Objective To assess the frequency and predictors of regular monitoring of metabolic parameters as recommended by the American Diabetes Association (ADA)/American Psychiatric Association (APA) guidelines in adolescents receiving antipsychotics compared with an untreated comparison group in a primary care setting.
Method A retrospective cohort study was conducted using an electronic medical record database in the USA from January 2004 to July 2009. The exposure group consisted of adolescents with a first prescription for second-generation antipsychotics (SGAs). The comparison group, without antipsychotics, was matched (3:1) to the exposed. Baseline and follow-up metabolic measurements were assessed and patients were categorised as being regularly monitored based on recommendations by the ADA/APA guidelines. Multivariate logistic regression was conducted to assess the predictors of regular monitoring, adjusting for demographic characteristics, baseline medications and medical conditions.
Results The frequency of regular monitoring of body mass index (BMI), blood pressure, total cholesterol and fasting blood glucose, as recommended by ADA/APA guidelines among antipsychotic users (25, 55, 2.4 and 1.7%) was low but significantly higher compared with the matched comparison group (9.5, 37.4, 0.8 and 0.7%, respectively) (P < 0.05). Overall, antipsychotic treatment was associated with 1.5- to 4.26-fold increase in the likelihood of metabolic monitoring compared with the comparison group (P < 0.05). Other predictors included oral antidiabetic use for BMI monitoring and dyslipidaemia for blood pressure, total cholesterol and fasting blood glucose.
Conclusion The majority of adolescents on antipsychotics were under-monitored for BMI, lipids and glucose levels. Antipsychotic users with pre-existing and newly diagnosed metabolic conditions were more likely to be regularly monitored for metabolic parameters.
adolescents; antipsychotics; guidelines; metabolic monitoring; primary care
Background There is evidence that the National Institute for Health and Clinical Excellence (NICE) guidelines for mental health disorders are used to varying degrees in primary care. A lack of access to cognitive–behavioural therapy (CBT) has been found to be a barrier to their implementation. The Improving Access to Psychological Therapies (IAPT) initiative was created in 2007 to increase the availability of NICE-recommended psychological treatments for depression and anxiety disorders within the National Health Service in England.
Aim This study aims to investigate whether general practitioners (GPs) who have access to IAPT services and use NICE guidelines are more likely to use NICE concordant treatments for depression than those who do not. Depression was chosen as it is the most common mental health problem facing primary care physicians.
Method Questionnaires were sent to 830 GPs in southeast England and six GPs were interviewed. The response rate to the questionnaires was 27% (n = 222).
Results Ninety-five per cent of GPs were aware of the NICE guidelines for depression, and 76% had read them. Concordance with the guidelines was significantly higher when GPs had access to a local IAPT service or had read the NICE guidelines.
Conclusions The interviews revealed favourable views to IAPT services when used, although access to treatments was still a common barrier to the implementation of the NICE guidelines for depression.
clinical guidelines; depression; evidence-based treatments
Background The mental health functioning of military spouses and intimate partners prior to the combat deployments of their loved ones is poorly studied.
Aims Whereas service members and veterans often receive healthcare directly from the military or the Department of Veterans Affairs, family members may be more likely to present in family care settings. An understanding of mental health problems commonly occurring in this population is therefore important.
Method National Guard soldiers and their spouses or cohabitating partners (n = 223 couples) were surveyed about mental health symptoms, social functioning and mental health service utilisation one to two months prior to a combat deployment to Afghanistan.
Results Screening rates for partner post-traumatic stress disorder, depression, alcohol problems and social impairment were 2.4, 15.3, 3.7 and 10.7%, respectively, and were significantly higher for partners than soldiers with regards to depression and social impairment. The majority of partners screening positive for psychiatric distress did not report utilising mental health services or military support services (i.e. family readiness groups). Clinical implications are discussed.
combat deployment; deployment cycle; depression; family well-being; PTSD
Kabuki syndrome (KS) is a rare genetic disorder first diagnosed in 1981. Unknown by most primary care physicians and clinicians in the mental health fields, children with KS present with unique facial characteristics, mental retardation, health problems and socio-emotional delays that are often mistaken for other diagnostic problems. Literature detailing the psychological and psychosocial features of this disorder is scant, and psychotherapeutic approaches have not been described. In this article, we present a case description and treatment of a child with KS and her family. A brief review of KS is then provided, highlighting its signs and symptoms. Factors related to differential diagnoses are identified to aid primary care and mental health clinicians in better understanding this unique syndrome. Interventions with similar populations are discussed from which a psychological approach to KS is suggested. Finally, implications for primary care physicians are described and suggestions for further research indicated.
differential diagnosis; Kabuki syndrome; psychosocial treatment
Background Child abuse survivors have an increased risk of developing various mental illnesses in adulthood, which may lead survivors to access primary healthcare services, in particular primary care mental health services.
Aim To determine the frequency with which different primary care mental health practitioners encounter child abuse survivors in their practice and differences in their views about routine screening, level of importance, confidence and comfort in screening and supporting survivors, a cross-sectional study was conducted with 186 practitioners.
Method The sample consisted of general practitioners (13.9%), psychologists (67.9%) and other professions such as psychiatrists, social workers, counsellors, psychotherapists, mental health nurses and other specific mental health practitioners (18.2%).
Results Over 91% of practitioners reported that child abuse was a healthcare issue and was a problem for women in their practice. However, only 51.4% believed that women should be routinely screened for child abuse experiences. Significant differences among practitioner groups were found in aspects of screening and responding to survivors. General practitioners were significantly less likely to screen routinely and reported lower levels of confidence and comfort in conducting screening of survivors when compared with psychologists and other practitioners. The majority of practitioners saw it as psychologists' role to routinely screen; however, 57–82% of practitioners within each group reported that they would benefit from further training in areas relating to asking about and supporting survivors.
Conclusion Findings highlighted further education as a potential area of need to enhance the knowledge and capacity of different practitioner groups in responding to women survivors of child abuse.
child abuse survivors; primary care practitioners; screening
Background Mindfulness-based cognitive therapy (MBCT) is an intervention developed for the prevention of recurrent depression which is now being applied to widening numbers of clinical populations. Despite evidence for its effectiveness in preventing relapse in depression, less is known about its efficacy within routine clinical practice for groups of patients with more varied mental health problems, despite this being a potentially promising context for its application.
Aims This pilot study aimed to investigate whether MBCT would be feasible and effective when delivered in a primary care context for patients who are vulnerable to recurrent depression and anxiety.
Results Attrition from the programme was low and both attendance and engagement with home practices (during and after the intervention) were comparable with or higher than those observed in the existing literature. Improvements in self-reported depression, anxiety, rumination, self-compassion and well-being were evident over the 8-week programme and at 6-month post intervention follow-up.
Conclusions Despite limitations in terms of sample size and the absence of a control group, the results demonstrate that the promising research results of MBCT for depression are transferable from a research to a practice setting, and demonstrate that it may be an effective and feasible intervention when delivered in a primary care setting for a range of mental health problems.
depression and anxiety; MBCT; primary care
Background General practitioners (GPs) often see patients presenting with mental health problems, but their training regarding mental health treatment varies. GPs' communication skills are of particular importance in these consultations, and communication skills training of GPs has been found to improve patients' mental health. To tailor a communication skills training by basing it on GPs' learning needs and self-efficacy, thereby maximising learning, we conducted a questionnaire study.
Objective To measure GPs' self-perceived needs regarding communication with and treatment of mental health patients.
Methods GPs in training for specialist general practice were given a questionnaire on communication and mental health in general practice. The questionnaire measured prevalence, referring practices, self-efficacy and self-perceived learning need regarding mental health treatment and communication skills, as well as interest in attending training.
Results A majority of GPs in our sample was interested in training on communication skills and mental health treatment. However, they reported moderate learning needs and high confidence on the different measures. GPs reported highest learning needs regarding specific communication skills and treatment of the most common mental health problems. At the same time, they reported highest self-efficacy in treating the same disorders. They also reported high confidence in communication skills.
Conclusion Despite being confident, GPs in this sample recognise the need for specific skills in consultations with patients with mental health problems, but may underestimate the importance of general communication skills. These results are informative when designing training for GPs in communication and mental health.
communication; general practice; mental health
Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed.
Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation.
Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients.
Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.
collaborative care; GP mental healthcare practice; mental disorders; mental primary healthcare; shared care
Introduction Depression is highly prevalent and has a considerable impact on the quality of life of affected individuals, and on healthcare resources. Evidence indicates that collaborative care models can improve patient outcomes within a primary care setting. The Primary Care Services Improvement Project (PCSIP) aims to investigate the costs and outcomes of different models of care for the management of patients with depression. These models have been defined based on the level of involvement of practice nurses in management processes within the primary care setting in Australia. This paper describes our study protocol and its progress.
Methods PCSIP is an observational study that will link retrospective data from a range of sources to estimate costs and intermediate outcomes (such as relapse rate) over a 3-year time horizon. The main sources of primary data include the medical records of patients held at participating practices and Medicare Australia.
Initial report We recruited 15 practices from a metropolitan area and allocated them to three models of care. Two hundred and sixty-one patients agreed to participate. Appropriate regression-based analyses will be used to evaluate the association between different models of care and patient-level outcomes while controlling for several covariates such as age and gender.
Discussion/conclusions This project will generate the knowledge required to promote investment in the most cost-effective initiatives, and to ensure that waste of resources due to the implementation of comparatively inefficient interventions is minimised. Given the scarcity of resources, the increasing costs of providing healthcare and the increasing prevalence of chronic diseases, such research is essential.
Australia; depression; economic evaluation; incentive programmes
Aim The impact of initial severity of depression on the rate of remission has not been well studied. The hypothesis for this study was that increased depression severity would have an inverse relationship on clinical remission at six months while in collaborative care management.
Participants The study cohort was 1128 primary care patients from a south-eastern Minnesota practice and was a longitudinal retrospective chart review analysis.
Results Clinical remission at six months was less likely in the severe depression group at 29.6% compared with 36.9% in the moderately severe group and 45.6% in the moderate depression group (P < 0.001). Multivariate analysis of a sub-group demonstrated that increased initial anxiety symptoms (odds ratio [OR] 0.9645, 95% confidence interval [CI] 0.9345–0.9954, P = 0.0248) and an abnormal screening for bipolar disorder (OR 0.4856, 95% CI 0.2659–0.8868, P = 0.0187) predicted not achieving remission at six months. A patient with severe depression was significantly less likely to achieve remission at six months (OR 0.6040, 95% CI 0.3803–0.9592, P = 0.0327) compared with moderate depression, but not moderately severe depression (P = 0.2324). There was no statistical difference in the adjusted means of the PHQ-9 score for those patients who were in remission at six months. However, in the unremitted patients, the six-month PHQ-9 score was significantly increased by initial depression severity when controlling for all other variables.
Conclusion Multivariate analysis in our study demonstrated that patients with severe depression have a decreased OR for remission at six months compared with moderate depression. Also, there was a significant increase in the six-month PHQ-9 score for those unremitted patients in the severe vs. moderate depression groups.
collaborative care management; depression; primary care
Purpose The association between intimate partner violence (IPV) and depression has been well established in cross-sectional research, but how IPV is associated with depressive symptoms over time has not been well studied.
Methods Using the Central Pennsylvania Women's Health Study, a population-based longitudinal survey of women aged 18–45 (N = 1,420), we performed a two-step logistic regression analysis. In step 1, the association of recent IPV exposure at baseline with depressive symptoms 2 years later was analysed adjusting for relevant covariates; in step 2, we additionally included positive coping strategies (social support, physical activity) and negative coping strategies (binge drinking/drug use, smoking) in the model.
Results Baseline IPV was reported by 4.6 percent of the sample and was independently associated with depressive symptoms 2 years later (adjusted or 1.88, 95% confidence interval [CI] 1.02–3.45). The strongest predictor was depressive symptoms at baseline, which was associated with a fivefold increase in the likelihood of depressive symptoms at 2-year follow-up. Other predictors of future depressive symptoms were IPV at follow-up, older age, lower educational attainment, and lower household income. When we controlled for potential coping strategies in the model (step 2), the relationship between recent IPV and follow-up depressive symptoms was attenuated (adjusted OR 1.50, 95% CI 0.80–2.80).
Conclusions Exposure to IPV increases the likelihood of depressive symptoms occurring two years later. Greater social support and binge drinking/drug use attenuates this association, suggesting that interventions focusing on coping mechanisms may serve to reduce the impact of IPV on future depression.
depression; depressive symptoms; domestic violence; intimate partner violence
Background General practitioners (GPs) play a key role in assessing and managing adult mental health problems, but this input is not seen in their management of child and adolescent mental health. Mental health problems in 5–19-year-olds are common, yet detection rates in primary care are low. The symptoms of most adult diagnoses of mental health problems are present by mid-adolescence, yet the typical time from onset to diagnosis is 5–15 years. The role of general practice in this area has been underexplored.
Aim This pilot study explores the potential of GPs to respond to common mental health problems in children and adolescents.
Design Children and young people who would have ordinarily been referred to Child and Adolescent Mental Health Services (CAMHS) were seen in a GP setting. In a UK general practice surgery serving a disadvantaged population.
Method Children and young people were seen for an initial biopsychosocial assessment and formulation of the presenting concerns. GP-based interventions were offered as appropriate or referred to CAMHS.
Results Data from the first 50 children (2–19 years) are presented. Twenty younger children (10 years and under) and 30 older children (11 years and above) were seen. Eighteen referrals were made to CAMHS. GP interventions included watchful waiting, brief behavioural interventions, non-directive counselling, brief cognitive– behavioural therapy (CBT) and liaison with colleagues in education, CAMHS and the voluntary sector.
Conclusion This clinical pilot demonstrates that with adequate time, access to supervision and practice support, children and young people experiencing emotional and behavioural problems associated with common mental health issues can be helped in primary care.
common child and adolescent mental health problems; early intervention in primary care; GP involvement
Background There is a lack of instruments to measure the needs, stigma and informal care of people with schizophrenia that take account of sociocultural variation and patients' and formal and informal carers' opinions and experiences.
Aims To develop questionnaires to measure stigma, needs and informal (non-professional) care for people with schizophrenia.
Method We undertook the study in seven countries and in English, Spanish and Portuguese. We first held focus group discussions with patients, formal carers (professionals) and informal carers (family and friends) in Spain, the UK, Argentina, Brazil, Chile and Venezuela to elicit the main dimensions of needs, stigma and informal care. We then held nominal group discussions about these dimensions with patients, family members and professionals in Spain, Portugal and the UK, to develop the instruments.
Results Three hundred and three people participated in 46 focus groups and results were discussed in three nominal groups, each involving eight participants. Three instruments were developed in this iterative process: needs for care (46 items), stigma (38 items) and informal care (20 items).
Conclusions These instruments are based on service users' and carers' views and experiences and have cross-cultural validity. They will have application in assessment of outcomes for people with schizophrenia and their families.
assessment; informal care; needs; schizophrenia; stigma
Background There is a huge unmet need for mental health services in low- and middle-in-come countries such as Nigeria. It has been suggested that one way of bridging the service gap is to plan for the effective integration of mental health services into primary care. We present the impact of a one-week training workshop on attitudes to and knowledge of mental health issues among the tutors of community health workers.
Method An intensive one-week training workshop was organised for 24 trainers of community health officers from eight Nigerian states. The package was designed for the training of primary care workers in low-income countries by one of the authors (RJ). Participants completed a questionnaire designed to assess knowledge of and attitudes to mental health issues before and on completion of the training.
Results There were 24 participants with a mean age of 47 years (SD ± 4.89). Eighteen (75%) of the participants were female. The overall assessment of knowledge of mental health issues increased from a mean score of 60.4% before training to a mean score of 73.7% after the training (t-test = 4.48, P = 0.001).
Conclusion We reported a significant improvement in the knowledge and attitudes of tutors of community health workers following an intensive one-week training workshop. This, we believe, should improve the quality of pre-service mental health training for community health workers and hopefully impact on mental health service delivery at the primary healthcare level.
community health workers; long-term impact; training of trainers
Introduction Sri Lanka has one of the highest suicide rates in the world, with recent protracted conflict and the tsunami aggravating mental health needs. This paper describes a project to establish a systematic “train the trainers” programme to integrate mental health into primary care in Sri Lanka's public health system and private sector.
Methods A 40 hour training programme was delivered to curriculum and teaching materials were adapted for Sri Lanka, and delivered to 45 psychiatrists, 110 medical officers of mental health and 95 registered medical practitioners, through five courses, each in a different region (Colombo, Kandy, Jaffna, Galle and Batticola). Participants were selected by the senior psychiatrist of each region, on the basis of ability to conduct subsequent roll out of the training. The course was very interactive, with discussions, role plays and small group work, as well as brief theory sessions.
Results Qualitative participant feedback was encouraging about the value of the course in improving patient assessments and treatments, and in providing a valuable package for roll out to others. Systematic improvement was achieved between pre- and post-test scores of participants at all training sites. The participants had not had prior experience in such interactive teaching methods, but were able to learn these new techniques relatively quickly.
Conclusions The programme has been conducted in collaboration with the Sri Lankan National Institute of Mental Health and the Ministry of Health, and this partnership has helped to ensure that the training is tailored to Sri Lanka and has the chance of long term sustainability.
mental health; primary care; trainers; training
Objective This study explores refugees' perspectives regarding the nature of communication barriers that impede the exploration of trauma histories in primary care.
Method Brief interviews were conducted with 53 refugee patients in a suburban primary care clinic in the Midwest USA. Participants were asked if they or their doctors had initiated conversations about the impact of political conflict in their home countries. Qualitative data analysis was guided by grounded theory. Peer debriefings of refugee healthcare professionals were incorporated into the analysis.
Results Two-thirds of refugee patients reported that they never shared how they were affected by political conflict with their doctors and that their doctors never asked them about it. Most refugees stated that they would like to learn more about the impact of trauma on their health and to discuss their experiences with their doctors.
Conclusion Refugees are hesitant to initiate conversations with physicians due to cultural norms requiring deference to the doctor's authority. They also lack knowledge about how trauma affects health. Physicians should be educated to inquire directly about trauma histories with refugee patients. Refugees can benefit from education about the effects of trauma on health and about the collaborative nature of the doctor–patient relationship.
cross-cultural communication; doctor–patient relationship; refugee; war trauma
Mental health care is important for everyone, especially teenagers. However, seeking mental health services may be challenging for teenagers, particularly when they are also parents. Offering mental health care in a safe, attractive and easily accessible manner, such as primary care, increases the chances that teenage parents will receive help. Comprehensive care models need to be established to address the many needs that at-risk young mothers and their children face. There are a number of programmes available to teenage mothers that either address healthcare and psychosocial needs or focus primarily on improvements in parenting skills; yet an integrated model that delivers medical, psychiatric and psychosocial care and facilitates positive parenting skills seems to be missing. Through a university–community partnership we have recently developed a model curriculum – the Mom Power (MP) group programme – at the University of Michigan which aims to close this gap in service delivery. We elaborate on core elements and key features of this 10-week group intervention programme for high-risk teenage mothers and their children, and present preliminary outcomes data. Analyses on the first 24 MP group graduates suggest that despite ongoing life trauma during the intervention period, teenage mothers show improvements in depression and post-traumatic stress disorder symptoms post intervention, and also self-rate as less guilty and shameful regarding their parenting skills after programme completion. Although preliminary, due to design and statistical limitations, these results show promise regarding feasibility and effectiveness of this integrated approach for teenage mothers with young children delivered through primary care.
adolescent mental health; intervention; primary care; teenage mothers
Background Like most low- and middle-income countries, Nigeria has a huge treatment gap for mental disorders. The World Health Organization has proposed the integration of mental health care into primary health service delivery as one of the ways to bridge this treatment gap. Studies have shown an immediate positive impact of mental health training for primary care workers. We evaluated the impact of training on the tutors of primary care workers approximately 12 months after the training.
Method An intensive five-day training workshop for college teachers of mental health in community health officer (CHO) training institutions in south-west Nigeria was conducted in January 2009. Four of the 24 participants were randomly selected for evaluation of the impact of training on their activities approximately 12 months after the workshop. Qualitative methods were used, namely in-depth interviews, direct observation of classroom teaching by the participants and focus group discussion with their students.
Results The participants interviewed reported a positive impact of the ‘training of trainers’ (TOT) workshop on their mental health course teaching. Direct observation of four participants revealed that three of them exhibited a high fidelity with the TOT course material and imbibed the teaching techniques advocated. The tutors' students also reported an improvement in the quality of their mental health classes.
Conclusion The training had an overall positive impact on the activities of the trainees approximately one year after the workshop.
community health workers; mental heath training; positive impact
Aim To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care.
Background Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services.
Methods Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis.
Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems.
Conclusions A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.
GRiST; Improving Access to Psychological Therapies (IAPT); mental health; primary care; risk assessment
Objective This study examined longitudinal relationships between maternal red-cell folate status and dietary intakes of vitamins B6, B12 and folate before and during pregnancy and subsequent postpartum depressive symptoms.
Study design and setting Within a cohort study of women aged 20–34 years (the Southampton Women's Survey) dietary data were obtained before pregnancy and at 11 and 34 weeks' gestation. Red-cell folate was measured before pregnancy and at 11 weeks' gestation. We derived relative risks of postpartum depressive symptoms using an Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 13 administered from 6 months to 1 year postpartum.
Results No significant differences were found between those with postpartum depressive symptoms (n = 905) and those without (n = 1951) in relation to red-cell folate concentration or dietary intake of folate, vitamin B12 and vitamin B6, before or during pregnancy. A prior history of mental illness (relative risk (RR) 1.83; 95% confidence interval (CI) 1.53–2.19) was associated with postpartum depressive symptoms, and women who breastfed until 6 months were less likely to experience postpartum depressive symptoms (RR 0.68; 95% CI 0.55–0.84).
Conclusion This study suggests that folate status and dietary folate, B6 and B12 intakes before and during pregnancy are not associated with postpartum depressive symptoms. A history of mental illness, however, was a strong risk factor.
B-vitamin intake; folate status; postpartum depression
Medication adherence is critical to the efficacy of available treatment for depression in primary care settings. This review identifies factors associated with adherence and what is known about the effectiveness of adherence-enhancement programmes. A comprehensive systematic review of English language publications from January 2002 to October 2011 was conducted using the following databases: PUBMED/MEDLINE, PsycINFO and the Cochrane database. Twenty-one studies met the inclusion criteria for adherence-enhancement evaluations. Eleven of the studies evaluated demonstrated significantly positive effects on adherence; the remaining 10 reported mixed or no effects. Similar to previous literature reviews, factors shown to be associated with adherence were multifactorial and in this analysis were grouped as patient, condition and comorbidities, therapy or treatment, patient–provider relationship and healthcare system level. Adherence improved most notably in studies that included sustainable system and patient-targeted changes. Evaluating adherence-enhancement interventions is key to promoting successful approaches; however, a number of gaps exist between intervention and implementation: (1) the cost in resources and time to implement and sustain these programmes is unknown, (2) specific details about which subgroups of patients are best helped with such programmes is not clear, and (3) what specific processes or content are critical to programme success is still to be identified. There are sufficient data supporting the substantial need for planning and implementing adherence interventions despite reported mixed results. Primary care providers are often positioned to impact patients' adherence; however, practice constraints can limit their implementation.
adherence-enhancement programmes; antidepressant adherence/non-adherence; associated factors
Attention-deficit hyperactive disorder (ADHD) is a psychiatric illness commonly diagnosed during the early years of childhood. In many adolescents with undiagnosed ADHD, presentation may not be entirely similar to that in younger children. These adolescents pose significant challenges to parents and teachers coping with their disability. Often adolescents with behavioural problems are brought to medical attention as a last resort. This case describes an adolescent who presented to a primary care clinic with school truancy. He was initially treated for depression with oppositional defiant disorder and sibling rivalry. Only following a careful detailed history and further investigations was the diagnosis of ADHD made. He showed a positive improvement with the use of methylphenidate for his ADHD and escitalopram for his depression. The success of his management was further supported by the use of behavioural therapy and parenting interventions. There is a need to increase public awareness of ADHD, especially among parents and teachers so that early intervention can be instituted in these children.
attention-deficit hyperactive disorder; primary care; school truancy
Background Among persons with type 2 diabetes (T2DM) it is not known whether the presence of hypertension could have a detrimental effect on learning ability and whether repeated exposure to information changes the amount of information retained. The aim of this study was to determine cross-sectional evidence for a differential burden to cognitive functioning among persons with T2DM and comorbid hypertension (HTN).
Methods This study performed a cross-sectional, retrospective analysis, by medical chart review, of patients with a diagnosis of T2DM.
Results Medical records information for history of HTN, age, gender and cognitive performance scores were recorded and analysed for 112 T2DM patients, with an average age of 60 years (SD = 13.84). Differences in cognitive performance scores were compared between patients with and without a history of HTN. The results show that participants who were diagnosed with hypertension produced lower average Rey Auditory–Verbal Learning Test scores than individuals who are not diagnosed with hypertension. Trial 2 was the only trial to prove significant with a P-value of 0.041.
Conclusions Our results support previous studies showing that HTN is associated with increased risk to learning and memory functioning, although the degree of interference with these cognitive functions could not be determined from our research. Recognising that people diagnosed with HTN may be at risk for poorer learning and memory skills, future research can investigate how the length of time with the diseases affects learning and memory, and how medication management can attenuate cognitive learning and memory performance.
cognitive function; hypertension; learning; memory; type 2 diabetes
Background Management of neuropsychiatric symptoms is a challenging task in primary care. Aims To assess self-reported confidence and knowledge of general practitioners (GPs) regarding the identification and management of behavioural and psychological symptoms of dementia (BPSD).
Methods A self-designed two-page paper questionnaire was sent to a random sample of 160 GPs practising in north Dublin. They were asked to evaluate their confidence and knowledge on several aspects of diagnosis and management of BPSD.
Results Completed questionnaires were returned from 109 GPs (response rate = 68%), of which 106 were usable. In general, GPs were somewhat critical of their self-reported skills in diagnosing (76.4%) and managing (77.4%) BPSD, as well as in discriminating BPSD from other behavioural disturbances (71.7%). Many of them (67.9%) also encountered difficulty accessing specialist services. There was no correlation between demographic characteristics of GPs or patient caseload with respect to their responses to questionnaire items. Although many GPs (92.5%) highly valued the important role of non-pharmacological interventions in BPSD, none of them reported recommending these in their daily practice.
Conclusions Despite the fact that GPs have a wealth of knowledge about BPSD, they are largely critical of their knowledge and management skills of these symptoms. Efforts should be focused on supporting GPs by means of educational interventions that consider all aspects of dementia, but additionally highlight the more challenging neuropsychiatric components of the illness. Health services need to be structured in a way that promotes collaboration between GPs and mental health professionals for a seamless delivery of care.
diagnosis; family medicine; general practitioner; health services; neuropsychiatric symptoms