Appropriate management of advanced dementia requires it to be recognised as a terminal condition that needs palliative care. Interventions during this stage should be carefully chosen to ensure the improvement or maintenance of the quality of life of the person with dementia. Advanced care planning is an important aspect of dementia care. Carers and relatives should be educated and encouraged to actively participate in discussions related to artificial nutrition, cardiopulmonary resuscitation (CPR) and other medical interventions.
advanced dementia; end-of-life care; palliative
Dementia is a major cause of disability and has immense cost implications for the individual suffering from the condition, family caregivers and society. Given the high prevalence of dementia in China with its enormous and rapidly expanding population of elderly adults, it is necessary to develop and test approaches to the care for patients with this disorder. The need is especially great in rural China where access to mental healthcare is limited, with the task made more complex by social and economic reforms over the last 30 years that have transformed the Chinese family support system, family values and health delivery systems. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for discussion of innovative approaches in the management of dementia in rural China, with particular focus on its implementation in the primary care system.
collaborative care; chronic disease management; dementia; rural China
This review considers key areas in primary care regarding the diagnosis of dementia. Issues surrounding assessment, policy and incentives are considered. In addition, the relevance of non-medication approaches for dementia in primary care, which aim to enhance or maintain quality of life by maximising psychological and social function in the context of existing disabilities, is deliberated. Finally, key issues about primary care medication management are considered, and relevant therapeutic strategies with recommendation for a collaborative approach that improve outcomes by linking primary and secondary healthcare services – including general practice and pharmacy – with social care needs are weighed up. A key aspect of such a collaborative approach is to support informal carers in optimising medication.
dementia; diagnosis; medication; primary care; psychosocial
Introduction Elderly patients occupy up to 65% of acute hospital beds and a significant proportion of them present with a comorbid psychiatric condition such as depression, delirium or dementia. Liaison old age psychiatry (LOAP) services have been developed to provide psychiatric consultation in medical and surgical settings, improving at the same time the knowledge and expertise of general ward staff.
Objective The aim of this study is to evaluate clinical characteristics across different psychiatric disorders among elderly patients in medical wards.
Method A prospective observational study was developed between October 2011 and January 2013, which involved 107 subjects aged 65 years or older that were hospitalised in the Department of Internal Medicine and referred to the LOAP service. Psychiatric diagnostic was assessed using the Confusion Assessment Method, the Geriatric Depression Scale, the Mini-Mental State Examination and the Clinical Global Impression Scale.
Results Delirium (40.6%), depression (22.4%) and dementia (20.4%) were the most common psychiatric diagnoses. Patients with delirium were significantly older, had more severe psychiatric symptomatology (mean CGI = 5.35) and presented infectious processes as acute medical conditions more frequently than the other patients.
Conclusion Psychiatric disturbances occurring in elderly inpatients in medical wards are highly prevalent and complex. A LOAP service may play an important role in effectively reducing the overutilisation and consumption of health resources through early recognition of these conditions, effective management and prevention of adverse outcomes, and effective communication with out-patient clinics, community mental health teams and day-care centres.
delirium; geriatric psychiatry; liaison
Bereavement in the elderly is a concern to primary care physicians (PCPs) as it can lead to psychological illness such as depression. Most people are able to come to terms with their grief without any intervention, but some people are not. This case highlights the importance of early recognition of bereavement-related depressive illness in elderly people. PCPs need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the family members' burden and suffering.
bereavement; depression; primary care physician
Background Recruitment rates of general practitioners (GPs) to do research vary widely. This may be related to the ability of a study to incorporate incentives for GPs and minimise barriers to participation.
Method A convenience sample of 30 GPs, ten each from the Sydney intervention and control groups Ageing in General Practice ‘Detection and Management of Dementia’ project (GP project) and 10 GPs who had refused participation, were recruited to determine incentives and barriers to participating in research. GPs completed the 11-item ‘Meeting the challenges of research in general practice: general practitioner questionnaire’ (GP survey) between months 15 and 24 of the GP project, and received brief qualitative interviews from a research GP to clarify responses where possible.
Results The most important incentives the 30 GPs gave for participating in the project were a desire to update knowledge (endorsed by 70%), to help patients (70%), and altruism (60%). Lack of time (43%) was the main barrier. GPs also commented on excessive paperwork and an inadequate explanation of research.
Conclusions While a desire to update knowledge and help patients as well as altruism were incentives, time burden was the primary barrier and was likely related to extensive paperwork. Future recruitment may be improved by minimising time burden, making studies simpler with online data entry, offering remuneration and using a GP recruiter.
general practitioner; recruitment; research
Complaints of depression and anxiety are very common among adult patients seeking treatment in primary care settings, and primary care providers prescribe the majority of medications for these conditions. Psychiatrists are often asked to evaluate and manage patients with major depression or anxiety disorders who have not improved after treatment in primary care.
We highlight ten frequently overlooked aspects of the care of patients who present with depression and anxiety in primary care. Chief among these aspects is the consideration of a thorough differential diagnosis, particularly bipolar disorder, psychotic disorders, dementia and substance abuse, each of which requires specific treatment approaches. Additional considerations include avoidance of medications or doses that may aggravate anxiety symptoms and regular follow-ups to assess symptomatic and functional improvement. Finally, it is important to actively manage the treatment through dose escalation, switching medications or employing additional treatment components until remission is achieved.
Judicious use of benzodiazepine clonazepam and appropriate referrals to psychotherapy can contribute to optimal treatment outcomes.
antidepressive agents; anxiety disorders; depressive disorder; medical errors; primary healthcare
Context Medically unexplained physical symptoms (MUPS) are frequently encountered in family medicine, and lead to disability, discomfort, medicalisation, iatrogenesis and economic costs. They cause professionals to feel insecure and frustrated and patients to feel dissatisfied and misunderstood. Doctors seek answers for rather than with the patient.
Objectives This study aimed to explore patients' explanations of the medically unexplained physical symptoms that they were experiencing by eliciting their own explanations for their complaints, their associated fears, their expectations of the consultation, changes in their ideas of causality, and the therapeutic approach that they considered would be useful.
Methodology A qualitative analysis was under-taken of interviews with 15 patients with MUPS in a family medicine unit, 6 months after diagnosis.
Results Experience is crucial in construction of the meaning of symptoms and illness behaviour. Many patients identify psychosocial causes under-lying their suffering. These patients received more medication and fewer requests for diagnostic examinations than they had expected. Normalisation is a common behaviour in the clinical approach. Normalisation without explanation can be effective if an effective therapeutic relationship exists that may dispense with the need for words. Listening is the procedure most valued by patients. Diagnostic tests may denote interest in patients' problems. The clinician's flexibility should allow adaptation to the patient's phases of acceptance of the significance of their physical, emotional and social problems.
Conclusion Patients with MUPS have explanations and fears associated with their complaints. The patient comes to the consultation not because of the symptom, but because of what he or she thinks about the symptom. The therapeutic relationship, therapeutic listening, and flexibility should be the basis for approaching patients with MUPS. Patients do not always expect medication, although it is what they most often receive. Diagnostic tests, although used sparingly, can be a way to maintain and build a relationship. Drugs and tests can be a ritual statement of clinical interest in the patient and their symptoms.
communication; physician-patient relationship; primary healthcare; qualitative research; somatoform disorders
Objectives Somatoform disorders are common in international primary care settings, but have been little studied in the developing world. The objective of this study was to determine the prevalence of severe undifferentiated somatoform disorder, and its relationship to depression and anxiety, among patients attending walk-in clinics in Trinidad.
Methods The study participants, who were all aged 18 years or older and attending walk-in clinics at 16 randomly selected health centres, were surveyed between May and August 2007 using the PRIME-MD questionnaire.
Results There were 594 participants (the response rate was 92%), of whom 72.7% were female. Their ages ranged from 18 to 93 years, and 54.5% were over 50 years of age. In total, 37.2% were married and 25.9% were single. Indo-Trinidadians represented 43.1% and Afro-Trinidadians represented 36% of the study sample; 56.5% of the participants reported that their income was less than US$ 400 per month, and 65.7% were unemployed. At walk-in clinics in Trinidad, the estimated prevalence of severe undifferentiated somatoform disorder was 10.3% (95% CI: 7.86–12.74), that of hypochondriasis was 28.5% (95% CI: 24.9–32.1), and that of body dysmorphic disorder was 15.8% (95% CI: 11.9–18.7). Severe undifferentiated somatoform disorder was statistically significantly associated with gender and ethnicity but not with age, level of education, employment status or income. Chi-square testing found significant associations between the presence of severe undifferentiated somatoform disorder and both depression and anxiety (P < 0.05), between hypochondriasis and both anxiety and depression (P < 0.05), and between body dysmorphic disorder and depression (P < 0.05) but not anxiety. Regression analysis suggested that the demographic features that predicted severe undifferentiated somatoform disorder were being female or Indo-Trinidadian.
Conclusions Walk-in clinics in Trinidad that serve older patients on a lower income have a high proportion of patients with somatoform disorders as measured by the PRIME-MD scale. These patients exhibit many features of anxiety and depression. These findings have implications for medical training and service delivery.
body dysmorphic disorder; hypochondriasis; primary care; somatoform disorders
Approximately 200 Family Health Teams (FHTs) have been implemented in Ontario to improve access to primary healthcare, including mental health and addiction. The objectives of this project were to examine, through a focus group and qualitative methodology with three FHTs, the profile of patients' mental health and addiction-related needs and to identify the implications for the development of core competencies in these innovative organisations. A spectrum of needs and service trajectories was identified, as well as the importance of a wide range of clinical skills and knowledge. The results indicate that ‘core’ competencies for mental health work in the context of an FHT go well beyond those required for an embedded mental health ‘programme’ or specialised mental health counsellors, but rather they relate to the core and discipline-specific competencies of members of the entire team. In addition to specific knowledge and skills, competencies include common attitudes and values relating to teamwork, good communication and collaboration. Challenges were noted with regard to working with some community service providers, especially addiction services. Implications for core competencies at the individual and organisational level were identified.
addictions; collaborative care; core competencies; family health teams; mental health
Background General practitioners often encounter patients with medically unexplained symptoms. These patients share many common features, but there is little agreement about the best diagnostic framework for describing them.
Aims This study aimed to explore how GPs make sense of medically unexplained symptoms.
Design Semi-structured interviews were conducted with 24 GPs. Each participant was asked to describe a patient with medically unexplained symptoms and discuss their assessment and management.
Setting The study was conducted among GPs from teaching practices across Australia.
Methods Participants were selected by purposive sampling and all interviews were transcribed. Iterative analysis was undertaken using constructivist grounded theory methodology.
Results GPs used a variety of frameworks to understand and manage patients with medically unexplained symptoms. They used different frameworks to reason, to help patients make sense of their suffering, and to communicate with other health professionals. GPs tried to avoid using stigmatising labels such as ‘borderline personality disorder’, which were seen to apply a ‘layer of dismissal’ to patients. They worried about missing serious physical disease, but managed the risk by deliberately attending to physical cues during some consultations, and focusing on coping with medically unexplained symptoms in others. They also used referrals to exclude serious disease, but were wary of triggering a harmful cycle of uncoordinated care.
Conclusion GPs were aware of the ethical relevance of psychiatric diagnoses, and attempted to protect their patients from stigma. They crafted helpful explanatory narratives for patients that shaped their experience of suffering. Disease surveillance remained an important role for GPs who were managing medically unexplained symptoms.
diagnosis; general practice; mental health; somatoform disorders; uncertainty
The findings reported here form part of a larger research project that examined non-compliance with medication among the mentally ill patients attending public clinics in a specific parish in Jamaica. The aim of the research was to explore the perceptions of caregivers about caring for the mentally ill at two outpatient psychiatric clinics. Caregivers involved in looking after their relatives with mental illness played a vital role in mental health promotion. This study sought to examine the caregivers' perception of mental illness, including how they thought the illness was best controlled, the reasons why their relatives found it difficult to take their medication as instructed, and the coping skills that they employed when caring for their relatives. There were two focus groups, consisting of four individuals each, at two psychiatric clinics.
The results revealed the following about the majority of the caregivers. First, it was recognised that caregivers have a good knowledge (and awareness) of medication usage inferred by either the absence or the presence of their relatives' symptoms. Secondly, they sometimes felt sad and hopeless as a result of being the victims of violent attacks by those for whom they provided care. Thirdly, they highlighted issues of cost, accessibility and availability of medications as being problematic. Fourthly, in some cases they received little or no assistance from other family members.
caregivers; family; Jamaica; medication; mental illness; relationship
Background Antonovsky's concept of sense of coherence (SOC) has been suggested to relate to health, especially mental health and preventive health behaviours. Psychological distress has been identified as a risk factor for pre-diabetes and type 2 diabetes mellitus. The study of SOC and diabetes has not received much attention in Greece. This study aims to explore the extent to which type 2 diabetes mellitus can affect the SOC score.
Methods An observational design was used to test the study hypothesis that individuals with type 2 diabetes mellitus would have a lower SOC than those without diabetes mellitus. A total of 202 individuals were studied, consisting of 100 people with diabetes mellitus (the study group) and 102 people with non-chronic orthopaedic conditions (the control group). All of the participants were patients of the Diabetic Clinic or the Orthopaedic Clinic of Livadia Hospital in Central Greece. SOC was assessed using a 29-item SOC questionnaire that had been translated into Greek and validated.
Results Patients without type 2 diabetes mellitus had 2.4 times higher odds of having a high SOC score than patients with type 2 diabetes mellitus (P = 0.036; odds ratio [OR] = 2.35, 95% confidence interval [CI] = 1.06–5.23). Male patients had 3.9 times higher odds of having a high SOC score (P < 0.001; OR = 3.85, 95% CI = 1.71–8.67) than female patients. With regard to education, patients with a lower level of education had almost three times higher odds of having a high SOC score than patients with a higher level of education (P = 0.024; OR = 2.97, 95% CI = 1.15–7.67).
Conclusions This study adds to the existing literature and indicates that SOC is a health asset. A study with an experimental design would clarify the interesting hypothesis of this study.
diabetes; sense of coherence; survey
Objective The primary aim of this study was to determine whether enrolment in collaborative care management (CCM) for treatment of major depression would have a significant impact on 6-month changes in weight compared with patients treated by their primary care provider with usual care. The secondary aim was to determine whether clinical remission would also affect 6-month weight changes.
Design A retrospective chart review study included 1550 patients who had been diagnosed with major depression or dysthymia and who had a Patient Health Questionnaire (PHQ-9) score of ≥ 10 with follow-up data (PHQ-9 score and weight) at 6 months.
Subjects The study sample consisted of adult patients (aged ≥ 18 years) from primary care practices, representing all body mass index (BMI) categories. The exclusion criteria were a diagnosis of bipolar disorder, recent obstetric delivery or recent gastric bypass procedure.
Measurements Weight was measured at index and 6 months, with BMI calculated from electronic medical record data. Patient assessment data (including PHQ-9 score and clinical diagnosis) and demographic variables (age, gender, marital status and clinical location) were also collected.
Results With regression modelling, neither enrolment in CCM (P = 0.306) nor clinical remission (P = 0.828) was associated with a significant weight gain.
Conclusion After 6 months, enrolment in CCM had no significant impact on weight gain or weight loss among patients treated for depression, nor was improvement to clinical remission a factor in the patient's weight after 6 months. Incorporating a weight loss management intervention within the model may be warranted if concomitant weight reduction is desired.
collaborative care management; depression; obesity; primary care
Background Slovenian psychiatry is predominantly hospital based. A programme for the development of general community psychiatric services was proposed to improve access to and quality and comprehensiveness of psychiatric care according to the modern standards of delivery of psychiatric services.
Aim The aim of the paper is to present the programme for developing community services that was proposed to the Slovenian government, and to describe the barriers to its implementation that were encountered, as well as the errors made by the programme authors, that contributed to the rejection of the programme last year.
Conclusions There are historical, political, professional and service organisation characteristics that impede the development of community psychiatry in Slovenia. These are to be addressed through coordinated action involving primary care professionals, non-government organisations with service users and carers, the Health Insurance Agency and politicians involved in the planning of health services.
community mental health teams; primary mental healthcare; public mental health indicators
Aims and methods It is now well established that antipsychotic medications are associated with adverse effects such as metabolic dysfunction, hyperprolactinaemia and cardiac arrhythmias. We completed an audit cycle between 2008 and 2010 to assess whether the implementation of a high-visibility prompt and an educational programme would improve monitoring rates among patients prescribed regular antipsychotics admitted to a 59-bedded psychiatric hospital in West Sussex.
Results There was an improvement in monitoring rates for most audit standards. The greatest improvement was seen in measurement of random plasma glucose and cholesterol levels. Rates improved irrespective of the risk of metabolic dysfunction. However, prolactin measurement remained static and the ECG recording deteriorated.
Clinical implications There appears to be a growing awareness of the need to screen for metabolic dysfunction among patients prescribed regular antipsychotic medication. A high-visibility prompt and educational programme helps to increase monitoring rates. However, more needs to be done to improve the mortality and morbidity rates among this patient subpopulation.
antipsychotic medication; metabolic dysfunction; monitoring
The present study was conducted primarily to determine the occurrence of polypharmacy in patients with schizophrenia on risperidone. The secondary aim was to ascertain the incidence of inappropriate prescribing with anticholinergics. A retrospective review of the medical records of all patients who were being followed up at the out-patient clinic of a tertiary-care hospital in Malaysia was conducted. Only patients who were being prescribed risperidone between 1 June 2008 and 31 December 2008 were included in the study. Demographic data such as patient’s age, gender and race were obtained from the patient’s medical records. In total, 113 patients met the selection criteria. Polypharmacy was found to occur in 34 patients (30.09%), with the majority (76.47%) being on two antipsychotics. In total, 27 patients (34.18%) on monotherapy with risperidone were prescribed an anticholinergic on scheduled dosing, while 19 patients (24.05%) were prescribed it on an as-needed basis. Of the patients on polypharmacy, 26 (76.47%) were on scheduled dosing of anticholinergics, while three (8.82%) were taking the medication on an as-needed basis. Polypharmacy should be avoided, and the use of anticholinergics should be closely reviewed. By adopting more efficient prescribing practices, costs can be reduced and financial resources can instead be channelled towards more beneficial areas for the patients.
anticholinergic; antipsychotic; polypharmacy; risperidone; schizophrenia
Background and objectives The purpose of this paper is to describe the use of resident performance on an observed structured clinical examination (OSCE) as a tool to refine a mood disorders curriculum, and to disseminate a mood disorders OSCE for use in other residency settings.
Methods A depression-focused OSCE and a direct observation evaluation tool were developed and implemented. A total of 24 first-year family medicine residents (PGY1) participated in the OSCE, and their performance was used to direct changes in a mood disorders curriculum.
Results Residents performed well on general interview behaviours, and 67% were able to uncover depression in a patient presenting with headaches. Less than 50% of the residents asked about suicidal ideation and recreational drug use. Curriculum was added that addressed the latter deficiencies.
Conclusions Tracking of resident performance on specific behaviours during OSCE sessions can be used for curriculum evaluation purposes. The mood disorders curriculum in additional family medicine residency programmes can now be evaluated using our depression-focused OSCE and Clinical Performance Checklist.
depression; OSCE; residency education
Aims This study aimed to examine the effectiveness of a primary care adult mental health service operating within a stepped care model of service delivery.
Methods Supervised by a principal psychologist manager, psychology graduate practitioners provided one-to-one brief cognitive behavioural therapy (CBT) to service users. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was used to assess service user treatment outcomes. Satisfaction questionnaires were administered to service users and referring general practitioners (GPs).
Results A total of 43 individuals attended for an initial appointment, of whom 19 (44.2%) completed brief CBT treatment. Of the 13 service users who were in the clinical range pre-treatment, 11 (84.6%) achieved clinical and reliably significant improvement. Of the six service users who were in the non-clinical range pre-treatment, three (50%) achieved reliably significant improvement. Both service users and GPs indicated high levels of satisfaction with the service, although service accessibility was highlighted as needing improvement.
Conclusion The service was effective in treating mild to moderate mental health problems in primary care. Stricter adherence to a stepped care model through the provision of low-intensity, high-throughput interventions would be desirable for future service provision.
brief CBT; service evaluation; stepped care model