Differences in psychiatric comorbidity patterns in patients diagnosed with chronic stress-induced exhaustion disorder and depression - A cohort study in the total population of Region Stockholm.

The high prevalence of stress-related disorders and depression underscores the urgent need to unravel their impact on individual well-being. This study aim to investigate common psychiatric and stress-related diagnoses, along with postviral fatigue, in individuals with prior stress-induced exhaustion disorder (SED) and prior depression compared to those without prior SED or depression, and to study whether the psychiatric comorbidity patterns differ. The study includes individuals in Region Stockholm who, in 2011, did not have a diagnosis of SED or depression. ICD-10 diagnosis of SED, depression, or both, recorded in 2012-2013, were compared to individuals without prior SED or depression in a cohort (n = 1,362,886), aged 18 to 65. Odds ratios (OR) with 99 % confidence intervals, adjusted for age and neighborhood socioeconomic status, were calculated for psychiatric disorders and post-viral fatigue in 2014-2022. Patients with prior SED showed associations primarily with stress related diagnoses, including acute stress reaction, reaction to severe stress, as well as post-COVID-19 and post-viral fatigue syndrome. These ORs were all larger for SED than depression. Depression was primarily associated with post-traumatic stress disorder (PTSD), alcohol related and substance use disorders, schizophrenia, schizotypal disorders, delusional disorders, manic episode, bipolar affective disorder, persistent mood disorder, neurotic disorder, borderline personality disorder, autistic disorder, Asperger's syndrome, attention -deficit hyperactivity disorder, attention-deficit disorders ADHD/ADD), and suicide attempt. These ORs were all higher for depression, although autistic disorders, ADHD/ADD and PTSD were also highly associated with prior SED (OR > 3.5). The divergent psychiatric comorbidity patterns suggest different underlying mechanisms and clinical prognosis.

"Returning to the core tasks": a qualitative interview study about how general practitioners in home health care solved problems during the COVID-19 pandemic.

OBJECTIVE: Optimizing care at home, or home health care (HHC), is necessary as the population of care-dependent older people receiving care at home steadily increases. The COVID-19 pandemic tested Swedish primary care professionals as they provided HHC for a population of very frail older homebound people, but a better understanding of what healthcare workers did to manage the crisis may be useful for the further development of HHC. In this study, we aimed to understand how HHC physicians solved the problems of providing home healthcare during the pandemic to learn lessons on how to improve future HHC. METHODS: This is a qualitative study of individual interviews with 11 primary care physicians working in HHC (8 women) from 7 primary care practices in Region Stockholm, Sweden. Interviews were conducted between 1 December 2020, and 11 March 2021. The data were analyzed using inductive thematic analysis. RESULTS: We generated an overarching theme in our analysis: Physicians focus on core tasks and professional values in response to crisis. This theme incorporated three underlying subthemes describing this response: physicians prioritize and resolve ethically challenging situations in new ways, cultivate the patient perspective, and build on existing teams. CONCLUSION: This study indicates that a healthcare system that gives HHC physicians agency to focus on core tasks and professional values could promote person-centered care.

Optimizing care at home, or home health care (HHC), is necessary as the population of care-dependent older people receiving care at home steadily increases.During the COVID-19 pandemic, HHC physicians in Stockholm were able work person-centred and focus on clinically relevant tasks.A healthcare system that allows HHC physicians to focus on core tasks and professional values can promote person-centered care.Strategies to promote quality HHC include supporting physician autonomy, building on existing teams, and promoting collaboration between primary care providers and other caregivers.

Stress, depression, and risk of dementia - a cohort study in the total population between 18 and 65 years old in Region Stockholm.

BACKGROUND: Chronic stress and depression are potential risk factors for mild cognitive impairment and dementia, including Alzheimer disease. The aim was to investigate whether any such risk is additive. METHODS: Cohort study including 1 362 548 people (665 997 women, 696 551 men) with records in the Region Stockholm administrative healthcare database (VAL). Exposure was a recorded ICD-10 diagnosis of chronic stress, depression, or both, recorded in 2012 or 2013. Outcome was a diagnosis of Alzheimer disease, other dementia, or mild cognitive impairment recorded from 2014 through 2022. Odds ratios with 99% confidence intervals (CI) adjusted for age, sex, neighborhood socioeconomic status, diabetes, and cardiovascular disorders were calculated. RESULTS: During the exposure period, 4 346 patients were diagnosed with chronic stress, 40 101 with depression, and 1 898 with both. The average age at baseline was around 40 years in all groups. In the fully adjusted model, the odds ratio of Alzheimer disease was 2.45 (99% CI 1.22-4.91) in patients with chronic stress, 2.32 (99% CI 1.85-2.90) in patients with depression, and 4.00 (99% CI 1.67-9.58) in patients with chronic stress and depression. The odds ratio of mild cognitive impairment was 1.87 (99% CI 1.20-2.91) in patients with chronic stress, 2.85 (99% CI 2.53-3.22) in patients with depression, and 3.87 (99% CI 2.39-6.27) in patients with both. When other dementia was analyzed, the odds ratio was significant only in patients with depression, 2.39 (99% CI 1.92-2.96). CONCLUSIONS: Documented chronic stress increased the risk of mild cognitive impairment and Alzheimer disease. The same was seen with depression. The novel finding is the potential additive effect of chronic stress to depression, on risk of MCI and AD.

How much are we worth? Experiences of nursing assistants in Swedish nursing homes during the first wave of COVID-19.

BACKGROUND: NHs have been severely exposed during the COVID-19 pandemic. Little is known about how staff who provide practical daily care of older residents experienced work during the pandemic. The aim of this study was to understand how nursing assistants (NAs) experienced their work at nursing homes (NHs) for older people during the first wave of the COVID-19 pandemic. METHODS: We conducted a qualitative study of focus group discussions with in total 20 participants from four NHs in Stockholm, Sweden. Discussions were held in November 2020. Transcripts were analyzed using inductive thematic analysis. RESULTS: We identified three major themes: 1) We felt abandoned, scared and disrespected, 2) We made sure we made it through, and 3) We can do good work with appropriate resources. NAs felt disregarded as they were often left alone without adequate support from managers, registered nurses and the municipalities. NAs felt distressed and guilty and developed their own strategies to cope and manage their work. CONCLUSION AND IMPLICATION FOR PRACTICE: During the first wave of the COVID-19 pandemic NAs felt abandoned and burdened due to lack of leadership. Organizational improvements are required to protect the wellbeing of NAs and to ensure sustainability of patient safety. NAs are crucial in the care for vulnerable older people and their experiences should constitute a keystone for development of future policy and practice in NHs.

Economic evaluation of the Target-D platform to match depression management to severity prognosis in primary care: A within-trial cost-utility analysis.

BACKGROUND: Target-D, a new person-centred e-health platform matching depression care to symptom severity prognosis (minimal/mild, moderate or severe) has demonstrated greater improvement in depressive symptoms than usual care plus attention control. The aim of this study was to evaluate the cost-effectiveness of Target-D compared to usual care from a health sector and partial societal perspective across 3-month and 12-month follow-up. METHODS AND FINDINGS: A cost-utility analysis was conducted alongside the Target-D randomised controlled trial; which involved 1,868 participants attending 14 general practices in metropolitan Melbourne, Australia. Data on costs were collected using a resource use questionnaire administered concurrently with all other outcome measures at baseline, 3-month and 12-month follow-up. Intervention costs were assessed using financial records compiled during the trial. All costs were expressed in Australian dollars (A$) for the 2018-19 financial year. QALY outcomes were derived using the Assessment of Quality of Life-8D (AQoL-8D) questionnaire. On a per person basis, the Target-D intervention cost between $14 (minimal/mild prognostic group) and $676 (severe group). Health sector and societal costs were not significantly different between trial arms at both 3 and 12 months. Relative to a A$50,000 per QALY willingness-to-pay threshold, the probability of Target-D being cost-effective under a health sector perspective was 81% at 3 months and 96% at 12 months. From a societal perspective, the probability of cost-effectiveness was 30% at 3 months and 80% at 12 months. CONCLUSIONS: Target-D is likely to represent good value for money for health care decision makers. Further evaluation of QALY outcomes should accompany any routine roll-out to assess comparability of results to those observed in the trial. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000537459).

A One-Session Treatment of PTSD After Single Sexual Assault Trauma. A Pilot Study of the WONSA MLI Project: A Randomized Controlled Trial.

Sexual abuse is a crime with devastating health consequences. Accessible, acceptable and affordable treatment of PTSD after sexual abuse is important. In this pilot study, a one-session PTSD treatment and a modified perspective to PTSD treatment is introduced. The aim of the study was to test the efficacy of one session of Modified Lifespan Integration (MLI) on reduction of symptoms of PTSD in individuals with PTSD after one sexual assault. This was a single-center, individually randomized waitlist-controlled treatment study with 1:1 allocation, with the intervention of one 90 - 140 minutes session of MLI and with post-treatment follow-up at 3 weeks (time point two). All participants were females, mean age 24, with PTSD symptoms after one sexual assault during the past 5 years. Exclusion criteria were poor understanding of Swedish, multiple traumas, active substance abuse, active psychosis, ADHD, or autism spectrum disorder. Of 135 interested participants, 38 were finally included, 36 completed baseline measures and were included in the intent to treat analyses and 33 were analyzed per protocol. The primary outcome was the difference between the two trial arms in mean PTSD symptoms as measured by the Impact of Event Scale Revised (IES-R) at time point two. In the intervention arm, 72% no longer scored PTSD in per-protocol analysis, compared to 6% in the waiting list arm. IES-R scores were on average halved in the intervention arm (F=21.37, P<0.001), but were essentially unchanged in the waiting list arm. No adverse effects or drop-outs were seen. One session of Modified Lifespan Integration was an effective treatment with a low drop-out rate for females aged 15-65 with PTSD after one sexual assault. Provided that this result can be replicated, MLI should be offered to these patients in clinical settings. Registration number NCT03141047 was given 03/25/2016 at ClinicalTrials.gov (https://register.clinicaltrials.gov/).

Specific content for collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care.

BACKGROUND: In primary care (PC) many patients suffer from multimorbidity involving depression and/or anxiety. Collaborative care (CC) has shown promising results for patients with depression, anxiety, and multimorbidity involving depression. However, specific content in CC for patients with multimorbidity involving depression and/or anxiety is unknown. OBJECTIVE: (i) To examine the effect of CC interventions in patients with multimorbidity involving depression and/or anxiety compared with usual care; (ii) to identify specific content of CC. METHODS: We conducted a systematic literature review of randomized controlled trial studies evaluating CC models for adults with multimorbidity involving depression and/or anxiety in PC settings. PubMed, CINAHL, Web of Science, and PsycInfo were searched in December 2019. We conducted a qualitative synthesis using an existing framework and developed a new framework to map the content for each studied intervention. RESULTS: We identified 1,447 studies. Twelve publications were included. Eleven had medium-to-high quality of CC for patients with multimorbidity involving depression. Specific content of CC in these studies is: A stepped care model, involving medication and psychotherapy delivered by a nurse or psychologist Care Manager (CM) focusing on problem-solving techniques; follow-up including monitoring of symptoms and function, and relapse prevention strategies; scheduled CM supervision. CONCLUSIONS: Specific content for CC for patients with multimorbidity involving depression is identified from current research. Research gaps were found regarding CC for patients with multimorbidity and anxiety, depression and anxiety, and depression and/or anxiety and more than 2 diseases.

Most patients in primary care have multimorbidity, defined as 2 or more chronic diseases. Depression and/or anxiety are common in this population. Collaborative care (CC) can improve symptoms for patients with multimorbidity involving depression. In CC, a Care Manager (CM) establishes a care plan with the patient, cooperates with the patient's physician, and has scheduled patient follow-ups. However, CC can differ in design and content. The focus of this systematic review and qualitative synthesis was to examine effectiveness of CC for patients suffering from multimorbidity involving depression and/or anxiety and identify specific content of CC for patients with multimorbidity involving depression and/or anxiety. We identified specific content of CC for patients with multimorbidity involving depression in medium-to-high-quality studies with positive effect: CM (nurse or psychologist) collaborating with the patient's physician in a stepped care model involving both medication and/or CM-delivered problem-solving psychological treatment; scheduled patient follow-ups with symptom and function monitoring, medication adherence and relapse prevention; regular CM supervision. No conclusions can be drawn regarding the effectiveness of CC in patients with multimorbidity involving anxiety, depression and anxiety, or depression and/or anxiety and more than 2 diseases.

Are we on the same page? Mental health literacy and access to care: a qualitative study in young Hazara refugees in Melbourne.

Hazaras, mostly aged <30 years, constituted the greatest number of people resettled under Australia's migration resettlement between 2009 and 2013. This group is at high risk of mental health issues due to pre- and post-forced migration experiences. This study explored the understanding of mental health and barriers to accessing primary mental health care in young Hazara refugees in Melbourne. Seventeen Hazaras aged 18-30 years were recruited for two sex-segregated focus groups; two individual semistructured interviews were also conducted (with one male and one female participant). Discussions were audiotaped, transcribed and analysed thematically. Participants had varied perspectives on mental health issues stemming from historical and current beliefs. Lack of knowledge and concerns over confidentiality within Hazaras were considered major barriers to seeking help. Community education through existing community groups and through the women could potentially help overcome barriers to mental health access by young Hazaras.

Delayed healthcare access among victims of sexual abuse, understood through internal and external gatekeeping mechanisms.

BACKGROUND: Sexual abuse is associated with severe health consequences, and the European Union has, through the Istanbul Convention, urged its member countries to provide specialist care for victims of sexual abuse. AIM: This aim of this study was to investigate patient- and abuse-related characteristics among patients seeking help at a specialist clinic in Sweden, with focus on disclosure, mental health and appropriate healthcare access. METHODS: This is a descriptive study where journal data from 100 consecutive patients January 2017 to February 2018 were analyzed. All adult individuals (women n = 80, men n = 8) who had taken part in the standardized semi-structured intake interview at the clinic were included (n = 88). RESULTS: At admission, mean age was 40.3 (SD 11.9), mean number of psychiatric diagnoses 6.3 (2.6), and 93% of the patients scored above cut-off (≥34) on IES-R for PTSD. A majority of the patients (87%) had been exposed to childhood sexual abuse (CSA), and mean time to first disclosure was 15.9 (SD 15.3) years. In total, 82% of the patients had, despite disclosure, experienced difficulties accessing appropriate healthcare before coming to the specialist clinic. CONCLUSION: Adult victims of sexual abuse have difficulties accessing appropriate healthcare. This constitutes a gender-based equality problem. A model of gatekeeping mechanisms with two dimensions (external and internal) and three categories (Competence related, Organizational and Emotional) is proposed to understand these difficulties.

Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial.

BACKGROUND: Mental health treatment rates are increasing, but the burden of disease has not reduced. Tools to support efficient resource distribution are required. AIM: To investigate whether a person-centred e-health (Target-D) platform matching depression care to symptom severity prognosis can improve depressive symptoms relative to usual care. DESIGN AND SETTING: Stratified individually randomised controlled trial in 14 general practices in Melbourne, Australia, from April 2016 to February 2019. In total, 1868 participants aged 18-65 years who had current depressive symptoms; internet access; no recent change to antidepressant; no current antipsychotic medication; and no current psychological therapy were randomised (1:1) via computer-generated allocation to intervention or usual care. METHOD: The intervention was an e-health platform accessed in the GP waiting room, comprising symptom feedback, priority-setting, and prognosis-matched management options (online self-help, online guided psychological therapy, or nurse-led collaborative care). Management options were flexible, neither participants nor staff were blinded, and there were no substantive protocol deviations. The primary outcome was depressive symptom severity (9-item Patient Health Questionnaire [PHQ-9]) at 3 months. RESULTS: In intention to treat analysis, estimated between- arm difference in mean PHQ-9 scores at 3 months was -0.88 (95% confidence interval [CI] = -1.45 to -0.31) favouring the intervention, and -0.59 at 12 months (95% CI = -1.18 to 0.01); standardised effect sizes of -0.16 (95% CI = -0.26 to -0.05) and -0.10 (95% CI = -0.21 to 0.002), respectively. No serious adverse events were reported. CONCLUSION: Matching management to prognosis using a person-centred e-health platform improves depressive symptoms at 3 months compared to usual care and could feasibly be implemented at scale. Scope exists to enhance the uptake of management options.

Patterns of multimorbidity and pharmacotherapy: a total population cross-sectional study.

BACKGROUND: Treatment of multimorbid patients can be improved. Development of patient-centred care of high-quality requires context-bound understanding of the multimorbid population's patterns of demographics, co-morbidities and medication use. OBJECTIVE: The aim of this study was to identify patterns of multimorbidity in the total population of Region Stockholm, Sweden, by exploring demographics, claimed prescription drugs, risk of mortality and non-random association of conditions. METHODS: In this cross-sectional descriptive population-based cohort study, we extracted data from the Swedish VAL database (N = 2 323 667) including all consultations in primary and specialized outpatient care, all inpatient care and all prescriptions claimed during 2017. We report number of chronic conditions and claimed prescription drugs, physical and mental co-morbidity, and 1-year mortality. We stratified the analyses by sex. We examined non-random associations between diseases using cluster analysis. RESULTS: In total, 21.6% had multimorbidity (two or more chronic conditions) and 24.1% had polypharmacy (more than five claimed prescription drugs). Number of claimed drugs, co-occurrence of mental and physical conditions, and 1-year mortality increased as multimorbidity increased. We identified seven multimorbidity clusters with clinically distinct characteristics. The smallest cluster (7% of individuals) had prominent cardiovascular disease, the highest 1-year mortality rate, high levels of multimorbidity and polypharmacy, and was much older. The largest cluster (27% of individuals) was younger and heterogenous, with primarily mental health problems. CONCLUSIONS: Individuals with chronic conditions often show clinical complexity with both concordant and discordant conditions and polypharmacy. This study indicates that clinical guidelines addressing clustering of conditions may be one strategy for managing complexity.

Validation and initial results of surveys exploring perspectives on risks and solutions for diagnostic and medication errors in primary care in Sweden.

OBJECTIVE: To (1) validate and (2) display initial results of surveys to health care professionals and patients on the importance and mitigation of specified risks for diagnostic and medication errors. DESIGN: For validation, psychometric properties were analysed by assessment of construct validity and internal consistency by factor analysis. Non-parametric analyses were used concerning areas of risk, and top ranking of solutions were reported descriptively. SETTING: Primary health care in Sweden. PARTICIPANTS: Health care professionals (HCPs); including physicians, nurses and practice managers, as well as patients who had experienced diagnostic or medication errors. MAIN OUTCOME MEASURES: Psychometric properties of the surveys. Median ratings for risks and top rankings of solutions for professionals and patients. RESULTS: There were 939 respondents to the HCP survey. Construct validity resulted in a model with four dimensions: Patient-provider level; Support systems for every day clinical work; Shared information and cooperation between different caregivers; Risks in the environment. Internal consistency was acceptable with Cronbach's α values above 0.7. Confirmatory factor analysis generally showed an acceptable fit. Initial results from the professionals showed the importance of continuity of care, a nationwide on-line medical platform and cooperation in transfer of care. The patient survey could not be validated because of low response rate. CONCLUSION: The HCP survey showed some contradicting results regarding model fit and may be tentatively acceptable but validity needs further study. HCP survey answers indicated that relational continuity of care and a nationwide on-line medical platform are highly valued. Current awareness Health care professionals and patients are rather untapped sources of knowledge regarding patient safety in primary health care Main statements Validation is performed on a new survey capturing rating of risks and solutions. The validation of the health care professional survey is tentatively acceptable. Survey answers indicate that health care professionals' and patients' perspectives are complementary.

Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study.

BACKGROUND: Patient safety issues in primary health care and in emergency departments have not been as thoroughly explored as patient safety issues in the hospital setting. Knowledge is particularly sparse regarding which patients have a higher risk of harm in these settings. The objective was to evaluate which patient-related factors were associated with risk of harm in patients with reports of safety incidents. METHODS: A case-control study performed in primary health care and emergency departments in Sweden. In total, 4536 patients (cases) and 44,949 controls were included in this study. Cases included patients with reported preventable harm in primary health care and emergency departments from January 1st, 2011 until December 31st, 2016. RESULTS: Psychiatric disease, including all psychiatric diagnoses regardless of severity, nearly doubled the risk of being a reported case of preventable harm (odds ratio, 1.96; p < 0.001). Adjusted for income and education there was still an increased risk (odds ratio, 1.69; p < 0.001). The preventable harm in this group was to 46% diagnostic errors of somatic disease. CONCLUSION: Patients with psychiatric illness are at higher risk of preventable harm in primary care and the emergency department. Therefore, this group needs extra attention to prevent harm.

Patient and provider perspectives on reducing risk of harm in primary health care: a qualitative questionnaire study in Sweden.

Objective: To explore how patients, that had experienced harm in primary care, and how primary providers and practice managers understood reasons for harm and possibilities to reduce risk of harm.Design: Inductive qualitative analysis of structured questionnaires with free text answers.Setting: Primary health care in Sweden.Patients/subjects: Patients (n = 22) who had experienced preventable harm in primary health care, and primary care providers and practice managers, including 15 physicians, 20 nurses and 24 practice managers.Main outcome measures: Categories and overarching themes from the qualitative analysis.Results: The three categories identified as important for safety were continuity of care, communication and competence. With flaws in these, risks were thought to be greater and if these were strengthened the risks could be reduced. The overarching theme for the patient was the experience of being neglected, like not having been properly examined. The overarching theme for primary care providers and practice managers was lack of continuity of care.Conclusion: Primary care providers, practice managers and patients understood the risks and how to reduce the risks of patient safety problems as related to three main categories: continuity of care, communication and competence. Future work towards a safer primary health care could therefore benefit from focusing on these areas.Key pointsCurrent awareness: • Patients and primary care providers are rather untapped sources of knowledge regarding patient safety in primary health care.Main statements: • Patients understood the risk of harm as stemming from that they were not properly examined. • Primary care providers understood the risk of harm to a great extent as stemming from poor continuity of care. • Patients, primary care providers and practice managers believed continuity, communication and competence play an important role in reducing risks.

Diagnostic errors reported in primary healthcare and emergency departments: A retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden.

Background: Diagnostic errors are a major patient safety concern in primary healthcare and emergency care. These settings involve a high degree of uncertainty regarding patients' diagnoses and appear to be those most prone to diagnostic errors. Diagnostic errors comprise missed, delayed, or incorrect diagnoses preventing the patient from receiving correct and timely treatment. Data regarding which diagnoses are affected in these settings are scarce. Objectives: To understand the distribution of diagnoses among reported diagnostic errors in primary health and emergency care as a step towards creating countermeasures for safer care. Methods: A retrospective and descriptive cohort study investigating reported diagnostic errors. A nationwide cohort was collected from two databases. The study was performed in Sweden from 1 January 2011 until 31 December 2016. The setting was primary healthcare and emergency departments. Results: In total, 4830 cases of preventable harm were identified. Of these, 2208 (46%) were due to diagnostic errors. Diagnoses affected in primary care were cancer (37% and 23%, respectively, in the two databases; mostly colon and skin), fractures (mostly hand), heart disease (mostly myocardial infarction), and rupture of tendons (mostly Achilles). Of the diagnostic errors in the emergency department, fractures constituted 24% (mostly hand and wrist, 29%). Rupture/injury of muscle/tendon constituted 19% (mostly finger tendons, rotator cuff tendons, and Achilles tendon). Conclusion: Our findings show that the most frequently missed diagnoses among reported harm were cancers in primary care and fractures in the emergency departments.

Development of a Mobile Clinical Prediction Tool to Estimate Future Depression Severity and Guide Treatment in Primary Care: User-Centered Design.

BACKGROUND: Around the world, depression is both under- and overtreated. The diamond clinical prediction tool was developed to assist with appropriate treatment allocation by estimating the 3-month prognosis among people with current depressive symptoms. Delivering clinical prediction tools in a way that will enhance their uptake in routine clinical practice remains challenging; however, mobile apps show promise in this respect. To increase the likelihood that an app-delivered clinical prediction tool can be successfully incorporated into clinical practice, it is important to involve end users in the app design process. OBJECTIVE: The aim of the study was to maximize patient engagement in an app designed to improve treatment allocation for depression. METHODS: An iterative, user-centered design process was employed. Qualitative data were collected via 2 focus groups with a community sample (n=17) and 7 semistructured interviews with people with depressive symptoms. The results of the focus groups and interviews were used by the computer engineering team to modify subsequent protoypes of the app. RESULTS: Iterative development resulted in 3 prototypes and a final app. The areas requiring the most substantial changes following end-user input were related to the iconography used and the way that feedback was provided. In particular, communicating risk of future depressive symptoms proved difficult; these messages were consistently misinterpreted and negatively viewed and were ultimately removed. All participants felt positively about seeing their results summarized after completion of the clinical prediction tool, but there was a need for a personalized treatment recommendation made in conjunction with a consultation with a health professional. CONCLUSIONS: User-centered design led to valuable improvements in the content and design of an app designed to improve allocation of and engagement in depression treatment. Iterative design allowed us to develop a tool that allows users to feel hope, engage in self-reflection, and motivate them to treatment. The tool is currently being evaluated in a randomized controlled trial.

Target-D: a stratified individually randomized controlled trial of the diamond clinical prediction tool to triage and target treatment for depressive symptoms in general practice: study protocol for a randomized controlled trial.

BACKGROUND: Depression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months' time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care. METHODS: The Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group. DISCUSSION: To our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR 12616000537459 ). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data.

Mental health interventions and future major depression among primary care patients with subthreshold depression.

BACKGROUND: Subthreshold depression is prevalent in primary care and is associated with poorer quality of life, higher health care use and increased risk of major depressive disorder (MDD). Currently, it is unclear how subthreshold depression should be managed in primary care and no studies have investigated the relationship between current models of care and the development of MDD. This study aimed to describe usual care over a six month follow-up for primary care patients with subthreshold depression and to investigate the relationship between usual care and the development of MDD. METHODS: Data were derived from 250 participants with subthreshold depression from the diamond study, a longitudinal cohort study of primary care patients. Participants completed questionnaires at three and six months on their health care use, the interventions they received and their depression status. Interventions were categorised according to the NICE guidelines for the management of depression in adults. Generalised estimating equation (GEE) models and logistic regression were used to estimate the association between receiving an intervention and MDD over six months. RESULTS: Four fifths (80.8%) of participants received a mental health intervention. Therapeutic listening, reassurance, pharmacotherapy and advice to exercise were most common. Subsequent MDD was predicted by history of depression, baseline depressive symptom severity and receiving a mental health intervention. LIMITATIONS: Usual care was assessed via patient self-report. CONCLUSIONS: Primary care physicians deliver mental health interventions to most subthreshold patients. However, it appears that current interventions are not averting MDD. Further research to identify effective interventions which are feasible in primary care is needed.

Functional and structural alterations in the cingulate motor area relate to decreased fronto-striatal coupling in major depressive disorder with psychomotor disturbances.

Psychomotor disturbances are a classic feature of major depressive disorders. These can manifest as lack of facial expressions and decreased speech production, reduced body posture and mobility, and slowed voluntary movement. The neural correlates of psychomotor disturbances in depression are poorly understood but it has been suggested that outputs from the cingulate motor area (CMA) to striatal motor regions, including the putamen, could be involved. We used functional and structural magnetic resonance imaging to conduct a region-of-interest analysis to test the hypotheses that neural activation patterns related to motor production and gray matter volumes in the CMA would be different between depressed subjects displaying psychomotor disturbances (n = 13) and matched healthy controls (n = 13). In addition, we conducted a psychophysiological interaction analysis to assess the functional coupling related to self-paced finger-tapping between the caudal CMA and the posterior putamen in patients compared to controls. We found a cluster of increased neural activation, adjacent to a cluster of decreased gray matter volume in the caudal CMA in patients compared to controls. The functional coupling between the left caudal CMA and the left putamen during finger-tapping task performance was additionally decreased in patients compared to controls. In addition, the strength of the functional coupling between the left caudal CMA and the left putamen was negatively correlated with the severity of psychomotor disturbances in the patient group. In conclusion, we found converging evidence for involvement of the caudal CMA and putamen in the generation of psychomotor disturbances in depression.

Pain, power and patience--a narrative study of general practitioners' relations with chronic pain patients.

BACKGROUND: Chronic pain patients are common in general practice. In this study "chronic pain" is defined as diffuse musculoskeletal pain not due to inflammatory diseases or cancer. Effective patient-physician relations improve treatment results. The relationship between doctors and chronic pain patients is often dysfunctional. Consultation training for physicians and medical students can improve the professional ability to build effective relations, but this demands a thorough understanding of the problems in the relation. Several studies have defined the issues that frequently cause problems, but few have described the process. The aim of this study was to understand and illustrate what GPs' experience in contact with chronic pain patients and what works and does not work in these consultations. METHODS: Our theoretical perspective is constructivist, based upon the relativist view that individuals construct realities to understand and navigate the world. Five Swedish General Practitioners (GPs), two male and three female, were interviewed and asked to tell a story about a difficult encounter with a chronic pain patient. Tapes of the interviews were transcribed and analysed using narrative analysis. Three GPs told narratives suited for our analytic tools and these were included in the final results. RESULTS: Each narrative highlights a certain dilemma and a strategy. The dilemmas were: power game; good intentions that fail when a patient is persuaded against her own conviction; persuasion of the unwilling; transferred tiredness; distrust and dissociation from the patient. Professional strategies of listening, encouraging and teamwork were central to handling difficult situations. CONCLUSIONS: The narratives show that GP's consultations with chronic pain patients sometimes are characterized by conflicts and difficult situations. They are facilitated by methods such as active listening and teamwork, but still may remain hard to handle. This has not before been studied among Swedish GPs. Narratives based on experience are known to be successful in education and this study suggest how narratives can serve as a training of consultation for medical students, but also in Continuing Professional Development groups for experienced doctors in practice.