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Background: Early detection could reduce the duration of untreated psychosis. GPs are a vital part of the psychosis care pathway, but find it difficult to detect the early features. An accurate risk prediction tool, P Risk, was developed to detect these., Aim: To externally validate P Risk., Design and Setting: This retrospective cohort study used a validation dataset of 1 647 934 UK Clinical Practice Research Datalink (CPRD) primary care records linked to secondary care records., Method: The same predictors (age; sex; ethnicity; social deprivation; consultations for suicidal behaviour, depression/anxiety, and substance misuse; history of consultations for suicidal behaviour; smoking history; substance misuse; prescribed medications for depression/anxiety/post-traumatic stress disorder/obsessive compulsive disorder; and total number of consultations) were used as for the development of P Risk. Predictive risk, sensitivity, specificity, and likelihood ratios were calculated for various risk thresholds. Discrimination (Harrell's C-index) and calibration were calculated. Results were compared between the development (CPRD GOLD) and validation (CPRD Aurum) datasets., Results: Psychosis risk increased with values of the P Risk prognostic index. Incidence was highest in younger age groups and, in the main, higher in males. Harrell's C was 0.79 (95% confidence interval = 0.78 to 0.79) in the validation dataset and 0.77 in the development dataset. A risk threshold of 1.0% gave sensitivity of 65.9% and specificity of 86.6%., Conclusion: Further testing is required, but P Risk has the potential to be used in primary care to detect future risk of psychosis., (© The Authors.)

Background: In the predictD-intervention, GPs used a personalised biopsychosocial programme to prevent depression. This reduced the incidence of major depression by 21.0%, although the results were not statistically significant., Aim: To determine whether the predictD-intervention is effective at preventing anxiety in primary care patients without depression or anxiety., Design and Setting: Secondary study of a cluster randomised trial with practices randomly assigned to either the predictD-intervention or usual care. This study was conducted in seven Spanish cities from October 2010 to July 2012., Method: In each city, 10 practices and two GPs per practice, as well as four to six patients every recruiting day, were randomly selected until there were 26-27 eligible patients for each GP. The endpoint was cumulative incidence of anxiety as measured by the PRIME-MD screening tool over 18 months., Results: A total of 3326 patients without depression and 140 GPs from 70 practices consented and were eligible to participate; 328 of these patients were removed because they had an anxiety syndrome at baseline. Of the 2998 valid patients, 2597 (86.6%) were evaluated at the end of the study. At 18 months, 10.4% (95% CI = 8.7% to 12.1%) of the patients in the predictD-intervention group developed anxiety compared with 13.1% (95% CI = 11.4% to 14.8%) in the usual-care group (absolute difference = -2.7% [95% CI = -5.1% to -0.3%]; P = 0.029)., Conclusion: A personalised intervention delivered by GPs for the prevention of depression provided a modest but statistically significant reduction in the incidence of anxiety., (© The Authors.)

Background: Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome., Aim: To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores., Design and Setting: Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013., Method: Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity., Results: Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months., Conclusion: This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes., (© British Journal of General Practice 2019.)

Background: Drug misuse is a serious public health problem. Evidence from previous epidemiological studies show that GPs are recording drug misuse in electronic patient records (EPR). However, although the recording trends are similar to national surveys, recording rates are much lower., Aim: To explore the factors that influence GPs to record drug misuse in the EPR, and to gain a clearer understanding of the gap between the amount of drug misuse recorded in primary care and that in national surveys and other studies., Design and Setting: A semi-structured qualitative interview study of GPs working in general practices across England., Method: Purposive sampling was employed to recruit 12 GPs, both with and without a special interest in drug misuse, from across England. Semi-structured face-to-face interviews were conducted to consider whether and why GPs record drug misuse, which methods GPs use for recording, GPs' actions if a patient asks for the information not to be recorded, and GPs' actions if they think a patient misuses drugs but does not disclose the information. Resulting data were analysed using a combination of inductive and deductive thematic analysis., Results: The complexity of asking about drug misuse preceded GPs' decision to record. They described how the context of the general practice protocols, interaction between GP and patient, and the questioning process affected whether, how, and in which circumstances they asked about drug use. This led to GPs making a clinical decision on whether, who, and how to record in the EPR., Conclusion: When making decisions about whether or not to record drug misuse, GPs face complex choices. Aside from their own views, they reported feelings of pressure from the general practice environment in which they worked and their clinical commissioning group, as well as government policies., (© British Journal of General Practice 2018.)

Background: Little is known about the risk of progressing to hazardous alcohol use in abstinent or low-risk drinkers., Aim: To develop and validate a simple brief risk algorithm for the onset of hazardous alcohol drinking (HAD) over 12 months for use in primary care., Design and Setting: Prospective cohort study in 32 health centres from six Spanish provinces, with evaluations at baseline, 6 months, and 12 months., Method: Forty-one risk factors were measured and multilevel logistic regression and inverse probability weighting were used to build the risk algorithm. The outcome was new occurrence of HAD during the study, as measured by the AUDIT., Results: From the lists of 174 GPs, 3954 adult abstinent or low-risk drinkers were recruited. The 'predictAL-10' risk algorithm included just nine variables (10 questions): province, sex, age, cigarette consumption, perception of financial strain, having ever received treatment for an alcohol problem, childhood sexual abuse, AUDIT-C, and interaction AUDIT-C*Age. The c-index was 0.886 (95% CI = 0.854 to 0.918). The optimal cutoff had a sensitivity of 0.83 and specificity of 0.80. Excluding childhood sexual abuse from the model (the 'predictAL-9'), the c-index was 0.880 (95% CI = 0.847 to 0.913), sensitivity 0.79, and specificity 0.81. There was no statistically significant difference between the c-indexes of predictAL-10 and predictAL-9., Conclusion: The predictAL-10/9 is a simple and internally valid risk algorithm to predict the onset of hazardous alcohol drinking over 12 months in primary care attendees; it is a brief tool that is potentially useful for primary prevention of hazardous alcohol drinking., (© British Journal of General Practice 2017.)

Background: Although screening and brief intervention is effective at reducing alcohol consumption in primary care and is recommended by guidelines, there are numerous barriers to its delivery. Screening newly-registered patients for alcohol-use disorders provides an opportunity for systematic collection of alcohol consumption data., Aim: To examine how alcohol screening data are recorded in primary care, the extent to which they are recorded, and whether reported levels of consumption differ from general population data., Design and Setting: Cross-sectional analysis, with data collected from patients in the year after registration., Method: Data on alcohol consumption were collected from The Health Improvement Network (THIN) primary care database from patients aged ≥18 years, newly registered with a general practice in 2007 to 2009, and compared with the Office for National Statistics Opinions (ONS Omnibus) survey., Results: A total of 292 376 (76%) of the 382 609 newly-registered patients had entries for alcohol consumption (units a week, Read Codes for level of consumption, and/or screening test). Only 25 975 (9%) were recorded as completing a validated screening test, most commonly AUDIT/AUDIT-C (16 004, 5%) or FAST (9419, 3%). Alcohol-use disorders are underreported in primary care (for example, higher risk drinking 1% males, 0.5% females) in comparison with the Opinions survey (8% males, 7% females). conclusion: Alcohol screening data are collected from most patients within 1 year of registration with a GP practice; however, use of a validated screening test is rarely documented and alcohol-use disorders are underreported. Further efforts are needed to encourage or incentivise the use of validated tests to improve the quality of data collected.

Background: It is well established that maternal depression is associated with enhanced child consultation for developmental and behaviour problems, but there is a dearth of research on paternal depression and child outcome., Aim: To assess the association of major paternal depressed mood and child consultation for developmental and behaviour problems., Design of Study: Cross-sectional study., Setting: General practices in London and Hertfordshire, UK., Method: Fathers of children aged 4-6 years were recruited via 13 general practices. A sample of 248 biological father and mother dyads completed measures on depressive syndrome (Patient Health Questionnaire), child consultations with health professionals for developmental and behaviour problems, fathering, couple relationship quality, alcohol misuse, other psychiatric impairment, and sociodemographic factors., Results: Eight out of 248 fathers (3%) had a major depressive syndrome. Sixty-five out of 247 (26%) fathers reported they were responsible for taking their child to see the doctor at least half the time compared with mothers. Children of fathers with a major depressive syndrome were almost nine times more likely to have consulted a health professional for speech and language problems (adjusted odds ratio [OR] = 8.67, 95% confidence interval [CI] = 1.99 to 37.67, P = 0.004) and seven times more likely to have consulted for externalising behaviour problems (adjusted OR = 6.98, 95% CI = 1.00 to 48.76, P = 0.05)., Conclusion: Children of fathers with major depression were more likely to consult for speech and language problems and externalising behaviour problems. A longitudinal study is recommended to identify causal mechanisms.

Background: Treating hypercholesterolaemia in patients with ischaemic heart disease can significantly reduce vascular deaths and events. Many such patients, however, do not receive effective treatment for hypercholesterolaemia., Aim: To ascertain the barriers to the detection and treatment of hypercholesterolaemia in patients with ischaemic heart disease as seen by primary care teams., Design of Study: Qualitative study using the nominal group technique., Setting: General practice teams in the North Thames region of the Medical Research Council General Practice Research Framework., Method: The main outcomes measures used were identification of the barriers to the detection and treatment of hypercholesterolaemia together with relative rankings., Results: Fourteen individual barriers were identified. The main barriers were: organisational barriers within general practices; confusing and conflicting guidelines from external sources; errors and omissions by GPs; communication problems at the interface between secondary and primary care; and reluctance by patients to take medication., Conclusions: The reasons for suboptimal detection and treatment of hypercholesterolaemia are complex and act at various levels. Interventions to improve the management of this condition must address these barriers in order to be successful.

Background: Educational outreach visits are commonly used to promote changes in prescribing in family practice. However, the effectiveness of outreach visits has not been evaluated across a range of settings., Aim: To estimate the effectiveness of educational outreach visits on United Kingdom (UK) general practice prescribing and to examine the extent to which practice characteristics influenced outcome., Design of Study: Randomised controlled trial., Setting: General practices in 12 health authorities in England., Method: Educational outreach visits were made to practices that received two of four guidelines. Each practice provided data on treatment of patients for all four guidelines for both pre and post-intervention periods. The primary outcome is average effect across all four guidelines. Secondary analyses examined the predictive effect of practice and guideline characteristics., Results: Seventy per cent of practices approached agreed to take part in the intervention. Overall, educational outreach was associated with a significant improvement in prescribing practice (odds ratio [OR] = 1.24 [95% CI = 1.07 to 1.42]), a 5.2% (95% CI = 1.7% to 8.7%) increase in the number of patients treated within the guideline recommendations. Smaller practices (two or fewer full-time equivalent practitioners) responded much more favourably to educational outreach than larger practices. Smaller practices improved their performance in line with the guidelines by 13.5% (95% CI = 6% to 20.9%) attributable to outreach, while larger practices improved by only 1.4% (95% CI = -2.4% to 5.3%, P-value for interaction <0.001)., Conclusion: In large practices, educational outreach alone is unlikely to achieve worthwhile change. There is good evidence to support the use of educational outreach visits in small practices.

Background: Several studies have shown that most patients with heart failure are not investigated and treated according to published guidelines. More effective management could reduce both mortality and morbidity from heart failure., Aim: To identify the reasons for gaps between recommended and actual management of heart failure in general practice., Design of Study: A nominal group technique was used to elicit general practitioners' (GPs') perceptions of the reasons for differences between observed and recommended practice., Setting: Ten Medical Research Council General Practice Framework practices in the North Thames region., Method: Data were collected on the investigation and treatment of heart failure in the 10 participating practices and presented to 49 GPs and 10 practice nurses from those practices., Results: Of the 674 patients requiring echocardiograms, 226 were referred for echocardiography (34%), and 183/391 (47%) with probable heart failure were prescribed angiotensin-converting enzyme inhibitors. A wide variety of barriers were elicited. The main barrier to the use of echocardiograms in the diagnosis of heart failure was lack of open access. The main barrier to the use of angiotensin-converting enzyme inhibitors in treating heart failure was GPs' concerns about their possible adverse effects., Conclusion: The barriers to the effective management of heart failure in general practice are complex. We recommend further research to establish whether multifaceted intervention programmes based on our findings can improve the management of heart failure in primary care.

Background: Dizziness is known to be a common, handicapping condition in the elderly, and a strong association between dizziness and anxiety disorders has been observed in hospital samples. However, little is known about the prevalence of dizziness among people of working age in the community and its implications for psychosocial functioning and general practice consultation and treatment., Aim: To determine the prevalence of dizziness, giddiness, vertigo, and unsteadiness, and associations with disability and handicap, symptoms of panic and agoraphobia, and general practice consultation and treatment., Method: Postal questionnaires were completed by 2064 people aged 18-64 years randomly sampled from the patient lists of four London practices. Validated survey items were used to assess symptoms, panic and agoraphobia, levels of occupational disability and handicap, and general practice consultation and treatment., Results: More than one in five responders (n = 480) had experienced dizziness during the past month; nearly half of these (n = 225) reported some degree of handicap and 30% had been dizzy for more than five years. Almost half (n = 221) of those with dizziness also reported anxiety and/or avoidance behaviour. Multiple physical and psychological symptoms were associated with higher levels of handicap. Only one in four of the 225 dizzy responders reporting some degree of handicap had received any form of treatment., Conclusion: Dizziness is a common, chronic, and often untreated symptom in people aged 18-65 years, associated with extensive handicap and psychological morbidity.

We evaluated the effectiveness of small-group education of general practitioners (GPs) in the management of drug users. A total of 40 doctors were trained. Some 28 doctors who were unable to attend and 30 who did not want training participated as comparison groups. Sixteen months after the education, trained doctors notified significantly more drug users to the British Home Office database and more often prescribed methadone at first consultation with a drug user.

Schizophrenia is a severe, chronic mental disorder that usually begins in early adulthood. Recurrent relapse leading to long-term psychological and social disability means that patients may require intensive community support. Despite a recent fall in the overall numbers of patients consulting their general practitioner with mental disorders, presentations by those suffering from severe mental disorders have risen. This review encompasses the role of general practitioner in the management of schizophrenia, considering in turn drug and psychological therapies, family interventions, innovations in care, the effects of community care developments, and the liasion between primary health care and mental health professionals. There is a need for further research in the area of family-practice-based interventions involving general practitioners and the practice team.

Background: Little is known about drug misusers' views of the care they receive from general practitioners., Aim: This study set out to determine drug users' views about primary health care and their relationship with their general practitioners., Method: A semi-structured interview was conducted with 180 drug users who were consecutive attenders at five treatment services in north east London--a general practice with a special interest in treating drug users, a private drug clinic, a community drug team, a drug dependence unit and a street agency for drug users., Results: The majority of the 145 London-based drug users attending the four treatment centres other than the general practice with a special interest were registered with a general practitioner (88%). Forty-two per cent of users sought out a general practitioner prepared to treat them, rather than register with a local or the family doctor. Most drug users reported that their general practitioners were aware of their drug problems (88%) but half of the general practitioners were not prescribing replacement drugs with almost 20% of the users not receiving prescriptions claiming that this was due to lack of knowledge or trust on the part of the doctor. Sixty per cent of the drug users attending the four centres perceived that their general practitioners held negative or neutral views about them. However, 34 of the 35 drug users interviewed in the specialist general practice believed their doctors had a positive view of drug users., Conclusion: Most drug users were registered with general practitioners but the relationship between doctor and patient was not always easy or productive. There is a need to clarify the role of general practitioners in this field and provide them with better educational opportunities.

Background: The transfer of patients with chronic schizophrenia from large mental hospitals into the community has had an impact on the role of the general practitioner in the effective delivery of primary care services to these patients., Aim: A study was undertaken to assess the care available in general practice for patients with schizophrenia, the attitudes of general practitioners and patients to the care provided and the factors influencing patients' use of services., Method: Eighty three patients with a diagnosis of schizophrenia and 26 doctors in 13 London practices registered on the VAMP research bank took part in a series of structured and semi-structured interviews. This was followed by a systematic examination of the patients' case notes., Results: Only 14 patients (17%) had no active symptoms according to the present state examination interview and 52 (63%) were currently taking antipsychotic medication. Fifty three patients were in contact with a psychiatrist. Approximately one quarter of patients were visited by a community psychiatric nurse; in 18 of these 19 cases, the main reason for contact was reported to be for administration of medication by depot injection. In all but one case, patients seeing a community psychiatric nurse were also being seen by a psychiatrist. Sixteen doctors reported having had a consultation in the previous month with a patient's relative, friend or member of hostel staff. There were considerable differences between patients and their doctors in their attitudes to the use of services. Of the 26 general practitioners, 23 were enthusiastic about the possibility of introducing shared care records. Of the 54 patients in contact with a mental health professional, only 18 favoured the use of shared care records. Most of the doctors (19, 73%) reported they would welcome a psychiatric liaison service in their practice; 40% of 53 patients said they would not. Patients receiving antipsychotic drugs and patients registered with inner city practices attended their general practitioners more frequently than those not taking antipsychotic medication and those registered with suburban practices. Use of antipsychotic medication (adjusted odds ratio (OR) 8.2, 95% confidence interval (CI) 2.2 to 30.7, P < 0.01), male sex (OR 5.8, 95% CI 1.5 to 22.1, P < 0.01) and active symptoms on the present state examination (OR 4.1, 95% CI 1.0 to 17.5, P = 0.06) were all predictive of current contact with mental health professionals., Conclusion: Family doctors were closely involved with the care of patients with schizophrenia and their relatives and were eager for increased liaison with secondary care services. Although patients were more resistant than doctors to management innovations this may reflect lack of familiarity with changes in community services. Greater input is needed by mental health professionals, particularly community psychiatric nurses, and some consideration of the burden of care in inner city practices is necessary in health service planning.