Primary Care Attenders Research Articles

Cognitive behaviour therapy for long-term frequent attenders in primary care: a feasibility case series and treatment development study.

Most frequent attendance in primary care is temporary. Long-term frequent attendance may be suitable for psychological intervention to address health management and service use. To explore the feasibility and acceptability of cognitive behaviour therapy (CBT) for long-term frequent attendance in primary care and obtain preliminary evidence regarding clinical and cost effectiveness. A CBT case series was carried out in five GP practices in the East Midlands. Frequent attenders (FAs) were identified from case notes and invited by their practice for assessment, then offered CBT. Feasibility and acceptability were assessed by CBT session attendance and thematic analysis of semi-structured questionnaires. Clinical and cost effectiveness was assessed by primary care use and clinically important change on a range of health and quality of life instruments. Of 462 FAs invited to interview, 87 (19%) consented to assessment. Thirty-two (7%) undertook CBT over a median of 3 months. Twenty-four (75%) attended at least six sessions. Eighteen FAs (86%, n = 21) reported overall satisfaction with treatment. Patients reported valuing listening without judgement alongside support to develop coping strategies. Thirteen (54%, n = 24), achieved clinically important improvement on the SF-36 Mental-Component Scale at 6-month follow-up and improved quality of life, but no improvement on other outcomes. Primary care use reduced from a median of eight contacts in 3 months at baseline (n = 32) to three contacts in 3 months at 1 year (n = 18). CBT appears feasible and acceptable to a subset of long-term FAs in primary care who halved their primary care use. With improved recruitment strategies, this approach could contribute to decreasing GP workload and merits larger-scale evaluation.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. clinicaltrials.gov Identifier: NCT01492348.

Longitudinal association between different levels of alcohol consumption and a new onset of depression and generalized anxiety disorder: Results from an international study in primary care

Background: Several studies that have examined the full range of alcohol consumption have pointed to a possible non-linear association between alcohol use and the common mental disorders. Most of these studies are cross sectional and assessed psychiatric morbidity using non-specific instruments. Our aim was to investigate the longitudinal association between varying levels of alcohol consumption at baseline and the new-onset of depression and generalized anxiety disorder (GAD), in a large international primary care sample.Methods: The sample consisted of 3201 primary care attenders from 14 countries in the context of WHO Collaborative Study of Psychological Problems in General Health Care. Alcohol use at baseline was assessed using AUDIT and the mental disorders were assessed with the Composite International Diagnostic Interview.Results: Light to moderate alcohol consumption at baseline was associated with a lower incidence of depression and GAD compared to abstinence while excessive alcohol consumption was associated with a higher incidence of depression but not GAD. This non-linear association was not substantially affected after adjustment for a range of possible confounding variables.Conclusion: Any causal interpretation of this association is difficult in the context of an observational study and further combined and consistent evidence from different sources is needed.

Análisis de las derivaciones realizadas a dermatología desde atención primaria y su concordancia diagnóstica

ObjectiveDermatological diseases are a frequent reason for consultations at Primary Care level. The aim of this study is to analyse the most frequent reasons for referral, the index of agreement in the diagnosis, and to determine the profile of referred patients. Material and methodA cross-sectional, descriptive study was conducted on patients referred from Primary Care to a dermatologist between the months of January and June 2013. At Primary Care level, social-demographic and attendance variables were collected, and at both levels, the diagnosis made, the request for complementary tests, and the treatment prescribed. The arithmetic mean was used for quantitative variables, and percentages for qualitative variables. The Kappa index was used for the level of agreement. ResultsThe analysis included 354 patients, with a mean age of 43.97±25.4, and predominantly female (59.3%). Almost three-quarters (71.5%) of the specialist referral notes contained a clear diagnosis, with nevus and warts being the most frequent. The dermatologist carried out complementary tests in 8.2% of the cases, and prescribed treatment in 33.6% of cases. No response was added to the medical records in 13.3% of cases. Overall agreement between the two care levels was 67.1%, with a Kappa index of 0.64. ConclusionsThe typical profile of a patient referred to a dermatology specialist is that of a middle-aged female. Although agreement between the diagnoses is good, many of the cases which are referred could be treated at Primary Care level with correct training, which would improve the efficiency of the system. Measurements should be implemented to reduce the lack of responses recorded in the medical records.

Medically unexplained symptoms in patients with PNES: Do they explain poor employment outcome in patients with good seizure outcomes?

Many patients with psychogenic nonepileptic seizures (PNES) have other medically unexplained symptoms (MUS). In order to assess their long-term contribution to ill-health and unemployment, we recorded MUS, employment, healthcare utilization, and seizure outcomes in a cohort of patients with PNES. We had complete computerized healthcare records and employment information in 120 patients with PNES, 5-10years postdiagnosis. We analyzed these data to assess the contribution of MUS to ill-health and to determine whether MUS could explain differences among seizure, employment, and healthcare utilization outcomes in PNES. At 5-10years, 41/120 patients (34.2%) were attending primary or secondary care for seizures, 42/120 patients (35.0%) had MUS other than PNES, and 36/120 patients (30.0%) were employed. Unemployment was predicted by age at presentation (OR: 0.90 (0.86-0.94), p<0.001), presenting to primary or secondary care with seizures (OR: 0.16 (0.05-0.52), p=0.003), and contact with psychiatric services at 5-10years (OR: 0.16 (0.05-0.58), p=0.005). No outcome measures were predicted by additional MUS, though MUS themselves were predicted by psychiatric contact (OR: 2.27 (1.01-5.01), p=0.048). Our data suggest that MUS do not contribute independently to unemployment in the population with PNES, whereas psychiatric morbidity appears to do so. Nonetheless, MUS and psychiatric morbidity persist in the long term in a substantial minority of patients with PNES. We found no evidence that seizures in patients whose PNES have resolved are replaced with other MUS.

Suicidality in primary care patients who present with sadness and anhedonia: a prospective European study.

BackgroundSadness and anhedonia (loss of interest in activities) are central symptoms of major depression. However, not all people with these symptoms meet diagnostic criteria for major depression. We aimed to assess the importance of suicidality in the outcomes for primary care patients who present with sadness and anhedonia.MethodCohort study of 2,599 unselected primary care attenders in six European countries followed up at 6 and 12 months.Results1) In patients with sadness and/or anhedonia who were not depressed at entry to the study, suicide plans (OR = 3.05; 95 % CI = 1.50–6.24; p = 0.0022) and suicide attempts (OR = 9.08; 95 % CI = 2.57–32.03; p = 0.0006) were significant predictors of developing new onset depression at 6 or 12 months. 2) In patients with sadness and/or anhedonia who met CIDI criteria for major depression at entry, suicidal ideation (OR = 2.93; 95 % CI = 1.70–5.07; p = 0.0001), suicide plans (OR = 3.70; 95 % CI = 2.08–6.57; p < 0.0001), and suicide attempts (OR = 3.33; 95 % CI = 1.47–7.54; p = 0.0040) were significant predictors of persistent depression at 6 or 12 months.ConclusionsThree questions on suicidality could help primary care professionals to assess such patients more closely without necessarily establishing whether they meet criteria for major depression.

Barriers of Chinese primary care attenders to seeking help for psychological distress in Hong Kong

BackgroundMost of the previous studies on help seeking for psychological distress were derived from Western countries. This study investigated the barriers to help-seeking for psychological distress among Chinese primary care attenders in Hong Kong. MethodsNine focus groups and 6 individual interviews were conducted among Chinese primary care attenders with/without known distress, patients' significant others and the general public. The identified barriers were investigated in a questionnaire survey with data from 1626 primary care attenders recruited from 13 private clinics and 6 public clinics. ResultsWorries about side effects of drugs (79.9%, 95% CI:(77.9%, 81.8%)) and drug dependency (74.7%, 95% CI:(72.5%, 76.8%)) were rated as the top barriers in the survey. Qualitative interviews found both worries and actual experience of the side effects of drugs, which weakened patients' trust in the treatment. Factor analysis on all barrier items suggested three factors: 1) worries of treatment, 2) uncertainties on primary care physicians' capacity, 3) public’s limited knowledge on distress and sources of help. Distress level, education level and age were associated with factor 1, whereas distress level and healthcare setting were associated with the other two factors. Qualitative interviews revealed that not having a regular primary care physician in the public setting discouraged disclosure of psychological problems. LimitationsThe findings were based on self-reported data from the respondents. Hong Kong is influenced by a mixed Chinese and Western culture. ConclusionsRelevant public education in a Chinese context should target at reducing patients' worries of drug treatment and strengthening the image of primary care physicians as a feasible source of help.

How common is bipolar disorder in general primary care attendees? A systematic review and meta-analysis investigating prevalence determined according to structured clinical assessments.

There are mounting calls for bipolar disorder to be managed in primary care, yet the exact prevalence remains unclear. We conducted a meta-analysis to investigate the prevalence of bipolar disorder in general primary care attendees without other comorbid psychiatric diagnosis. We systematically searched major electronic databases from inception till 03/2015. Articles were included that reported the prevalence of bipolar disorder determined in line with structured clinical assessment in primary care settings. Two independent authors conducted searches, completed methodological appraisal and extracted data. A random effects meta-analysis and meta-regression were performed. Sixteen studies were included accounting for 425,691 participants (mean age = 41.1 years [standard deviation = 7.2 years] 33.3% males). Overall, the global prevalence of bipolar disorder was 1.9% (95% confidence interval = [0.6, 5.4]). The prevalence of bipolar disorder in studies recording a current diagnosis was 3.7% (95% confidence interval = [1.9, 6.0]) and 0.7% (95% confidence interval = [0.2, 1.5]) in studies considering a 12-month period. A diagnosis of bipolar disorder appeared higher in North America (3.7%, 95% confidence interval = [0.9, 8.1]) compared to Europe (0.8%, 95% confidence interval = [0.3, 1.5]). Meta-regression suggests that a more recent publication date (co-efficient = 0.089, 95% confidence interval = [0.0173, 0.1654], z = 2.19, p = 0.01, R(2) = 0.21) and younger age of participants (co-efficient -0.0851, 95% confidence interval = [-0.1696, 0.005], z = -1.97, p = 0.04, R(2) = 0.24) moderated a higher prevalence of bipolar disorder. The global prevalence of bipolar disorder in primary care is 1.9%, with potentially higher prevalence rates in North America compared to Europe. A more recent study publication date is a significant predictor of higher prevalence of bipolar disorder. Potential reasons/drivers of this are considered within the text.

Awareness of Cancer Symptoms and Barriers to Seeking Medical Help Among Adult People Attending Primary Care Settings in Oman.

Objectives:To explore the public’s awareness of cancer symptoms and the barriers to seeking medical help among Omani adults attending primary care settings in Muscat governorate, the capital city of Oman.Methods:The Cancer Awareness Measure (CAM) questionnaire (translated into Arabic) was used to collect data from a total of 12 randomly selected local health centers (LHCs) in Muscat governorate, the capital city of Oman. Omani adults aged 18 years and above attending LHCs during the study period were invited to participate in the study. Statistical Package for the Social Sciences (SPSS version 22) was used to analyze the data.Results:A total of 999 participants completed the CAM questionnaire from 1200 invitations (response rate = 83%). The overall recognition of common cancer symptoms was less than 50% except for an unexplained lump/swelling, which was 71%. Multinomial logistic regression showed that women recognized more cancer symptoms than men (odds ratio [OR] = 1.79; 95% confidence interval [CI]: 1.27-2.51), that more highly educated participations recognized more cancer symptoms than less educated participants (OR = 39; 95% CI: 0.23-0.69). The majority of participants (91.2%) agreed that the right time to seek medical help for possible cancer symptom was within 2 weeks. Multinomial logistic regression showed that women rather than men were more likely to perceive barriers to seeking medical help (OR = 2.10; 95% CI: 1.60-2.76). Also the less educated participants, rather than more educated, were more likely to perceive barriers to seeking medical help (OR = 2.17; 95% CI: 1.16-4.05).Conclusion:Levels of awareness of cancer symptoms are low in Oman. More national CAMs are needed in Oman to increase public knowledge of cancer symptoms. Also, more public awareness is needed to overcome the barriers to seeking timely medical help particularly among groups of women and the unmarried, widowed, divorced, or separated if delays in presentation are to be minimized.

Socioeconomic predictors and consequences of depression among primary care attenders with non-communicable diseases in the Western Cape, South Africa: cohort study within a randomised trial.

BackgroundSocioeconomic predictors and consequences of depression and its treatment were investigated in 4393 adults with specified non-communicable diseases attending 38 public sector primary care clinics in the Eden and Overberg districts of the Western Cape, South Africa.MethodsParticipants were interviewed at baseline in 2011 and 14 months later, as part of a randomised controlled trial of a guideline-based intervention to improve diagnosis and management of chronic diseases. The 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) was used to assess depression symptoms, with higher scores representing more depressed mood.ResultsHigher CESD-10 scores at baseline were independently associated with being less educated (p = 0.004) and having lower income (p = 0.003). CESD-10 scores at follow-up were higher in participants with less education (p = 0.010) or receiving welfare grants (p = 0.007) independent of their baseline scores. Participants with CESD-10 scores of ten or more at baseline (56 % of all participants) had 25 % higher odds of being unemployed at follow-up (p = 0.016), independently of baseline CESD-10 score and treatment status. Among participants with baseline CESD-10 scores of ten or more, antidepressant medication at baseline was independently more likely in participants who had more education (p = 0.002), higher income (p < 0.001), or were unemployed (p = 0.001). Antidepressant medication at follow up was independently more likely in participants with higher income (p = 0.023), and in clinics with better access to pharmacists (p = 0.053) and off-site drug delivery (p = 0.013).ConclusionsSocioeconomic disadvantage appears to be both a cause and consequence of depression, and may also be a barrier to treatment. There are opportunities for improving the prevention, diagnosis and treatment of depression in primary care in inequitable middle income countries like South Africa.Trial registrationThe trial is registered with Current Controlled Trials (ISRCTN20283604).

Gender differences in the impact of mental disorders and chronic physical conditions on health-related quality of life among non-demented primary care elderly patients

This paper aims to estimate the comorbidity of mental disorders and chronic physical conditions and to describe the impact of these conditions on health-related quality of life (HRQoL) in a sample of older primary care (PC) attendees by gender. Cross-sectional survey, conducted in 77 PC centres in Catalonia (Spain) on 1192 patients over 65years old. Using face-to-face interviews, we assessed HRQoL (SF-12), mental disorders (SCID and MINI structured clinical interviews), chronic physical conditions (checklist), and disability (Sheehan disability scale). We used multivariate quantile regressions to model which factors were associated with the physical component summary-short form 12 and mental component summary-short form 12. The most frequent comorbidity in both men and women was mood disorder with chronic pain and arthrosis. Mental disorders mainly affected 'mental' QoL, while physical disorders affected 'physical' QoL. Mental disorders had a greater impact on HRQoL than chronic physical conditions, with mood and adjustment disorders being the most disabling conditions. There were some gender differences in the impact of mental and chronic physical conditions on HRQoL. Anxiety disorders and pain had an impact on HRQoL but only in women. Respiratory diseases had an effect on the MCS in women, but only affected the PCS in men. Mood and adjustment disorders had the greatest impact on HRQoL. The impact profile of mental and chronic physical conditions differs between genders. Our results reinforce the need for screening for mental disorders (mainly depression) in older patients in PC.

Changing circumstances drive changing attendance: A longitudinal cohort study of time varying predictors of frequent attendance in primary health care

ObjectiveTo investigate risk factors for frequent attendance in primary care over time, contrasting models based on baseline and time-varying characteristics. MethodsAnalysis of data from the Personality and Total Health (PATH) Through Life Project: a representative community cohort study from the Canberra region of Australia. A balanced sample of 1734 respondents, initially aged in their early 40s, were assessed on three occasions over 8years. The survey assessed respondents' experience of chronic physical conditions, self-reported health, depression symptoms, personality, life events, socio-demographic characteristics and self-reported medication use. Survey data were linked to respondent's own administrative health service use data, and used to generate an objective measure of general practitioner (GP) consultations over a 12-month period. For each gender, respondents in the (approximate) highest decile of GP consultations at each time point were defined as frequent attenders (FAs). ResultsAnalysis showed chronic health conditions, self- reported health, mental health and medication use measured at baseline was associated with FA status, with some gender differences evident. However taking into account of changing circumstances improved the model fit and the prediction over FA status over time. ConclusionsThe study showed that there is considerable variability in frequent attender status over the study period. While baseline characteristics can predict current and future frequent attender status, it is clear that frequent attender in primary care does reflect changing circumstances over time.

Longitudinal cohort study describing persistent frequent attenders in Australian primary healthcare

ObjectivesTo describe patterns of frequent attendance in Australian primary care, and identify the prospective risk factors for persistent frequent attendance.Design, setting and participantsThis study draws on data from the Personality...

Problem Management Plus (PM+) for common mental disorders in a humanitarian setting in Pakistan; study protocol for a randomised controlled trial (RCT).

BackgroundIn humanitarian settings common mental disorders (depression, anxiety disorders, posttraumatic stress disorder) are highly prevalent. The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, individual psychological intervention program, delivered by paraprofessionals that addresses common mental disorders in people in communities affected by adversity. The objectives of this study are to test effectiveness and cost-effectiveness of the locally adapted PM+ compared to Treatment as usual (TAU) in Peshawar District, Pakistan.MethodsA randomised controlled trial will be conducted in 346 primary care attendees in 3 health care centres in Peshawar District, Pakistan. After informed consent, primary care attendees with high levels of psychological distress according to the General Health Questionnaire-12 (GHQ-12) and functional impairment (WHO Disability Assessment Schedule 2.0 (WHODAS)) will be assigned to PM+ (n = 173) or TAU (n = 173). At baseline, 1 week and 3 months following PM+, independent assessors will assess psychological distress with the Hospital Anxiety and Depression Scale (HADS), and functional disability with the WHODAS. Secondary outcomes are posttraumatic stress disorder (PTSD) symptoms, and client-perceived priority problems. Further, cost-effectiveness will be assessed using the Service Receipt Inventory (SRI).DiscussionIf proven effective, PM+ will be rolled out to other areas for further adaptation and testing in diverse humanitarian settings.Trial registrationACTRN12614001235695. Registered 26 November 2014. Australian New Zealand Clinical Trials Registry

Consultation liaison in primary care for people with mental disorders.

Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary healthcare has been identified as essential to improving the delivery of mental healthcare. Consultation liaison is a model of mental healthcare where the primary care provider maintains the central role in the delivery of mental healthcare, with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental healthcare in the primary care setting and, in turn, improve outcomes for people with a mental disorder.

Details of development of the resource for adults with asthma in the RAISIN (randomized trial of an asthma internet self-management intervention) study.

BackgroundAround 300 million people worldwide have asthma and prevalence is increasing. Self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. We aimed to develop an evidence based, theory informed, online resource to support self-management in adults with asthma, called ‘Living well with Asthma’, as part of the RAISIN (Randomized Trial of an Asthma Internet Self-Management Intervention) study.MethodsWe developed Living well with Asthma in two phases.Phase 1: A low fidelity prototype (paper-based) version of the website was developed iteratively through input from a multidisciplinary expert panel, empirical evidence from the literature, and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process.Phase 2: The paper-based designs were converted to a website through an iterative user centred process. Adults with asthma (n = 10) took part in think aloud studies, discussing the paper based version, then the web-based version. Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Think aloud transcripts were also thematically analysed, further informing resource development.ResultsThe website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback on the contents of the resource was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties.ConclusionsOur multifaceted approach to online intervention development underpinned by theory, using evidence from the literature, co-designed with end users and a multidisciplinary panel has resulted in a resource which end users find relevant to their needs and easy to use. Living well with Asthma is undergoing evaluation within a randomized controlled trial.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-015-0177-z) contains supplementary material, which is available to authorized users.

Distinguishing between emotional distress and psychiatric disorder in primary care attenders: A cross sectional study of the four-dimensional symptom questionnaire (4DSQ)

BackgroundDetection of psychiatric disorder in primary care is a complex issue. Distinctions between ‘normal’ emotional distress and psychiatric disorder depend on how disorder is conceptualized. Our aim was to explore two different conceptualizations by examining patients' scores on one-dimensional depression measures and scores on the Four Dimensional Symptom Questionnaire (4DSQ), a measure that uniquely has separate dimensions for general distress and depressive disorder. MethodsThis was a cross sectional study of 487 primary care patients attending general clinics in Hampshire, UK. Patients completed the 4DSQ, Patient Health Questionnaire-9 (PHQ-9), General Health Questionnaire-12 (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS) whilst in the waiting room. ResultsThe 4DSQ classified 26% (126/485) of patients as having heightened distress levels and 8% (38/468) as possible cases of depressive disorder. Casesness was consistently higher across the one-dimensional measures (PHQ-9: 16%, GHQ-12: 28%, HADS-D: 13%). Of those patients deemed possible cases by the PHQ-9 (≥10), the 4DSQ classified 91% (71/78) as having heightened distress and 44% (32/72) as possible cases of depressive disorder. LimitationsThe sample was predominately older and white, which may limit generalizability of the findings to more diverse patient groups. There are limits to self-report measures in the assessment of complex diagnostic issues. ConclusionsInclusion of a distinct general distress dimension alongside a dimension focusing on specific depression symptomatology lowered the number of primary care patients classified as possible cases of disorder. This view of symptoms may have implications for the targeting of existing treatments, and may be useful in guiding the development of novel self-management interventions.

Serotonin transporter polymorphism (5HTTLPR), severe childhood abuse and depressive symptom trajectories in adulthood.

BackgroundCross-sectional studies suggest that the serotonin transporter promoter region polymorphism (5-HTT gene-linked polymorphic region, 5HTTLPR) moderates the relationship between childhood abuse and major depressive disorder.AimsTo examine whether the 5HTTLPR polymorphism moderates the effect childhood abuse has on 5-year depressive symptom severity trajectories in adulthood.MethodAt 5-year follow-up, DNA from 333 adult primary care attendees was obtained and genotyped for the 5HTTLPR polymorphism. Linear mixed models were used to test for a genotype × childhood abuse interaction effect on 5-year depressive symptom severity trajectories.ResultsAfter covariate adjustment, homozygous s allele carriers with a history of severe childhood abuse had significantly greater depressive symptom severity at baseline compared with those without a history of severe childhood abuse and this effect persisted throughout the 5-year period of observation.ConclusionsThe 5HTTLPR s/s genotype robustly moderates the effects of severe childhood abuse on depressive symptom severity trajectories in adulthood.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

The Friendship Bench programme: a cluster randomised controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe.

BackgroundCommon mental disorders (CMD) are a leading cause of disability globally. Emerging evidence indicates that in low and middle income countries the treatment gap for CMD can be addressed through the use of trained and supervised lay health workers (LHWs). Few clinical trials have evaluated the use of such task-shifting approaches in sub-Saharan Africa. In Zimbabwe, we have successfully piloted a task-shifting intervention delivered by LHWs. This protocol describes a cluster randomised controlled trial to assess the effectiveness of this intervention.MethodsEach of 24 randomly selected clinics from a pool of 42 in Harare will recruit 24 participants (N = 576). The clinics are randomised in a 1:1 ratio to receive either the intervention package [a problem solving therapy package delivered over a 4–6 week period by LHWs (N = 24) followed by a 6-week group support programme which focuses mainly on teaching a craft skill] or enhanced usual care, which includes usual care and psycho-education. Primary care attenders aged 18 years and above who score positive on a locally validated CMD screening questionnaire (Shona Symptom Questionnaire, SSQ-14) will be eligible for recruitment and asked for informed consent to participate in the trial. The primary measure is the SSQ score at 6 months.ConclusionThis effectiveness trial using LHWs to address the treatment gap for CMD will contribute to the body of knowledge on the feasibility and ability for scale-up of interventions for CMD.Trial registrationPACTR201410000876178.

Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study.

The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65 years and younger women with increased risk. "Choosing Wisely" initiatives advise avoiding DXA screening in women younger than 65 years without osteoporosis risk factors. We aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system. This was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region. The study included 50,995 women aged 40-85 years without prior osteoporosis screening, diagnosis, or treatment attending primary care visits from 2006 to 2012, observed for a mean of 4.4 years. We examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass index < 20, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking). Among previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8 % among women aged 60-64 years with ≥ 1 risk factor (95 % CI: 51.9-65.8 %), 57.8 % for women aged 65-74 years (95 % CI: 55.6-60.0 %), and 42.7 % for women aged ≥ 75 years (95 % CI: 38.7-46.7 %). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5 % among women aged 50-59 years (95 % CI 44.1-46.9 %) and 58.6 % among women aged 60-64 years without risk factors (95 % CI 55.9-61.4 %). DXA screening was underused in women at increased fracture risk, including women aged ≥ 65 years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis.