A pragmatic cluster randomized controlled trial of an educational intervention for GPs in the assessment and management of depression

Gask, Linda; Dowrick, Chris; Dixon, Clare; Sutton, Chris J; Perry, Rachel; Torgerson, David; Usherwood, Tim

doi:10.1017/s0033291703001065

Cited by 71 publications

(64 citation statements)

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Section: Training Issuesmentioning

confidence: 99%

“…Passive educational interventions have been shown to be ineffective, however, 43 and more-interactive educational initiatives involving patients as teachers should be considered. 44 Learning relationship-centered consultation skills 44 during both their undergraduate and postgraduate training is essential for family physicians.In addition, patient initiatives, such as the Expert Patient Programme, 45 may help to reduce the disparity between family physicians and patients; indeed, it has been shown that the Expert Patient Programme might reinforce the medical paradigm. …”

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confidence: 99%

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Using Multiple Sources of Knowledge to Reach Clinical Understanding of Chronic Fatigue Syndrome

Chew‐Graham

Cahill²,

Dowrick³

et al. 2008

The Annals of Family Medicine

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PURPOSE Chronic fatigue syndrome (CFS), or myalgic encephalitis (ME), is a contentious condition and often a diagnosis of exclusion. Current policy in the United Kingdom recommends management in primary care. We explored how patients with CFS/ME and family physicians understand this condition and how their understanding might affect the primary care consultation. METHODSWe undertook a qualitative study with patients and family physicians from North West England participating in a primary care-based randomized controlled trial (FINE Trial). Data were collected through purposive sampling and in-depth semistructured interviews with 24 patients and 14 family physicians. We analyzed interview transcripts using constant comparison methods. RESULTSFamily physicians access social and cultural knowledge to reach a clinical understanding of CFS/ME and its management. Patients recognize the diffi culties family physicians encounter in understanding their symptoms and access similar nonclinical sources of information. We suggest that both patients and physicians use biomedical discourse within the consultation: the physician to maintain the position as an expert, the patient to engage the physician. CONCLUSIONSFamily physicians obtain information about CFS/ME from their nonprofessional world, which they incorporate into their professional realm. Patients and physicians describe the use of the discourse of science within consultations about CFS/ME. This form of shared understanding could lead to a positive collaborative interaction. Family physicians need a biomedical, evidence-based knowledge about CFS/ME. There is potential to use the rich knowledge base that patients can bring to consultations in training initiatives directed at family physicians. Ann Fam Med 2008;6:340-348. DOI: 10.1370/afm.867. INTRODUCTIONC hronic fatigue syndrome (CFS), or myalgic encephalitis (ME), is a chronic incapacitating illness that leads to individual disability 1 and lost productivity. 2,3 The annual economic impact of chronic fatigue syndrome in the United States is estimated to be $9.1 billion in lost productivity, not including medical costs or disability payments. The average family affected by CFS/ME loses $20,000 a year in wages and earnings.1 Patients usually experience multiple additional symptoms, 4 commonly with comorbid psychiatric disorders. 5 Prognosis is poor 6 and is accompanied by functional impairment and reduced quality of life. 7 Persons with CFS/ME are high users of health care services and more likely than others to be out of work. 8 The diagnosis is surrounded by controversy. 9 Most researchers now accept the view that CFS/ME is multifactorial and distinguish among factors that predispose, precipitate, and perpetuate the condition. In 2002 the UK Department of Health recommended that CFS/ME should be managed wherever possible in the community by family physicians supported by local multidisciplinary teams. 11 In the absence of a fi rm evidence base for treatment of CFS/ME in primary care, this recommendation was ...

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Section: Training Issuesmentioning

confidence: 99%

mentioning

confidence: 99%

Using Multiple Sources of Knowledge to Reach Clinical Understanding of Chronic Fatigue Syndrome

Chew‐Graham

Cahill²,

Dowrick³

et al. 2008

The Annals of Family Medicine

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“…Two articles (Moreno et al, 2003;Scott et al, 2002) found improved identification of depression in patients. On the other hand, two further interventions (Gask et al, 2004;Scott et al, 2002) resulted in significant improvements in only one out of two different locations. Finally, the remaining two interventions (Kick, 1999;Thompson et al, 2000) did not result in any significant effects.…”

Section: General Remarksmentioning

confidence: 98%

“…Although Gask et al (2004) did not describe a needs assessment as such, the results still allow for relevant interpretation. As discussed above, this intervention had a significant effect in Manchester but not in Liverpool, whilst on baseline measurements participating GPs in Liverpool had greater previous experience in psychiatry and training in counselling skills.…”

Section: Needs Assessments Reasoning For Using Needs Assessmentsmentioning

confidence: 99%

Prevention of depression and suicide in Primary Health Care settings: a systematic review of the evidence

Söderqvist¹,

Mittendorfer‐Rutz²

2015

Suicid.

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Suicide is increasing world-wide and is now one of the three most common causes of death in the age group of 15-44 (SUPRE, WHO, 2007; MittendorferRutz et al., 2004). This increasing problem warrants the development of tailormade prevention strategies. To date, evidence on a wide range of intervention methods both within Public Health and the Health care sector is emerging (Mann et al., 2005; Mittendorfer-Rutz et al., 2004a). The public health strategies include restricting access to lethal means such as weapons and pesticides; responsible media reporting and educational programmes for the public, and populations at risk. The strategies focusing on health care include improved medical care, improved follow-up of patients with a suicidal history and education of general practitioners (GPs) in detecting and treating depression. A recently published review of suicide prevention strategies by Mann and colleagues (2005), concludes that education of primary care physicians and gatekeepers as well as interventions restricting access to lethal means both show promising results in reducing suicide rates (Mann et al., 2005). Rationale for educational interventions at a primary health care levelEven though suicidal behaviour has a multifactorial ethiology, the majority of suicides are committed by people who suffer from some kind of mental illness. Lönnqvist et al. (1995) carried out psychological autopsies on all suicides committed in Finland during one year (a total of 1397 cases) and found that 93% of these cases could be diagnosed with some kind of psychiatric disorder.Out of these 66% were diagnosed as having suffered from depression. In a more recent review the same authors estimated that 29-88% of suicide victims were suffering from depression (Lönnqvist, 2000). Although 60-80% of cases of depression can be successfully treated (by medication and/or other types of therapy) the WHO estimates that only around 25% of cases are offered sufficient treat-ment. Lack of trained caregivers, lack of resources, low help-seeking behaviour and social stigma related to the disorder are identified as possible explanations (WHO, 2007).An international review by Luoma et al. from 2002 suggests that a majority of suicide victims (approximately 75%) were in contact with the primary health care within the year prior to suicide; while in contrast, only around 30% were in contact with the mental health service during that same period. This suggests that the primary health care is an appropriate arena in order to reach groups at risk. By improving the detection of depression and suicidal tendencies in such patients, suicidal outcomes should be able to be prevented. Aims and questionsThe primary question being asked in this review is whether educational programmes targeting primary health care staff can be effective in preventing suicide and depression. Outcomes that are of interest for this purpose include changes in rates of completed suicide and suicide attempts as well as the reported occurrence of suicidal thoughts and depressive sym...

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“…8,13 Even following identification, many young people with psychological disorders receive no specific management or follow-up, 8 perhaps because health professionals hesitate to address issues when they lack confidence in their own skills, or in the treatments available. 14 An authoritative statement that (in this age group) symptoms of depression are common and often resolve without psychological or medical intervention may have influenced practitioners. 15 While there has been considerable emphasis on training GPs to identify and manage adult psychiatric disorders, little work has addressed psychopathology in…”

Section: Introductionmentioning

confidence: 99%

Therapeutic identification of depression in young people: lessons fromthe introduction of a new technique in general practice

Iliffe¹,

Gallant²,

Kramer³

et al. 2012

Br J Gen Pract

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BackgroundMild-to-moderate depression in young people is associated with impaired social functioning and high rates of affective disorder in adult life. Earlier recognition of depression in young people has the potential to reduce the burden of depression in adulthood. However, depression in teenagers is underdiagnosed and undertreated. AimTo assess the usability and usefulness of a cognitive-behavioural-therapy-based technique for Therapeutic Identification of Depression in Young people (TIDY). Design and settingA qualitative study of four group practices in northwest London. MethodFace-to-face semi-structured interviews were conducted with practitioners who had been trained in the use of the TIDY technique. ResultsTwenty-five GPs and six nurses were interviewed. The key themes that emerged from the interviews were: practitioners were 'making sense of teenage depression' when interpreting signs and symptoms; the training in the technique was variable in its impact on practitioners' attitudes and practice; and time factors constrained practitioners in the application of the technique. ConclusionThe TIDY technique is usable in routine practice, but only if practitioners are allowed to use it selectively. This need for selectivity arises partly from concerns about time management, and partly to avoid medicalisation of psychological distress in young people. The perceived usefulness of the TIDY technique depends on the practitioner's prior knowledge, experience, and awareness. . 16 They specifically recommend that primary care professionals should be trained in the detection of depression but there has been little systematic study of how this can be achieved.There are two problems that must be overcome if the NICE guidelines are to be implemented. First, young people with psychological morbidity are difficult to engage in psychological therapies, 17 although such therapies appear to be effective in reducing symptoms and case prevalence. 18 Second, specialist child and young people's mental health services are already struggling to meet the demand for services. It is therefore important that specialist services are focused on those with the more severe disorder.Improved skills in primary care would improve identification of those with severe depression requiring referral, and facilitate intervention for mild-to-moderate depressive disorders within the primary care setting, thus broadening access to treatment for many young people. While there is at least one suitable and valid screening instrument for detecting depression in young people in primary care, 19 there is no solution to the problem of engaging young people in therapy.An approach that supports GPs in both identifying hidden psychological morbidity and engaging young persons in therapy ('therapeutic identification') in an opportunistic way during routine consultations would fit the NICE proposals.Such an intervention has been developed in a joint project between specialists in adolescent psychiatry and GPs, 20 and consists of a workplace-based trai...

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A pragmatic cluster randomized controlled trial of an educational intervention for GPs in the assessment and management of depression

Abstract: Background. General practitioners (GPs) can be provided with effective training in the skills to manage depression. However, it remains uncertain whether such training achieves health gain for their patients.

Cited by 71 publications

References 24 publications

Using Multiple Sources of Knowledge to Reach Clinical Understanding of Chronic Fatigue Syndrome

Using Multiple Sources of Knowledge to Reach Clinical Understanding of Chronic Fatigue Syndrome

Prevention of depression and suicide in Primary Health Care settings: a systematic review of the evidence

Therapeutic identification of depression in young people: lessons fromthe introduction of a new technique in general practice

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