patients are ambivalent to the effects of coronary heart disease, but some report positive effects. Negative perceptions are associated with reported functional impairment, chest pain and anxiety, but not illness severity or patient characteristics. Future work will track the implications of these perceptions, but nurses managing patients with coronary heart disease should consider these effects as they may be modifiable predictors of adaptation.

Detecting depression in patients with coronary heart disease: a diagnostic evaluation of the PHQ-9 and HADS-D in primary care, findings from the UPBEAT-UK study.

OBJECTIVE: People with coronary heart disease (CHD) are at heightened risk of depression, and this co-occurrence of conditions is associated with poorer outcomes including raised mortality. This study compares the diagnostic accuracy of two depression case finding instruments in CHD patients relative to a diagnostic standard, the revised Clinical Interview Schedule (CIS-R). METHODS: The Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the CIS-R depression module were administered to 803 patients identified from the CHD registers of GP practices in Greater London. RESULTS: Of 730 recruited patients without previously identified depression, 32 (4.4%) met ICD-10 depressive episode criteria according to the CIS-R. For the PHQ-9 and HADS-D lower cut-points than those routinely recommended were associated with improved case identifying properties. The PHQ-9 appeared the superior instrument using a cut-point of ≥8 (sensitivity=94%; specificity=84%). Using categorical scoring the PHQ-9 was 59% sensitive and 95% specific. For the HADS-D using cut-point ≥5, sensitivity was 81% and specificity was 77%. Areas under the curves (AUC) (standard error) were 0.95 (0.01) and 0.88 (0.02) for the PHQ-9 and HADS-D, and 0.91 (0.02) for PHQ-9 using the categorical algorithm. Statistically significant differences between AUCs of the PHQ-9 and the HADS-D favoured the former. Severity ratings compared across measures indicated inconsistency between recommended bandings: the PHQ-9 categorised a larger proportion of participants with mild and moderate depression. CONCLUSION: This is the first large-scale investigation of the accuracy of these commonly used measures within a primary care CHD population. Our results suggest that although both scales have acceptable abilities and can be used as case identification instruments for depression in patients with CHD, the PHQ-9 appeared diagnostically superior. Importantly, optimal cut-off points for depression identification in this population appear to differ from standard values, and severity ratings differ between these measures.

Late-onset agoraphobia: general population incidence and evidence for a clinical subtype.

OBJECTIVE: The purpose of this study was to estimate the general population incidence of late-life agoraphobia and to define its clinical characteristics and risk factors. METHOD: A total of 1,968 persons ≥65 years old were randomly recruited from the electoral rolls of the district of Montpellier, France. Prevalent and incident agoraphobia diagnosed with a standardized psychiatric examination and validated by a clinical panel were assessed at baseline and over a 4-year follow-up. RESULTS: The 1-month baseline prevalence of agoraphobia was estimated to be 10.4%. Among persons with agoraphobia, 10.9% reported having their first episode at age 65 or above. During the 4-year follow-up, 11.2% of participants without agoraphobia at baseline had a first episode, resulting in an incidence rate of 32 per 1,000 person-years. These 132 incident late-onset cases were associated with higher incidence rates of anxiety disorders and suicidal ideation. Of the incident cases, only two were characterized by past or concurrent panic attacks, a rate that was not significantly different from that of the noncase group. The principal baseline risk factors for incident cases, derived from a multivariate model incorporating all significant risk factors, were younger age at onset (odds ratio=0.94, 95% CI=0.90-0.99), poorer visuospatial memory performance (odds ratio=1.60, 95% CI=1.02-2.49), severe depression (odds ratio=2.62, 95% CI=1.34-5.10), and trait anxiety (odds ratio=1.73, 95% CI=1.03-2.90). No significant association was found with cardiac pathologies. CONCLUSIONS: Agoraphobia has a high prevalence in the elderly, and unlike cases in younger populations, late-onset cases are not more common in women and are not associated with panic attacks, suggesting a late-life subtype. Severe depression, trait anxiety, and poor visuospatial memory are the principal risk factors for late-onset agoraphobia.

Characteristics of people with low health literacy on coronary heart disease GP registers in South London: a cross-sectional study.

OBJECTIVE: To explore characteristics associated with, and prevalence of, low health literacy in patients recruited to investigate the role of depression in patients on General Practice (GP) Coronary Heart Disease (CHD) registers (the Up-Beat UK study). DESIGN: Cross-sectional cohort. The health literacy measure was the Rapid Estimate of Health Literacy in Medicine (REALM). Univariable analyses identified characteristics associated with low health literacy and compared health service use between health literacy statuses. Those variables where there was a statistically significant/borderline significant difference between health literacy statuses were entered into a multivariable model. SETTING: 16 General Practices in South London, UK. PARTICIPANTS: Inclusion: patients >18 years, registered with a GP and on a GP CHD register. Exclusion: patients temporarily registered. PRIMARY OUTCOME MEASURE: REALM. RESULTS: Of the 803 Up-Beat cohort participants, 687 (85.55%) completed the REALM of whom 106 (15.43%) had low health literacy. Twenty-eight participants could not be included in the multivariable analysis due to missing predictor variable data, leaving a sample of 659. The variables remaining in the final model were age, gender, ethnicity, Indices of Multiple Deprivation score, years of education, employment; body mass index and alcohol intake, and anxiety scores (Hospital Anxiety and Depression Scale). Univariable analysis also showed that people with low health literacy may have more, and longer, practice nurse consultations than people with adequate health literacy. CONCLUSIONS: There is a disadvantaged group of people on GP CHD registers with low health literacy. The multivariable model showed that patients with low health literacy have significantly higher anxiety levels than people with adequate health literacy. In addition, the univariable analyses show that such patients have more, and longer, consultations with practice nurses. We will collect 4-year longitudinal cohort data to explore the impact of health literacy in people on GP CHD registers and the impact of health literacy on health service use.

Attitudes toward depression among Japanese non-psychiatric medical doctors: a cross-sectional study.

BACKGROUND: Under-recognition of depression is common in many countries. Education of medical staff, focusing on their attitudes towards depression, may be necessary to change their behavior and enhance recognition of depression. Several studies have previously reported on attitudes toward depression among general physicians. However, little is known about attitudes of non-psychiatric doctors in Japan. In the present study, we surveyed non-psychiatric doctors' attitude toward depression. METHODS: The inclusion criteria of participants in the present study were as follows: 1) Japanese non-psychiatric doctors and 2) attendees in educational opportunities regarding depression care. We conveniently approached two populations: 1) a workshop to depression care for non-psychiatric doctors and 2) a general physician-psychiatrist (G-P) network group. We contacted 367 subjects. Attitudes toward depression were measured using the Depression Attitude Questionnaire (DAQ), a 20-item self-report questionnaire developed for general physicians. We report scores of each DAQ item and factors derived from exploratory factor analysis. RESULTS: We received responses from 230 subjects, and we used DAQ data from 187 non-psychiatric doctors who met the inclusion criteria. All non-psychiatric doctors (n = 187) disagreed with "I feel comfortable in dealing with depressed patients' needs," while 60 % (n = 112) agreed with "Working with depressed patients is heavy going." Factor analysis indicated these items comprised a factor termed "Depression should be treated by psychiatrists" - to which 54 % of doctors (n = 101) agreed. Meanwhile, 67 % of doctors (n = 126) thought that nurses could be useful in depressed patient support. The three factors derived from the Japanese DAQ differed from models previously derived from British GP samples. The attitude of Japanese non-psychiatric doctors concerning whether depression should be treated by psychiatrists was markedly different to that of British GPs. CONCLUSIONS: Japanese non-psychiatric doctors believe that depression care is beyond the scope of their duties. It is suggested that educational programs or guidelines for depression care developed in other countries such as the UK are not directly adaptable for Japanese non-psychiatric doctors. Developing a focused educational program that motivates non-psychiatric doctors to play a role in depression care is necessary to enhance recognition and treatment of depression in Japan.

A pilot randomised controlled trial of personalised care for depressed patients with symptomatic coronary heart disease in South London general practices: the UPBEAT-UK RCT protocol and recruitment.

BACKGROUND: Community studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings. METHODS: This pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care.81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire. Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant's physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant's mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient's self efficacy to solve their problems.Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation. DISCUSSION: This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care. TRIAL REGISTRATION: ISRCTN21615909.

Frequent attendance in family practice and common mental disorders in an open access health care system.

UNLABELLED: Frequent attenders in family practice are known to have higher rates of mental disorder. However little is known about specific psychiatric disorders and whether this behavior extends to specialist services, in an open access fee-for-service health care system. METHODS: 1060 patients from 46 family practices completed the Patient Health Questionnaire and the Client Service Receipt Inventory. During the consultation, family practitioners blind to the questionnaire responses rated the severity of mental health and physical disorders. The 10% of patients with the highest number of 6-month consultations in six age and sex stratified groups were defined as frequent attenders. RESULTS: After adjustments for sociodemographic variables, physical health and other psychiatric diagnoses, patients with a somatoform disorder were more likely to be frequent attenders, with an odds ratio of 2.3 (95% CI: 1.3-3.8, p=.002). CONCLUSION: When adjusting for confounders, among the four psychiatric diagnoses investigated only somatoform disorders remain significantly associated with frequent attendance. Physical health and chronic disease were no longer associated with frequent attendance which does not support the hypothesis that in an open access fee-for-service system, patients will consult for a wider range of health problems. Greater investigation into unexplained somatic symptoms could help reduce the frequency of attendance in both primary and secondary care, as this behaviour appears to be a general health-seeking drive than extends beyond family practice.

Beliefs and attitudes of French family practitioners toward depression: the impact of training in mental health.

OBJECTIVE: To study, in a sample of French Family Practitioners (FPs), beliefs and attitudes toward depression and how they vary according to training received in mental health. METHODS: The Depression Attitude Questionnaire (DAQ) was completed by 468 FPs from all regions of France, recruited by pharmaceutical company representatives to attend focus groups on the management of depression in general practice. RESULTS: A three-factor model was derived from the DAQ, accounting for 37.7% of the total variance. The correlations between individual items of each component varied from 0.4 to 0.65, with an overall internal consistency of 0.47 (Cronbach's alpha). FPs had an overall neutral position on component 1, professional ease, a positive view on the origins of depression and its amenability to change (component 2), and a belief in the necessity of medication and the benefit of antidepressant therapy (component 3). Training in mental health, specifically through continuing medical education and postgraduate psychiatric hospital training, was significantly and positively associated with both professional ease and a medication approach to treating depression. CONCLUSION: This study is the first description of the beliefs and attitudes of French FPs toward depression using a standardized measure, the DAQ, despite the instrument's limited psychometric properties. It shows the positive effect of training in mental health on attitudes toward depression.

Up-beat UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients.

BACKGROUND: Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression. METHODS/DESIGN: This programme of research will consist of 4 inter-related studies. A 4 year prospective cohort study of primary care patients with coronary heart disease will be conducted to explore the relationship between coronary heart disease and depression. Within this, a nested case-control biological study will investigate genetic and blood-biomarkers as predictors of depression in this sample. Two qualitative studies, one of patients' perspectives of treatments for coronary heart disease and co-morbid depression and one of primary care professionals' views on the management of patients with coronary heart disease and depression will inform the development of an intervention for this patient group. A feasibility study for a randomised controlled trial will then be conducted. DISCUSSION: This study will provide information on the relationship between coronary heart disease and depression that will allow health services to determine the efficiency of case-finding for depression in this patient group. The results of the cohort study will also provide information on risk factors for depression. The study will provide evidence on the efficacy and feasibility of a joint patient and professional led intervention and data necessary to plan a definitive randomised controlled trial of the intervention.

The mental health of doctor-shoppers: experience from a patient-led fee-for-service primary care setting.

BACKGROUND: Doctor-shopping may reflect unmet patient needs and places a significant burden on health resources; however little is known about its underlying reasons and how it relates to mental illness and its recognition in an open access fee-for-service setting. METHODS: In 2003-2004, consecutive patients of 46 French general practitioners (GPs), completed in the waiting room the self-report Patient Health Questionnaire and reported on service use in the past six months. During the consultation, GPs rated the severity of any physical and psychiatric disorders. RESULTS: Of 1079 patients, those rated by the GP as having a common mental disorder were significantly more likely to be doctor-shoppers but only if visiting another GP because of dissatisfaction with previous care (OR=2.3, 95% CI: 1.4-3.7). A similar trend is observed for those identified as having a common mental disorder by the Patient Health Questionnaire. Among patients with a common mental disorder, 'dissatisfied' doctor-shoppers were significantly more likely to be recognised as cases by the GP, adjusting for covariates (OR=6, 95% CI: 2.1-17.2). This was not the case for those doctor-shopping for practical reasons alone. CONCLUSION: Doctor-shopping behaviour is associated with higher rates of mental illness and, among cases, an increased likelihood of recognition by the GP, only however for doctor-shoppers dissatisfied with previous care. This suggests a benefit to letting patients choose their GP as is the case in France and change if not satisfied.

Role of the general practitioner in the care of patients recently discharged from the hospital after a first psychotic episode: influence of length of stay.

OBJECTIVE: It is unclear to what extent general practitioners are involved in the postdischarge care of patients hospitalized for a first psychotic episode and whether this involvement is influenced by length of stay in the hospital. The objectives of this study were to describe the role of the general practitioner in providing postdischarge care to patients with first-episode psychosis in terms of frequency and type of consultation and the extent of collaboration with hospital-based specialist services and to determine whether decreasing length of stay was accompanied by a modification in this role. METHOD: Six months after hospital discharge, a postal questionnaire was sent to the general practitioners of patients recruited to the French STEP cohort (Schizophrenie et son Traitement: une Evaluation de la Prize en charge), a prospective study of the clinical and social determinants of care pathways and prognosis for patients hospitalized for a first psychotic episode (DSM-IV criteria) in 5 services of the La Colombière Psychiatric Hospital, Montpellier, France. Length of stay in the hospital was dichotomized according to the median value of 35 days. Data collection took place from February 2008 to March 2009. RESULTS: Of the 121 STEP patients, 65% (n=79) had a regular general practitioner. The general practitioners had been informed by the hospital of the admission of their patient in only 17.9% (7/39) of cases. Of the general practitioners, 78.3% (47/60) had seen the patient at least once since discharge, with a median number of visits standardized over 6 months of 0.86 (range, 0-8.6). General practitioners were better informed with regard to diagnosis, date of discharge, name of psychiatrist, treatment, and community follow-up at discharge for patients with a short length of stay in the hospital, who were also more likely than those with a long length of stay to be consulting for mental health problems. CONCLUSIONS: Our findings suggest a low level of implication of general practitioners in providing postdischarge care to first-episode psychotic patients, irrespective of their length of hospital stay. Yet, the general practitioner has a role to play in coordinating and providing care for somatic health problems as well as psychiatric symptoms, specifically in the case of early discharge.

Understanding the explanatory model of the patient on their medically unexplained symptoms and its implication on treatment development research: a Sri Lanka Study.

BACKGROUND: Patients with medically unexplained symptoms (MUS) are often distressed, disabled and dissatisfied with the care they receive. Illness beliefs held by patients have a major influence on the decision to consult, persistence of symptoms and the degree of disability. Illness perception models consist of frameworks to organise information from multiple sources into distinct but interrelated dimensions: identity (the illness label), cause, consequences, emotional representations perceived control and timeline. Our aim was to elicit the illness perceptions of patients with MUS in Sri Lankan primary care to modify and improve a CBT intervention. METHOD: An intervention study was conducted in a hospital primary care clinic in Colombo, Sri Lanka using CBT for MUS. As a part of the baseline assessment, qualitative data was collected using; the Short Explanatory Model Interview (SEMI), from 68 patients (16-65 years) with MUS. We categorised the qualitative data in to key components of the illness perception model, to refine CBT intervention for a subsequent larger trial study. RESULTS: The cohort was chronically ill and 87% of the patients were ill for more than six months (range six months to 20 years) with 5 or more symptoms and 6 or more visits over preceding six months. A majority were unable to offer an explanation on identity (59%) or the cause (56%), but in the consequence domain 95% expressed significant illness worries; 37% believed their symptoms indicated moderately serious illness and 58% very serious illness. Reflecting emotional representation, 33% reported fear of death, 20% fear of paralysis, 13% fear of developing cancer and the rest unspecified incurable illness. Consequence and emotional domains were significant determinants of distress and consultations. Their repeated visits were to seek help to alleviate symptoms. Only a minority expected investigations (8.8 %) or diagnosis (8.8%). However, the doctors who had previously treated them allegedly concentrated more on identity than cause. The above information was used to develop simple techniques incorporating analogies to alter their perceptions CONCLUSION: The illness perception model is useful in understanding the continued distress of patients with persistent symptoms without an underlying organic cause. Hence it can make a significant contribution when developing and evaluating culturally sensitive patient friendly interventions.

Use of the PRIME-MD Patient Health Questionnaire for estimating the prevalence of psychiatric disorders in French primary care: comparison with family practitioner estimates and relationship to psychotropic medication use.

OBJECTIVES: The objectives of this study were to establish provisional psychiatric diagnoses using the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ) and to describe family practitioner (FP) case recognition, survey-day prescription of anxiolytic and antidepressant medications and overall consumption rates (medication use). METHODS: Between October 2003 and April 2004, 1151 consecutive patients (> or = 18 years old) of 46 FPs practicing in and around the city of Montpellier, France, completed the PHQ. During the consultation, FPs rated the severity of any psychiatric disorder. RESULTS: PHQ prevalence rates (FP case recognition percentages are given in parentheses) were as follows: 10.9% (36%) for probable alcohol abuse/dependence; 11.3% (40%) for somatoform disorder; 9.1% (75%) for major depression; 7.4% (42%) for other depressive disorders; 7.5% (69%) for panic disorder; and 6% (69%) for other anxiety disorders. The prescription rate for all study patients was 11.3%, ranging from 6.2% for those without a PHQ disorder to 30.3% for those with a PHQ diagnosis of anxiety or depression to 48.2% for FP-recognized cases. The estimated survey-day consumption rate for these medications was 19.4%. CONCLUSIONS: High consumption of anxiolytic and antidepressant medications in France is confirmed but not explained either by higher prevalence rates of psychiatric disorders as compared with other locations or by unusually high survey-day prescription rates. A possible explanation would be the organization of the French health care system, which has multiple sources for obtaining medication.

How should financial support for research be distributed to universities? The Research Assessment Exercise (RAE) in England and Wales.

In the United Kingdom, the "Research Assessment Exercise" is used by central government as a way of distributing infra-structure funds to University departments to support research. Departments with the highest ratings get extra support, while departments with low ratings may have their existing support withdrawn. The paper describes an exercise aimed at improving the rating obtained by one such department.