Impact of a national campaign on GP education: an evaluation of the Defeat Depression Campaign.

BACKGROUND: The Defeat Depression Campaign, which was run by the Royal College of Psychiatrists and the Royal College of General Practitioners (RCGP) from 1992 to 1996, aimed to educate general practitioners (GPs) to recognize and manage depression. AIM: To measure the educational impact on GPs of the Defeat Depression Campaign. METHOD: A postal survey using a structured questionnaire was distributed to 2046 GPs obtained by systematically sampling 1 in 14 GPs from alphabetical lists from family health services authorities (FHSAs) in England and Wales. The questionnaire covered awareness of the campaign, awareness and use of campaign materials, and ratings of the usefulness of the campaign in relation to other educational activities. RESULTS: Two-thirds of GPs were aware of the campaign and 40% had definitely or possibly made changes in practice as a result of it. Impact of materials was highest for a consensus statement on the recognition and management of depression in general practice and for guidelines derived from it, each of which had been read in detail by about one quarter of responders and was known of by an additional one third. Impact was low for the other materials. The campaign had the highest impact among younger GPs, members of the RCGP, and (less strongly) among those who had undertaken a six-month post in psychiatry, those who were working in larger practices and fundholding practices, and women; 56% of GPs had attended a teaching session on depression in the past three years. CONCLUSION: A national campaign of this kind can have a useful impact, but it needs to be supplemented by local and practice-based teaching activities.

A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients.

The objective of this paper is to compare the cost effectiveness of a co-ordination service with standard services for terminally ill cancer patients with a prognosis of less than one year. We designed a randomized controlled trial, with patients randomized by the general practice with which they were registered. Co-ordination group patients received the assistance of two nurse coordinators whose role was to ensure that patients had access to appropriate services. The setting was in a South London health authority. Complete service use and outcome data were collected on 167 patients, 86 in the co-ordination group, and 81 in the control group. Our results, as previously reported, show that no differences in outcomes were detected between the co-ordination and control groups; the mean total costs incurred by the co-ordination group were significantly less than those of the control group. The co-ordinated group used significantly fewer inpatient days (mean 24 versus 40 inpatient days; t = 2.4, p = 0.002) and nurse home visits (mean 14.5 versus 37.5 visits; t = 0.3, p = 0.01). Mean cost per co-ordinated patient was almost half that of the control group patients 4774 pounds versus 8034 pounds, t = 2.8, p = 0.006). Although the unit cost data were relatively crude, these cost reductions were insensitive to a wide range of unit costs. These differences persisted when, in order to control for any putative differences in severity between the two groups, the analysis was restricted to patients who had died by the end of the study. The ratio of potential cost savings to the cost of co-ordination service was between 4:1 and 8:1. In conclusion, the co-ordination service for cancer patients who were terminally ill with a prognosis of less than one year was more cost effective than standard services, due to achieving the same outcomes at lower service use, particularly inpatient days in acute hospital. Assuming that the observed effects are real, improved co-ordination of palliative care offers the potential for considerable savings. Further research is needed to explore this issue.

Investigation of whether on-site general practice counsellors have an impact on psychotropic drug prescribing rates and costs.

BACKGROUND: Counselling services are now widespread within general practice. Although the cost-effectiveness of such services has yet to be fully investigated, benefits could include a reduction in prescribing of psychotropic drugs and of other drugs. AIM: A study set out to determine whether practices with counsellors differed from those without in terms of their prescribing rates and costs of psychotropic drugs. METHOD: Prescribing analyses and cost (PACT) level two data reports for the quarter to November 1991 ending January 1992, as appropriate, were sought from 354 practices with counsellors and a matched sample of 216 practices without counsellors which had participated in a previous national survey of counselling in general practice. The drug groups examined were: hypnotics and anxiolytics; antidepressants; analgesics; all central nervous system drugs; and all drugs apart from central nervous system drugs. For each group of drugs, the numbers of prescribed items, total prescribing costs, and costs per item were expressed as a proportion of the practice's number of prescribing units (that is, the age-adjusted number of registered patients) and as a percentage of the average for similar practices in its family health services authority. Practice characteristics were compared between practices with an on-site counsellor and those without. Practices with and without counsellors were compared with respect to their prescribing indicators. RESULTS: PACT reports were obtained from 214 practices (response rate 38%)--126 with counsellors and 88 without. Practices with counsellors and practices without counsellors were well matched in terms of location, list size, proportion of elderly patients, training and fundholding status, and number of health promotion clinics. No significant differences were found between practices with and without counsellors in the prescribing indicators for any group of psychotropic drugs examined or for central nervous system drugs as a whole. CONCLUSION: There were no appreciable differences found in this study between practices with and without counsellors in terms of psychotropic drug prescribing rates or costs. The reasons for this are unclear; more indepth studies of individual counselling services are required.

How does the content of consultations affect the recognition by general practitioners of major depression in women?

BACKGROUND: Major depression is a common and disabling condition. However, for many reasons, the condition is not recognized in about half of the patients with major depression. AIM: The aim of the study was to establish whether the content of general practice consultations affected general practitioners' recognition of major depressive illness in women patients. METHOD: The 30-item general health questionnaire was used as a first stage screening instrument for psychiatric morbidity. Patients newly recognized as depressed by their general practitioner and those not recognized as depressed who scored 11 or more on the questionnaire were interviewed, usually within three days of consulting their general practitioner, using the combined psychiatric interview. Videorecordings of the consultations for these two groups of women were analysed; analyses were based on mentions of physical, psychiatric and social symptoms and on whether the first mention of a psychiatric symptom was within the first four mentions of any symptoms (early in the consultation) or after four mentions of any symptoms (late) or if psychiatric symptoms were not mentioned. RESULTS: A paired sample of 72 women with major depression was obtained from patients consulting 36 general practitioners, each general practitioner providing one patient whom he or she had correctly recognized as being depressed and one patient whose depression had not been recognized. Women with major depression were about five times more likely to have their depression recognized if they mentioned their psychiatric symptoms early in the consultation compared with those who either left it later to mention such symptoms or never mentioned them. Major depression was more likely to be recognized if no physical illness was present. After adjusting for physical illness, depression was 10 times less likely to be recognized if the first psychiatric symptom was mentioned late in the consultation, or not mentioned at all, than if it was mentioned early in the consultation. CONCLUSION: General practitioners need to remember that patients who present with symptoms of physical illness may also have depression. They also need to remember to give equal importance diagnostically to mentions of symptoms at whatever point they occur in the consultation, regardless of the presence or absence of physical illness.

Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long term mentally ill patients.

OBJECTIVE: To assess the impact of teaching general practitioners to carry out structured assessments of their long term mentally ill patients. DESIGN: Randomised controlled trial. SETTING: Sixteen group general practices in South Thames (west) region. SUBJECTS: 440 adults disabled by long term mental illness. INTERVENTIONS: Patients were identified by using practice data with help from local psychiatric and social services. In eight practices the practitioners were taught a structured assessment schedule to use with patients every six months for two years. MAIN OUTCOME MEASURES: Changes in drug treatments, referrals, consultation rates, and recording of preventive health data in the two years after intervention. RESULTS: Follow up data were available on 373 patients (84.7%). At least one structured assessment was recorded for 127 patients in the intervention group but only 29 had four assessments recorded. Participating practitioners considered the structured assessment to be time consuming and reported that it did not often lead directly to changes in treatment or referrals. Changes in treatment with neuroleptic drugs and referrals to community psychiatric nurses, however, were significantly more frequent in the intervention group (differences for intervention group minus control group adjusted for activity in two years before intervention were 14.3% (95% confidence interval 4.3% to 24.33%; P < 0.01) for neuroleptic drugs and 13.3% (2.0% to 24.6%; P < 0.05) for referrals). There were no significant differences in psychiatric admissions, use of the Mental Health Act, drug overdoses, prescriptions, referrals or admissions for physical problems, consultation rates, continuity of care, or recording of preventive data. CONCLUSIONS: Teaching general practitioners about the problems of long term mentally ill patients may increase their involvement in patients' psychiatric care. Regular structured assessments do not seem feasible in routine surgery appointments. More training for general practitioners and increased resources such as more nurse time may be necessary if improvements in care of long term mentally ill patients in general practice are to be generalised.

Near patient testing in general practice: attitudes of general practitioners and practice nurses, and quality assurance procedures carried out.

BACKGROUND: The evaluation of near patient testing in British general practice has largely been confined to studies examining individual tests or comparing equipment. AIM: This study set out to determine the attitudes of practice staff to near patient testing, and the extent to which staff undertook quality assessment. METHOD: Four types of near patient testing machines were introduced into 12 general practices in two regions of England, south west Thames and west Midlands. General practitioner and practice nurse attitudes to near patient testing were assessed by semi-structured interview before and six months after the introduction of the machines. The extent to which routine quality assurance procedures were carried out within the surgery and as part of local and national schemes was examined. RESULTS: Although 80% of general practitioners anticipated changing patient management with near patient testing, only two fifths reported having done so after six months. Nurses generally were enthusiastic at the outset, although one third were unhappy about incorporating near patient testing into their work schedules. Time pressure was the most important factor restricting uptake of near patient testing. Nurses performed quality control regularly but complete local external quality assurance procedures were established in only half the practices. All the practices participated in a national scheme for cholesterol assays. CONCLUSION: General practitioners in this study did not find near patient testing a very useful addition to their resources. Pressure on nurses' time was the most frequently reported limitation.

Telephone versus postal surveys of general practitioners: methodological considerations.

BACKGROUND: High response rates to surveys help to maintain the representativeness of the sample. AIM: In the course of a wider investigation into counselling services within general practice it was decided to assess the feasibility of increasing the response rate by telephone follow up of non-respondents to a postal survey. METHOD: A postal survey was undertaken of a random sample of 1732 general practitioners followed by telephone administration of the questionnaire to non-respondents. The identical questionnaire was administered by telephone to a separate random sample of 206 general practitioners. RESULTS: Of 1732 general practitioners first approached by mail, 1683 were still in post of whom 881 (52%) completed the postal questionnaire and a further 494 (29%) the telephone interview. Of 206 general practitioners first contacted by telephone, 197 were still in post of whom 167 (85%) completed interviews. Compared with doctors first approached by mail, those first approached by telephone were significantly more likely to report having a partner with a special interest in psychiatry (P < 0.01); and a general practitioner, practice nurse or health visitor who worked as a counsellor (P < 0.01 in each case). A comparison of doctors first approached by telephone with those who completed telephone interviews after failing to respond to the postal questionnaire showed that postal non-respondents were significantly less likely to report having a general practitioner, practice nurse, health visitor or community psychiatric nurse who worked as a counsellor (P < 0.01 in each case). CONCLUSION: These findings suggest that non-response to the postal survey was associated with lack of activity in the study area. Telephone administration of questionnaires to postal non-respondents increased response rates to above 80% but, as telephone administration enhanced the reporting of counsellors, a social desirability bias may have been introduced.

Provision of care to general practice patients with disabling long-term mental illness: a survey in 16 practices.

BACKGROUND: Increasing numbers of long-term mentally ill people now live in the community, many of whom lose contact with psychiatric services and come to depend on general practitioners for medical care. However, it has been suggested that general practitioners may be unaware of some of these patients and their needs. AIM: This study set out to investigate the care received by this group of patients. METHOD: Case registers of adults disabled by long-term mental illness were set up in 16 of 110 group general practices asked to participate. A search of each practice's record systems was combined with a survey of local psychiatric and social service teams, to seek practice patients who might not be identified from the general practice data. RESULTS: Of the 440 patients found, 90% were identified from information within the practices, mainly computerized repeat prescription and diagnostic data. The other 10% were identified only by psychiatric services. Over one third of the patients had no current contact with psychiatric services. Patients in contact with psychiatric services had been ill for a shorter time than those not in contact. More patients suffering from psychotic illnesses were in current contact than those with non-psychotic diagnoses. Over 90% of the patients had been seen by their general practitioners within 12 months, on average eight times. Most consultations were for minor physical disorders, repeat prescriptions and sickness certificates. Elements of the formal mental state examination were recorded in one third of cases and adjustments of psychotropic medication in one fifth. CONCLUSION: These findings suggest that patients in long-term contact with specialist services cannot be taken as representative of the whole population with long-term mental illness. General practitioners could use their frequent contacts with long-term mentally ill people to play a greater role in monitoring the mental state and drug treatment of this group.

Impact of introducing near patient testing for standard investigations in general practice.

OBJECTIVE: To assess the clinical and economic impact of surgery based near patient testing in general practice for six commonly used biochemical and bacteriological tests. DESIGN: After four months' monitoring, equipment for two bacteriological and four biochemical tests was introduced without cost into 12 practices using a crossover design. Structured request forms were used to monitor laboratory investigations. SETTING: 12 general practices in west midlands and south west Thames with list sizes above 9000. MAIN OUTCOME MEASURES: Investigation rates per 1000 consultations. Changes from baseline rates. Reasons for requesting investigations and provisional diagnoses. Cost per test and sensitivity of costs to rate of use. RESULTS: Investigation rates for the six tests rose by 16.5% (from 78.6/1000 consultations to 91.6/1000) when equipment was available in the surgery and reverted to baseline rates when it was withdrawn. The average weekly number of tests when equipment was available ranged from 0.5 to 10.5 (mean 9.0). Cholesterol tests were used as an addition to laboratory testing, usually for screening. Midstream urine analysis was often done in the surgery instead of in the laboratory, although 30% of samples were tested by both methods. Doctors' reasons for investigation and conditions tested were largely unaffected by availability of surgery tests. Costs for surgery tests were higher for all tests except midstream urine. CONCLUSIONS: Availability of surgery based testing increased the number of tests performed. It was cost effective only for midstream urine analysis.

Why do general practitioners recognize major depression in one woman patient yet miss it in another?

The aim of this study was to establish whether psychiatric patient characteristics and the presence of physical illness affected general practitioners' recognition of major depressive illness in women patients. The 30-item general health questionnaire was used as a first stage screening instrument for psychiatric morbidity and each patient selected was interviewed, usually within three days of consulting their general practitioner, using the combined clinical interview. A sample of 72 women with major depressive disorder was obtained from patients consulting 36 general practitioners mainly from the south west Thames region of England, each general practitioner providing one patient he or she had correctly recognized as being depressed and one patient whose depression had not been recognized. Few differences were found between the groups with recognized and unrecognized depression in their psychiatric or physical features. More patients with unrecognized depression experienced physical illness and were tired. Patients with serious physical disease were five times more likely not to be recognized as depressed than those without physical disease. Patients with recognized depression described a more distinct quality to their depressed mood. Women with unrecognized major depression are similar to those women whose major depression is recognized by their general practitioner. These findings require further elaboration by process and content analysis of the women's consultations.

Distribution of mental health professionals working on site in English and Welsh general practices.

OBJECTIVE: To describe the nature and distribution of mental health professionals working on site in general practices. DESIGN: Postal questionnaire and telephone interview survey. SETTING: English and Welsh general practices. SUBJECTS: 1880 general practitioners, of whom 1542 (82%) responded. MAIN OUTCOME MEASURES: Prevalence, types, and distribution of mental health professionals working on site among general practices. Factors predicting the presence of mental health professionals on site. RESULTS: The number of practices reporting the presence on site of each type of professional were 528 for community psychiatric nurses; 266 for practice counsellors; 177 for clinical psychologists; 132 for psychiatrists; 96 for psychiatric social workers; and 45 for psychotherapists. Mental health professionals tended to cluster together in practices more often than expected by chance alone. Practice characteristics which independently predicted the presence of a mental health professional on site were having four or more partners; being a training practice; and running stress, bereavement, or other mental health clinics. The proportions of practices with mental health professionals on site varied significantly among health regions. There was no association between the presence of mental health professionals on site and the location of practices, the social class mix of patients, or the estimated percentage of elderly patients or patients of non-European origin. CONCLUSIONS: Mental health professionals tend to cluster together, with a preponderance in larger training practices. Specialist mental health care provision within general practices is unevenly distributed. Further research is needed to determine whether this uneven distribution reflects differences in need or inequalities in the provision of mental health services.

A communication skills course for preclinical students: evaluation of general practice based teaching using group methods.

Teaching preclinical medical students about doctor-patient communication gives them an opportunity to develop their interviewing skills prior to their having to elicit lists of symptoms in their clinical years. General practitioners should be among the more efficient interviewers in clinical medicine and therefore able to make important contributions to the teaching of interviewing skills. This paper describes the aims, objectives and methods of the preclinical communications skills course at St George's Hospital Medical School. The contribution of the Division of General Practice and Primary Care to the teaching of interviewing skills in the preclinical course has been evaluated using rapid group methods. Students were asked to identify examples of specific interviewing behaviours in videotaped general practice consultations, and to judge whether the behaviours were helpful or unhelpful in eliciting relevant information from the patient. Students who had been given experience in interviewing patients in small groups led by general practitioners identified significantly more helpful and unhelpful interviewing behaviours in the taped consultations than students who had not received the small-group teaching. Students rated the teaching as relevant and effective in terms of giving insights into the interviewing skills they needed to develop. Group methods of evaluation such as these might prove useful to other medical schools with class sizes of 150 students or more.

A randomized, double-blind, multi-centre, parallel-group study comparing the tolerability and efficacy of moclobemide and dothiepin hydrochloride in depressed patients in general practice.

A randomized, double-blind, multi-centre, parallel-group study compared the tolerability and efficacy of 450 mg of moclobemide and 75-150 mg of dothiepin in the management of depressed patients in general practice. Patients who fulfilled the DSM-III-R criteria for major depressive disorder and who scored 13 or more on the Hamilton Depression Rating Scale were admitted. The trial lasted six weeks. The dose of moclobemide was 150 mg three times daily and that of dothiepin was 75 mg daily for the first two weeks and 150 mg thereafter. Assessments were made at baseline and after one, three and six weeks using the HDRS, the Zung SRS and the CGI. Adverse events and vital signs were monitored at each visit, and laboratory screening tests performed at the beginning and end of the study. Sixty-four general practitioners from four centres recruited 345 patients: 175 received dothiepin and 170 moclobemide; 265 completed six weeks of treatment. Thirty-eight dothiepin-treated patients (22%) and 42 who received moclobemide (25%) dropped out, most commonly because they experienced adverse events. More patients on dothiepin (24) than on moclobemide (16) dropped out for this reason; the incidence of adverse events was 10% higher in the dothiepin-treated group and of "side effects" more than 10% higher, the latter difference being statistically significant. Both treatments resulted in significant improvement; this was greater in the dothiepin-treated group and the difference was statistically significant, although clinically small.

Counsellors in English and Welsh general practices: their nature and distribution.

OBJECTIVE: To establish the prevalence of counselling services in English and Welsh general practices and factors associated with their distribution; to describe qualifications, working arrangements, and case mix of "counsellors." DESIGN: Postal questionnaire and telephone interview survey of a sample of about one in 20 general practitioners in England and Wales. SETTING: English and Welsh general practices. SUBJECTS: 1880 general practitioners of whom 1542 (82%) completed questionnaires. MAIN OUTCOME MEASURES: Prevalence and distribution of practice counselling services; counsellors' qualifications and funding; types of patients referred. RESULTS: 586 counsellors were distributed among 484 of the 1542 practices. Three types of counsellor predominated: community psychiatric nurses (187); "practice counsellors" (145); and clinical psychologists (95). Practice characteristics which independently predicted the presence of a counsellor were for community psychiatric nurses four or more partners (odds = 1.72, 95% confidence interval 1.18 to 2.26); for practice counsellors stress clinic (odds = 2.22; 1.83 to 2.61), training practice (odds = 1.70; 1.24 to 2.16), and health region (chi 2 = 55.94; df = 14; p < 0.001); and for clinical psychologists list size of > or = 10,500 (odds = 1.79; 1.09 to 2.49), training practice (odds = 1.78; 1.31 to 2.25), health region (chi 2 = 48.31; df = 14; p < 0.001). 197 counsellors had training in counselling. The qualifications of 85 were unknown to the general practitioner. The principal source of funding was the district health authority for community psychiatric nurses (150) and clinical psychologists (58) and the family health services authority for practice counsellors (76). All counsellors were referred a wide range of problems. CONCLUSIONS: Counselling services are wide-spread in general practice, but a high proportion of counsellors lack qualifications, and many may be referred problems outside their knowledge.

Guidelines for treating depressive illness with antidepressants: A statement from the British Association for Psychopharmacology.

Depression is a common illness which affects some 3% of the population per year. At least 25% of those with marked depression do not consult their general practitioner and in half of those who do the illness is not detected. Depression is easy to recognize when four or five of the core symptoms have been present for 2 weeks which often coincides with some occupational and social impairment. The core symptoms are depressed mood, loss of interest or pleasure, loss of energy or fatigue, concentration difficulties, appetite disturbance, sleep disturbance, agitation or retardation, worthlessness or self blame and suicidal thoughts. A diagnosis of depression is made when five of these core symptoms, one of which should be depressed mood or loss of interest or pleasure, have been present for 2 weeks. Four core symptoms are probably sufficient. Response to antidepressants is good in those with more than mild symptoms. When there are only few or very mild depressive symptoms evidence of response to antidepressants is more uncertain. Antidepressants are effective, they are not addictive and do not lose efficacy with prolonged use. The newer antidepressants have fewer side effects than the older tricyclics, they are better tolerated and lead to less withdrawals from treatment. They are less cardiotoxic and are safer in overdose. Antidepressants should be used at full therapeutic doses. Treatment failure is often due to too low a dose being used in general practice. It may be difficult to reach the right dose with the older tricyclics because of side effects. To consolidate response, treatment should be continued for at least 4 months after the patient is apparently well. Stopping the treatment before this is ill-advised as the partially treated depression frequently returns. Most depression is recurrent. Long-term antidepressant treatment is effective in reducing the risk of new episodes of depression and should be continued to keep the patient well.

Randomised controlled trial of effects of coordinating care for terminally ill cancer patients.

OBJECTIVES: To measure effects on terminally ill cancer patients and their families of coordinating the services available within the NHS and from local authorities and the voluntary sector. DESIGN: Randomised controlled trial. SETTING: Inner London health district. PATIENTS: Cancer patients were routinely notified from 1987 to 1990. 554 patients expected to survive less than one year entered the trial and were randomly allocated to a coordination or a control group. INTERVENTION: All patients received routinely available services. Coordination group patients received the assistance of two nurse coordinators, whose role was to ensure that patients received appropriate and well coordinated services, tailored to their individual needs and circumstances. MAIN OUTCOME MEASURES: Patients and carers were interviewed at home on entry to the trial and at intervals until death. Interviews after bereavement were also conducted. Outcome measures included the presence and severity of physical symptoms, psychiatric morbidity, use of and satisfaction with services, and carers' problems. Results from the baseline interview, the interview closest to death, and the interview after bereavement were analysed. RESULTS: Few differences between groups were significant. Coordination group patients were less likely to suffer from vomiting, were more likely to report effective treatment for it, and less likely to be concerned about having an itchy skin. Their carers were more likely to report that in the last week of life the patient had had a cough and had had effective treatment for constipation, and they were less likely to rate the patient's difficulty swallowing as severe or to report effective treatment for anxiety. Coordination group patients were more likely to have seen a chiropodist and their carers were more likely to contact a specialist nurse in a night time emergency. These carers were less likely to feel angry about the death of the patient. CONCLUSIONS: This coordinating service made little difference to patient or family outcomes, perhaps because the service did not have a budget with which it could obtain services or because the professional skills of the nurse-coordinators may have conflicted with the requirements of the coordinating role.