Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study.

OBJECTIVES: Patients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS. DESIGN AND SETTING: Records from the longitudinal population-based ('Lifelines') cohort study were linked to electronic health records from general practitioners (GPs). PARTICIPANTS: We included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort. OUTCOME MEASURES: The outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed. RESULTS: 18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29-0.47). CONCLUSIONS: Several theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.

The course of untreated anxiety and depression, and determinants of poor one-year outcome: a one-year cohort study.

BACKGROUND: Little is known about the course and outcome of untreated anxiety and depression in patients with and without a self-perceived need for care. The aim of the present study was to examine the one-year course of untreated anxiety and depression, and to determine predictors of a poor outcome. METHOD: Baseline and one-year follow-up data were used of 594 primary care patients with current anxiety or depressive disorders at baseline (established by the Composite Interview Diagnostic Instrument (CIDI)), from the Netherlands Study of Depression and Anxiety (NESDA). Receipt of and need for care were assessed by the Perceived Need for Care Questionnaire (PNCQ). RESULTS: In depression, treated and untreated patients with a perceived treatment need showed more rapid symptom decline but greater symptom severity at follow-up than untreated patients without a self-perceived mental problem or treatment need. A lower education level, lower income, unemployment, loneliness, less social support, perceived need for care, number of somatic disorders, a comorbid anxiety and depressive disorder and symptom severity at baseline predicted a poorer outcome in both anxiety and depression. When all variables were considered at the same time, only baseline symptom severity appeared to predict a poorer outcome in anxiety. In depression, a poorer outcome was also predicted by more loneliness and a comorbid anxiety and depressive disorder. CONCLUSION: In clinical practice, special attention should be paid to exploring the need for care among possible risk groups (e.g. low social economic status, low social support), and support them in making an informed decision on whether or not to seek treatment.

Use of general practice services 5 years after an episode of mental illness: case-control study using electronic records.

BACKGROUND: Depression, anxiety, and emotional distress occur frequently and are usually treated in general practice. Little has been reported about the long-term course of these conditions and the long-term use of medical services. AIM: To follow up patients with depression, anxiety, and emotional distress in general practice for 5 years and examine the length and number of index episodes, prescribing behaviour, and the use of services in general practice. DESIGN AND SETTING: A case-control study using data from electronic medical records. METHOD: Three cohorts of patients with depression (n = 453), anxiety (n = 442), and emotional distress (n = 185) were compared against a cohort of control patients (n = 4156) during a 5-year follow-up from 2007 to 2011. The occurrence or recurrence of the index disorders, other psychological disorders or medical conditions, the numbers of prescriptions, and the number of contacts with the general practice were all examined. RESULTS: Patients in the depression group had 1.1 followup episodes of depression, those in the anxiety group had 0.9 follow-up episodes of anxiety, and those in the emotional distress group had 0.5 follow-up episodes of emotional distress during the 5 years. All three groups had more consultations (for both psychological and somatic reasons) during each of the follow-up years than control patients. Furthermore, the groups with mental health disorders were given more prescriptions for psychopharmacological treatment. CONCLUSION: Five years after the index episode in 2007, patients with an episode of depression, anxiety, or emotional distress are still not comparable with control patients, in terms of the prevalence of mental health conditions, the number of prescriptions, and healthcare use.

Long-term antidepressant use: a qualitative study on perspectives of patients and GPs in primary care.

BACKGROUND: Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission. AIM: To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use. DESIGN AND SETTING: Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands. METHOD: Patients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20). RESULTS: The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation. CONCLUSION: Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan.

GP mental health care in 10 European countries: patients’ demands and GPs’ responses

There is a large variation between different countries regarding the presentation of psychological symptoms, their diagnosis and treatment in general practice. A possible explanation for such variation might be the conditions of the health care system in different countries. A gate-keeping function might be facilitating the recognition and treatment of mental disorder. Furthermore, the payment system and insurance system are considered of importance. Method: To test these hypotheses, data were collected in 10 European countries with different health care systems. 25 - 43 GPs in each country collected data on 20 consecutive doctor-patient contacts, including videotaped consultations, patient and GP questionnaires per contact and a general GP questionnaire. Results: There are differences, not related to health care system characteristics, between countries concerning the prevalence of mental distress among patients visiting their GP. Only a minority of distressed patients presented psychological symptoms. Although GPs did not limit their psychological diagnoses to patients presenting with psychological symptoms, they also diagnosed only a minority of distressed patients with a psychological diagnosis. In general, psychological presentation and diagnosis in gate-keeping countries and in Switzerland (where GPs were remunerated for psychological diagnosis and treatment) was more frequent than in other countries. Especially in Eastern European countries Estonia, Poland and Rumania the presentation of psychological symptoms by distressed patients was very uncommon. Psychological treatment was not related to gate-keeping. In case of Switzerland, remuneration seemed an effective incentive. Conclusion: Overall prevalence of mental distress cannot be explained by gate-keeping function of the GP, payment system, remuneration system or differences between Eastern and Western Europe. However, a gate-keeping system appears to lower the threshold for help seeking and diagnosis. Gate-keeping has no clear impact on treatment of mental disorder in general practice. In this case, remuneration is observed to be effective (AU)

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