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1.  Concerns voiced by patients and GPs’ responses during psychosocial visits in primary care: a historical cross-sectional study 
BMC Family Practice  2014;15(1):188.
Background
In a recent study comparing psychosocial consultations prior to and after the implementation of national clinical guidelines in the Netherlands, we found that general practitioners (GPs) showed less empathy in the more recent consultations. As a consequence, patients possibly have less scope to express their worries. The objective is to investigate whether patients have become more reluctant to open up about their concerns during psychosocial consultations and how GPs respond.
Methods
Consultations from previous study samples videotaped between 1977 and 2008 and categorized by GPs as ‘completely psychosocial’ were selected for the present study. These consultations were observed using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to capture cues and concerns expressed by patients and GPs’ immediate responses. We compared consultations prior to (N = 121) and after (N = 391) introduction of national clinical guidelines in the 1990s.
Results
In 92% of the consultations, patients presented at least one worry. These were most often expressed implicitly. However, the proportion of consultations containing at least one explicit concern changed from 24% to 37% over time. The increased number of expressed cues and concerns was partly explained by a change in GP characteristics; the latter sample contained more female and more experienced GPs. Furthermore, cues and concerns were more often expressed during later phases of consultations in recent years.
Conclusions
Our study shows that patients have become somewhat more explicit in expressing their worries. However, GPs need to be aware that, still, most worries are expressed implicitly and that new concerns may appear towards the end of consultations.
doi:10.1186/s12875-014-0188-3
PMCID: PMC4247880  PMID: 25421612
Doctor-patient relations; General practice; Cues; Empathy; Psychosocial factors
2.  Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation 
BMC Family Practice  2014;15:35.
Background
Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing.
Methods
A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network.
Results
A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92).
Conclusions
An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.
doi:10.1186/1471-2296-15-35
PMCID: PMC3996100  PMID: 24552140
General practice; Guidelines; Antidepressants; Implementation; Stepped care
3.  Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study 
BMC Psychiatry  2011;11:180.
Background
There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement.
Methods
This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).
Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records.
Results
721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N = 281) suffered from more severe symptoms than patients who received non-guideline concordant care (N = 440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes.
Conclusion
The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.
doi:10.1186/1471-244X-11-180
PMCID: PMC3288826  PMID: 22099636
4.  Referral of patients with depression to mental health care by Dutch general practitioners: an observational study 
BMC Family Practice  2011;12:41.
Background
Depression is a common illness, often treated in primary care. Guidelines provide recommendations for referral to mental health care. Several studies investigated determinants of referral, none investigated guideline criteria as possible determinants.
We wanted to evaluate general practitioner's referral of depressed patients to mental health care and to what extent this is in agreement with (Dutch) guideline recommendations.
Methods
We used data of primary care respondents from the Netherlands Study of Depression and Anxiety with major depressive disorder in the past year (n = 478). We excluded respondents with missing data (n = 134). Referral data was collected from electronic patient files between 1 year before and after baseline and self report at baseline and 1-year follow-up. Logistic regression was used to describe association between guideline referral criteria (e.g. perceived need for psychotherapy, suicide risk, severe/chronic depression, antidepressant therapy failure) and referral.
Results
A high 58% of depressed patients were referred. Younger patients, those with suicidal tendency, chronic depression or perceived need for psychotherapy were referred more often. Patients who had used ≥2 antidepressants or with chronic depression were more often referred to secondary care. Referred respondents met on average more guideline criteria for referral. However, only 8-11% of variance was explained.
Conclusion
The majority of depressed patients were referred to mental health care. General practitioners take guideline criteria into account in decision making for referral of depressed patients to mental health care. However, other factors play a part, considering the small percentage of variance explained. Further research is necessary to investigate this.
doi:10.1186/1471-2296-12-41
PMCID: PMC3119074  PMID: 21615899
5.  Care provided by general practitioners to patients with psychotic disorders: a cohort study 
BMC Family Practice  2010;11:92.
Background
Patients suffering from psychotic disorders have an increased risk of comorbid somatic diseases such as cardiovascular disorders and diabetes mellitus. Doctor-related factors, such as unfamiliarity with these patients, as well as patient-related factors, such as cognitive disturbance and negative symptoms, contribute to suboptimal health care for these patients.
General practitioners (GPs) could play a key role in diagnosing and treating this somatic comorbidity as in the Netherlands, almost all residents are registered at a general practice. This study aims to find out whether there are any differences between the levels of health care provided by GPs to patients with psychotic disorders, compared to other types of patients.
Methods
A cohort of patients with an ICPC code of psychosis and two matched control groups, one consisting of patients with other mental problems and the other one of patients without any mental problems, were followed over a period of 5 years.
Results
Patients with psychotic disorders (N = 734) contacted the GP practice more often than patients in the control groups. These patients, both adults (p = 0.051) and the elderly (p < 0.005), received more home visits from their GPs. In the adult group (16 to 65 years old inclusive), the number of consultations was significantly higher among both psychosis patients and the group of patients with other mental problems (p < 0.0005). The number of telephone consultations was significantly higher in both age categories, adult group (p < 0.0005), and > 65 years old (p = 0.007). With regard to chronic illnesses, elderly psychosis patients had fewer contacts related to cardiovascular diseases or chronic lung diseases.
Conclusion
Patients with psychotic disorders contact the GP practice more frequently than other types of patients. Adult psychosis patients with diabetes mellitus, cardiovascular diseases or chronic lung diseases receive the same amount of health care for these diseases as other primary care patients. The finding that older patients with psychotic disorders are diagnosed with cardiovascular diseases and obstructive lung diseases less frequently than other types of elderly patients requires further study.
doi:10.1186/1471-2296-11-92
PMCID: PMC3004870  PMID: 21108807
6.  Characteristics of general practice care: What do senior citizens value? A qualitative study 
BMC Geriatrics  2010;10:80.
Background
In view of the increasing number of senior citizens in our society who are likely to consult their GP with age-related health problems, it is important to identify and understand the preferences of this group in relation to the non-medical attributes of GP care. The aim of this study is to improve our understanding about preferences of this group of patients in relation to non-medical attributes of primary health care. This may help to develop strategies to improve the quality of care that senior citizens receive from their GP.
Methods
Semi-structured interviews (N = 13) with senior citizens (65-91 years) in a judgement sample were recorded and transcribed verbatim. The analysis was conducted according to qualitative research methodology and the frame work method.
Results
Continuity of care providers, i.e. GP and practice nurses, GPs' expertise, trust, free choice of GP and a kind open attitude were highly valued. Accessibility by phone did not meet the expectations of the interviewees. The interviewees had difficulties with the GP out-of-office hours services. Spontaneous home visits were appreciated by some, but rejected by others. They preferred to receive verbal information rather than collecting information from leaflets. Distance to the practice and continuity of caregiver seemed to conflict for respondents.
Conclusions
Preferences change in the process of ageing and growing health problems. GPs and their co-workers should be also aware of the changing needs of the elderly regarding non-medical attributes of GP care. Meeting their needs regarding non-medical attributes of primary health care is important to improve the quality of care.
doi:10.1186/1471-2318-10-80
PMCID: PMC2984451  PMID: 21044316
7.  The course of untreated anxiety and depression, and determinants of poor one-year outcome: a one-year cohort study 
BMC Psychiatry  2010;10:86.
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.
doi:10.1186/1471-244X-10-86
PMCID: PMC2974663  PMID: 20961414
8.  Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations 
BMC Family Practice  2009;10:60.
Background
General practitioners' (GPs') feelings of burnout or dissatisfaction may affect their patient care negatively, but it is unknown if these negative feelings also affect their mental health care. GPs' available time, together with specific communication tools, are important conditions for providing mental health care. We investigated if GPs who feel burnt out or dissatisfied with the time available for their patients, are less inclined to encourage their patients to disclose their distress, and have shorter consultations, in order to gain time and energy. This may result in less psychological evaluations of patients' complaints.
Methods
We used 1890 videotaped consultations from a nationally representative sample of 126 Dutch GPs to analyse GPs' communication and the duration of their consultations. Burnout was subdivided into emotional exhaustion, depersonalisation and reduced accomplishment. Multilevel regression analyses were used to investigate which subgroups of GPs differed significantly.
Results
GPs with feelings of exhaustion or dissatisfaction with the available time have longer consultations compared to GPs without these feelings. Exhausted GPs, and GPs with feelings of depersonalisation, talk more about psychological or social topics in their consultations. GPs with feelings of reduced accomplishment are an exception: they communicate less affectively, are less patient-centred and have less eye contact with their patients compared to GPs without reduced accomplishment.
We found no relationship between GPs' feelings of burnout or dissatisfaction with the available time and their psychological evaluations of patients' problems.
Conclusion
GPs' feelings of burnout or dissatisfaction with the time available for their patients do not obstruct their diagnosis and awareness of patients' psychological problems. On the contrary, GPs with high levels of exhaustion or depersonalisation, and GPs who are dissatisfied with the available time, sometimes provide more opportunities to discuss mental health problems. This increases the chance that appropriate care will be found for patients with mental health problems. On the other hand, these GPs are themselves more likely to retire, or risk burnout, because of their dissatisfaction. Therefore these GPs may benefit from training or personal coaching to decrease the chance that the process of burnout will get out of hand.
doi:10.1186/1471-2296-10-60
PMCID: PMC2754435  PMID: 19706200
9.  Detecting depressive and anxiety disorders in distressed patients in primary care; comparative diagnostic accuracy of the Four-Dimensional Symptom Questionnaire (4DSQ) and the Hospital Anxiety and Depression Scale (HADS) 
BMC Family Practice  2009;10:58.
Background
Depressive and anxiety disorders often go unrecognized in distressed primary care patients, despite the overtly psychosocial nature of their demand for help. This is especially problematic in more severe disorders needing specific treatment (e.g. antidepressant pharmacotherapy or specialized cognitive behavioural therapy). The use of a screening tool to detect (more severe) depressive and anxiety disorders may be useful not to overlook such disorders. We examined the accuracy with which the Four-Dimensional Symptom Questionnaire (4DSQ) and the Hospital Anxiety and Depression Scale (HADS) are able to detect (more severe) depressive and anxiety disorders in distressed patients, and which cut-off points should be used.
Methods
Seventy general practitioners (GPs) included 295 patients on sick leave due to psychological problems. They excluded patients with recognized depressive or anxiety disorders. Patients completed the 4DSQ and HADS. Standardized diagnoses of DSM-IV defined depressive and anxiety disorders were established with the Composite International Diagnostic Interview (CIDI). Receiver Operating Characteristic (ROC) analyses were performed to obtain sensitivity and specificity values for a range of scores, and area under the curve (AUC) values as a measure of diagnostic accuracy.
Results
With respect to the detection of any depressive or anxiety disorder (180 patients, 61%), the 4DSQ and HADS scales yielded comparable results with AUC values between 0.745 and 0.815. Also with respect to the detection of moderate or severe depressive disorder, the 4DSQ and HADS depression scales performed comparably (AUC 0.780 and 0.739, p 0.165). With respect to the detection of panic disorder, agoraphobia and social phobia, the 4DSQ anxiety scale performed significantly better than the HADS anxiety scale (AUC 0.852 versus 0.757, p 0.001). The recommended cut-off points of both HADS scales appeared to be too low while those of the 4DSQ anxiety scale appeared to be too high.
Conclusion
In general practice patients on sick leave because of psychological problems, the 4DSQ and the HADS are equally able to detect depressive and anxiety disorders. However, for the detection of cases severe enough to warrant specific treatment, the 4DSQ may have some advantages over the HADS, specifically for the detection of panic disorder, agoraphobia and social phobia.
doi:10.1186/1471-2296-10-58
PMCID: PMC2753335  PMID: 19698153
10.  Patients with persistent medically unexplained symptoms in general practice: characteristics and quality of care 
BMC Family Practice  2007;8:33.
Background
Medically unexplained physical symptoms (MUPS) are common in general practice (GP), and are even more problematic as they become persistent. The present study examines the relationship between persistent MUPS in general practice on the one hand and quality of life, social conditions, and coping on the other hand. Additionally, it is examined how patients with persistent MUPS evaluate the quality of GP-care.
Methods
Data were used from a representative survey of morbidity in Dutch general practice, in which data from the electronic medical records were extracted. A random sample of patients participated in an extensive health interview and completed self-reported measures on social isolation, coping and the quality of GP-care. Patients with persistent MUPS (N = 192) were compared with general practice patients not meeting the criteria for persistent MUPS (N = 7.314), and with a group of patients that visited the GP in comparable rates for medical diagnoses (N = 2.265). Multiple logistic regression analyses were used to control for relevant socio-demographic variables and chronic diseases.
Results
After adjustment for demographics and chronic diseases, patients with persistent MUPS reported more psychological distress, more functional impairment, more social isolation, and they evaluated the quality of GP-care less positive than the other two patient groups. Although the majority of MUPS patients were positive about the quality of GP-care, they more often felt that they were not taken seriously or not involved in treatment decisions, and more often reported that the GP did not take sufficient time. The three groups did not differ with respect to the statement that the GP unnecessarily explains physical problems as psychological ones.
Conclusion
Strengthening MUPS patients' social network and encouraging social activities may be a meaningful intervention in which the GP may play a stimulating role. To further improve MUPS patients' satisfaction with GP-care, GPs may pay extra attention to taking sufficient time when treating MUPS patients, taking the problems seriously, and involving them in treatment decisions.
doi:10.1186/1471-2296-8-33
PMCID: PMC1894968  PMID: 17540013
11.  Does the attention General Practitioners pay to their patients' mental health problems add to their workload? A cross sectional national survey 
BMC Family Practice  2006;7:71.
Background
The extra workload induced by patients with mental health problems may sometimes cause GPs to be reluctant to become involved in mental health care. It is known that dealing with patients' mental health problems is more time consuming in specific situations such as in consultations. But it is unclear if GPs who are more often involved in patients' mental health problems, have a higher workload than other GPs. Therefore we investigated the following: Is the attention GPs pay to their patients' mental health problems related to their subjective and objective workload?
Methods
Secondary analyses were made using data from the Second Dutch National Survey of General Practice, a cross sectional study conducted in the Netherlands in 2000–2002. A nationally representative selection of 195 GPs from 104 general practices participated in this National Survey. Data from: 1) a GP questionnaire; 2) a detailed log of the GP's time use during a week and; 3) an electronic medical registration system, including all patients' contacts during a year, were used. Multiple regression analyses were conducted with the GP's workload as an outcome measure, and the GP's attention for mental health problems as a predictor. GP, patient, and practice characteristics were included in analyses as potential confounders.
Results
Results show that GPs with a broader perception of their role towards mental health care do not have more working hours or patient contacts than GPs with a more limited perception of their role. Neither are they more exhausted or dissatisfied with the available time. Also the number of patient contacts in which a psychological or social diagnosis is made is not related to the GP's objective or subjective workload.
Conclusion
The GP's attention for a patient's mental health problems is not related to their workload. The GP's extra workload when dealing in a consultation with patients' mental health problems, as is demonstrated in earlier research, is not automatically translated into a higher overall workload. This study does not confirm GPs' complaints that mental health care is one of the components of their job that consumes a lot of their time and energy. Several explanations for these results are discussed.
doi:10.1186/1471-2296-7-71
PMCID: PMC1693554  PMID: 17147799
12.  Mental health in the Dutch population and in general practice: 1987–2001 
Background
In the last 15 years, both the demand for and supply of specialised mental health care increased considerably in the Netherlands. Increased demand may reflect a change in psychological morbidity, but may also be a consequence of increased supply. Specialised health care in the Netherlands is accessible only through referral by a GP, and so it is important to consider the role of primary care in the diagnosis of mental health problems.
Aim
The aim of this study is to achieve a better understanding of the development of mental health status in the Dutch population and the consequent help-seeking behaviour in primary care.
Method
Using two comparable morbidity studies carried out in the Dutch population and in primary care, we compared data from 1987 and 2001 to assess the following: possible differences in mental health between 1987 and 2001; possible differences in prevalence of mental disorder as diagnosed by GPs in 1987 and 2001; possible differences in the sociodemographic determinants of mental health and mental disorder in primary care between 1987 and 2001.
Results
Our results show an increase in mental and social problems in the population between 1987 and 2001. However, GPs diagnosed fewer patients as having a mental disorder in 2001 than they did in 1987. The risk of mental disorders or social problems in several sociodemographic groups remained largely the same, as did the chance of receiving a psychological or social diagnosis.
Conclusion
We conclude that, while mental disorder in the population is increasing, the role of primary care has changed. Although GPs diagnose a lower percentage of mental problems as such, they refer an increasingly larger proportion of these to secondary care.
PMCID: PMC1562334  PMID: 16212852
diagnosis; mental health; referral rates
13.  The workload of GPs: consultations of patients with psychological and somatic problems compared 
Background
GPs report that patients' psychosocial problems play a part in 20% of all consultations. GPs state that these consultations are more time-consuming and the perceived burden on the GP is higher.
Aim
To investigate whether GPs' workload in consultations is related to psychological or social problems of patients.
Design of study
A cross-sectional national survey in general practice, conducted in the Netherlands from 2000–2002.
Setting
One hundred and four general practices in the Netherlands.
Method
Videotaped consultations (n = 1392) of a representative sample of 142 GPs were used. Consultations were categorised in three groups: consultations with a diagnosis in the International Classification of Primary Care chapter P 'psychological' or Z 'social' (n = 138), a somatic diagnosis but with a psychological background according to the GP (n = 309), or a somatic diagnosis and background (n = 945). Workload measures were consultation length, number of diagnoses and GPs' assessment of sufficiency of patient time.
Results
Consultations in which patients' mental health problems play a part (as a diagnosis or in the background) take more time and involve more diagnoses, and the GP is more heavily burdened with feelings of insufficiency of patient time. In consultations with a somatic diagnosis but psychological background, GPs more often experienced a lack of time compared to consultations with a psychological or social diagnosis.
Conclusion
Consultations in which the GP notices psychosocial problems make heavier demands on the GP's workload than other consultations. Patients' somatic problems that have a psychological background induce the highest perceived burden on the GP.
PMCID: PMC1463219  PMID: 16105369
general practice; mental health; referral and consultation; time factors; workload
14.  Measuring mental health of the Dutch population: a comparison of the GHQ-12 and the MHI-5 
Backgroud
The objective is to compare the performance of the MHI-5 and GHQ-12, both measures of general mental health. Therefore, we studied the relationship of the GHQ-12 and MHI-5 with sociodemographic characteristics, self-reported visits to general practice and mental health care, and with diagnoses made by the general practitioner.
Methods
Data were used from the Second Dutch National Survey of General Practice, which was carried out in 104 practices. This study combines data from a representative sample of the Dutch population with data from general practice.
Results
The agreement between the GHQ-12 and MHI-5 is only moderate. Both instruments are however similarly associated with demographic characteristics (except age), self-reported health care use, and psychological and social diagnoses in general practice.
Conclusions
The performance of the MHI-5 and GHQ-12 in terms of predicting mental health problems and related help seeking behaviour is similar. An advantage of the MHI-5 is that it has been widely used, not only in surveys of mental health, but also in surveys of general health and quality of life, and it is shorter. A disadvantage of the MHI-5 is that there is no cut-off point. We recommend a study to establish a valid, internationally comparable cut-off point.
doi:10.1186/1477-7525-2-23
PMCID: PMC428585  PMID: 15132745

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