Usual General Practitioner Research Articles

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: Cost effectiveness

Objective: To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.Design: Prospective, controlled trial with randomised and patient preference allocation arms.Setting:...

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: Clinical effectiveness

Objective: To compare the clinical effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.Design: Prospective, controlled trial with randomised and patient preference allocation arms.Setting:...

A randomised controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector

Objectives: To compare outcome and resource utilisation among patients referred to the Amalthea Project, a liaison organisation that facilitates contact between voluntary organisations and patients in primary care, with patients...

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care.

The aim of this study was to determine both the clinical and cost-effectiveness of usual general practitioner (GP) care compared with two types of brief psychological therapy (non-directive counselling and cognitive-behaviour therapy) in the management of depression as well as mixed anxiety and depression in the primary care setting. The design was principally a pragmatic randomised controlled trial, but was accompanied by two additional allocation methods allowing patient preference: the option of a specific choice of treatment (preference allocation) and the option to be randomised between the psychological therapies only. Of the 464 patients allocated to the three treatments, 197 were randomised between the three treatments, 137 chose a specific treatment, and 130 were randomised between the psychological therapies only. The patients underwent follow-up assessments at 4 and 12 months. The study was conducted in 24 general practices in Greater Manchester and London. A total of 464 eligible patients, aged 18 years and over, were referred by 73 GPs and allocated to one of the psychological therapies or usual GP care for depressive symptoms. The interventions consisted of brief psychological therapy (12 sessions maximum) or usual GP care. Non-directive counselling was provided by counsellors who were qualified for accreditation by the British Association for Counselling. Cognitive-behaviour therapy was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies. Usual GP care included discussions with patients and the prescription of medication, but GPs were asked to refrain from referring patients for psychological intervention for at least 4 months. Most therapy sessions took place on a weekly basis in the general practices. By the 12-month follow-up, GP care in some cases did include referral to mental healthcare specialists. The clinical outcomes included depressive symptoms, general psychiatric symptoms, social function and patient satisfaction. The economic outcomes included direct and indirect costs and quality of life. Assessments were carried out at baseline during face-to-face interviews as well as at 4 and 12 months in person or by post. At 4 months, both psychological therapies had reduced depressive symptoms to a significantly greater extent than usual GP care. Patients in the psychological therapy groups exhibited mean scores on the Beck Depression Inventory that were 4-5 points lower than the mean score of patients in the usual GP care group, a difference that was also clinically significant. These differences did not generalize to other measures of outcome. There was no significant difference in outcome between the two psychological therapies when they were compared directly using all 260 patients randomised to a psychological therapy by either randomised allocation method. At 12 months, the patients in all three groups had improved to the same extent. The lack of a significant difference between the treatment groups at this point resulted from greater improvement of the patients in the GP care group between the 4- and 12-month follow-ups. At 4 months, patients in both psychological therapy groups were more satisfied with their treatment than those in the usual GP care group. However, by 12 months, patients who had received non-directive counselling were more satisfied than those in either of the other two groups. There were few differences in the baseline characteristics of patients who were randomised or expressed a treatment preference, and no differences in outcome between these patients. Similar outcomes were found for patients who chose either psychological therapy. Again, there were no significant differences between the two groups at 4 or 12 months. Patients who chose counselling were more satisfied with treatment than those who chose c

Risk factors for sudden unexpected cardiac death in Tasmanian men.

Sudden unexpected cardiac death (SUCD) accounts for approximately 25% of deaths from ischaemic heart disease (IHD) but is relatively poorly understood because of the difficulties involved in researching aetiology. Clinical differences between instances of SUCD and those cases of acute chest pain that survive long enough to be proven as myocardial infarction but are eventually fatal might reflect differences in aetiology. To determine the risk factors for sudden unexpected cardiac death in Tasmanian men. A population-based case-control method was used with the study population, an estimated 125,225 men aged 25-74 years living in the island State of Tasmania, Australia. The case group of 102 men who had a SUCD was validated using necropsy reports, hospital records and information provided by the usual general practitioner. Cases were matched with 204 community controls. Spouses or partners of eligible subjects answered a detailed questionnaire. Multi-variate odds ratios (ORs) for risk factors were calculated using stepwise analysis. Risk factors measured included: smoking habit, treated hypertension, hypercholesterolaemia, diabetes mellitus, family history of IHD, alcohol intake and exercise habits. Independent risk factors for SUCD were: history of diabetes mellitus (OR = 4.2, 95% CI: 1.39, 12.81), current smoking status (OR = 3.5, 95% CI: 1.80, 6.82), and family history of IHD (OR = 2.6, 95% CI: 1.34, 4.92). Some accepted risk factors for acute myocardial infarction (AMI) also predict sudden death in men with no history of coronary disease. Efforts to reduce smoking, the incidence of diabetes mellitus and mean blood pressure must be continued as SUCD is, by definition, untreatable but is potentially avoidable in many instances.

A behavioral typology of hypertensive out-patients followed up in general practice

Summary2275 hypertensive patients consulting their usual general practitioner were analyzed using a specifically designed questionnaire. Sixty-two percent of the subjects were already treated and 38% were untreated prior to inclusion in the study. The data, collected during the usual medical consultation, included several questions answered by the physician concerning the patient's psychological status as well as a series of behavioural scales. The aim of this study was to describe a small number of different and homogeneous psychological patterns rather than a unique profile of hypertensive out-patients. Four types were thus defined using a statistical clustering procedure and were designated as ‘everything is OK”, “hyper-reactive”, “depressed”, and “dynamic-competitive”, representing respectively 43%, 33%, 10% and 14% of the population studied. The first type consists of patients who do not express subjective complaints and claim to have no conflicts, but who have difficulty adjusting to environmental changes. The second type is characterized by emotionally unstable individuals who are easily overwhelmed by their difficulties. The third type corresponds to pessimistic subjects, still affected by previous painful life events. Finally, the fourth type, close to coronary-prone type A behaviour, is composed of subjects whose aggression is channelled into social competition. The distribution of hypertensives amongst these 4 types is the same whether previously treated or not. Under treatment throughout the 6 months’ follow-up, the evolution of mean systolic blood pressure (SUP) and of mean diastolic blood pressure (DBP) was similar in the 4 types, although the second type showed the highest SBP during this period. Second and third type subjects more frequently reported the classical symptoms of hypertension. First and third type subjects reported more side-effects with antihypertensive treatment. Each type's vulnerability to stress is discussed from a psychosomatic viewpoint of essential hypertension. This study provides evidence that several behavioural patterns can be described amongst hypertensive patients. Knowledge of these patterns may be very useful in clinical practice to manage the Patient-physician relationship, and to increase patient compliance with antihypertensive therapy.