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OBJECTIVE--Patients with diabetes suffer high rates of mental health problems, and this combination is associated with poor outcomes. Although effective treatments exist for both diabetes and mental health problems, delivering [...]

Abstract Objectives To identify issues that facilitate the successful integration of evaluation and development of telehealthcare services. Design Ethnographic study using various qualitative research techniques to obtain data from several [...]

It took a patient and empathic therapist to help me feel safe and emotionally held enough to begin to explore those opposing feelings. Nonetheless, I found it easy to speak to patients with mental health problems - which encouraged me to pursue a career in psychiatry myself. Early in my career and in the throes of depression, despite working harder than ever to help my patients, I failed an important professional examination. [Extracted from the article]

The success of any consultation depends on how well the patient and doctor communicate with each other. There is now firm evidence linking the quality of this communication to clinical […]

The article presents an excerpt from the book "Finding True North: The Healing Power of Place" by Linda Gask.

Changing terminology is no substitute for good consultation skills As children many of us learnt the old rhyme 'Sticks and stones may break my bones but words can never hurt [...]

Practice nurses, midwives, health visitors, school nurses and district nurses have to cope with the emotional problems of their clients, according to a review by the National Primary Care Research and Development Centre at the University of Manchester. However, although some nurses are good at determining signs of distress, others often do not recognize symptoms. Assessment is an important first step and counselling skills are significant in helping patients with emotional problems. Practice, role-play and feedback from audio or video recordings are seen as suitable methods of teaching mental health skills.

Aims and methodTo explore the portrayal of homicide-suicide in newspaper articles, particularly how mental illness was reported. We carried out a qualitative study in England and Wales (2006–2008). Data from newspaper articles obtained via the LexisNexis database were used to examine a consecutive series of 60 cases.ResultsA fascination with extreme violence, vulnerable victims and having someone to blame made homicide-suicides newsworthy. Some offenders were portrayed in a stereotypical manner and pejorative language was used to describe mental illness. The findings showed evidence of inaccurate and speculative reference to mental disorder in newspaper reports.Clinical implicationsThe media should avoid speculation on people's mental state. Accurate reporting is essential to reduce stigma of mental illness, which may in turn encourage people to seek help if they experience similar emotional distress.

Objectives: To consider what the barriers are to effective depression education; to understand what attitudes, knowledge, and skills doctors need to acquire, and finally to examine what we currently know about effective ways of training family physicians (FPs) about depression.Methods: A narrative review of the published literature compiled from searching reviews and original articles was conducted using the following key words: education, training, attitudes, depression, and primary care. Further relevant articles were identified from reference lists.Results: The identified barriers are FPs' attitudes and confidence toward recognizing and managing depression, the way in which they conceptualize depression, and the difficulties they face in implementing change in the systems in which they work. We, as educators, can identify what FPs need to know, and this should include novel ways of organizing care. However, of key importance is the need to address how more effective interventions may be provided, recognizing that FPs may be starting from many different points on 3 differing continua of attitude, skills, and knowledge in relation to depression.Conclusions: We have to not only ensure that the content of what we teach is perceived as relevant to primary care but also review exactly how we go about providing it, using methods that will engage and stimulate doctors at differing stages of readiness to acquire new attitudes, skills, and knowledge about depression. However, we still need to find better ways of helping FPs to recognize and acknowledge their educational needs. Further research is also required to thoroughly evaluate these novel approaches to tailoring educational interventions.

The death of a patient by suicide can severely affect mental health professionals, particularly if it occurs despite major efforts to intervene. Notwithstanding the difficulties faced by clinicians, suicide prevention remains of paramount importance in order to help save lives. This article seeks to promote a pragmatic and compassionate biopsychosocial response using evidence-based interventions to reduce suicide. It introduces practical strategies that psychiatrists can use in everyday clinical practice, in particular the paradigm shift of suicide mitigation to help prevent suicide. We believe that every encounter with a suicidal person is an opportunity to intervene to reduce their distress and, potentially, to save a life. We believe that it is no longer acceptable for clinicians to state that if patients wish to kill themselves they can do so, in the absence of any attempt at a compassionate intervention.

Self-harm is an important health issue. It is more prevalent in the UK than the rest of Europe. An estimated 170 000 people present to hospital each year but most acts of self-harm do not result in presentation for medical attention; so self-harm is largely a community problem with real-term figures an unknown. This article explains the terminology associated with self-harm, provides explanations for the different motives and suggest ways in which primary care can contribute to assessing and responding to patients engaging in self-harm. It will also explain a process to mitigate risk.

It is 3 a.m. and your patient is at home, wide awake and being tormented by suicidal thoughts. What is likely to stop him ending his life and make him seek help? A complex lengthy risk assessment he underwent earlier that day or the skill and understanding of an empathic and trusted GP with whom he agreed a simple crisis plan? Every contact a suicidal individual has with a health care professional represents an opportunity to intervene and prevent that individual from going on to die by suicide. As long as suicide is seen as the preserve of specialist mental health services, opportunities for early intervention will be missed. This paper will introduce a comprehensive way of assessing and responding to patients experiencing suicidal thoughts in primary care.

The arrival of the ‘polyclinic’ or ‘GP-led health centre’ has been signalled in the review of the National Health Service. A variety of options have been proposed for the way in which polyclinics will incorporate specialist services to work alongside primary care, and the relevance of these models to mental healthcare is considered. Polyclinics provide new opportunities but with those possibilities come potential threats and risks. Of key importance is the threat that they will re-institutionalise mental healthcare after many years of breaking down such barriers. Buildings provide shared space, but new working practices are more difficult to achieve.

The authors aim to identify any benefits or limitations of psychiatric residents attending a Balint-style case discussion group, to explore those experiences, to study the process of the learning experience, and to identify potential educational implications. Seventeen psychiatric residents and counselors completing two parallel case discussion groups at a U.K. psychotherapy service were given in-depth interviews about their experiences of this training. Interview transcripts were analyzed using qualitative methodology. The groups were anxiety provoking; most participants were able to progressively accommodate to and benefit from the psychological learning process, but some struggled to adapt. Basic psychological competency and the awareness of the self in relation to the patient can be fostered through attendance at a case discussion group. With some limitations, Balint groups continue to be a useful way of introducing young psychiatrists to psychological processes.

An interview with professor Linda Gask is presented. When asked on the preferred choice of antidepressant, she asserts that she finds convenience with citalopram. She stresses that tricyclics are very good sedatives and increases risk in milder depressions. Further, she reveals that the placement of depressed patients who had two or three episodes for lifetime treatment is a matter of choice and negotiation if there is an indication of longer-term treatment.

This article presents the findings of a focused literature review and consensus meetings on the definition and clinical significance of painful symptoms in patients with depression. About 50% of depressed patients report pain, and many types of pain occur more frequently in people with depression than in those without. There is some evidence that pain in depressed patients is associated with a poor response to treatment. Pain and depression may share common pathways and may both respond to treatment with certain antidepressants. Doctors need to be alert to pain in depressed patients and be prepared to treat it.

A number of studies have shown that the communication style of GPs has a significant impact on their ability to recognize and manage psychiatric disorders. Italian training programmes do exist, but none have been evaluated for effectiveness.

One of the indicators of success of the new UK primary care organizations will be the extent to which they are able to implement the agendas for have engaged with this new policy agenda. It service provision that are outlined in the National Service Frameworks (NSFs). The contribution here focuses on the readiness of primary care groups and trusts for tackling the mental health agenda prior to the launch of the NSF and assesses the extent to which primary care groups compares the progress made with the mental health agenda with the coronary heart disease NSF, which was launched at approximately the same time.

Reattribution training is an 8-hour, skills-based training program delivered to family doctors so that they may better manage patients with somatized mental disorder. Separate consecutive cohorts of 103 and 112 patients with somatized mental disorder, respectively, visited eight family doctors before and after these physicians had undergone reattribution training. Reattribution training was associated with more frequent endorsement by patients after 1 month that they received the help they wanted and fewer beliefs by patients after 3 months that their symptoms had only a physical cause. Reattribution training did not change the incidence of investigations initiated by the family doctor, prescriptions for psychotropic or nonpsychotropic drugs, or referrals over 3 months.

There is a shortage of health staff available in primary care who can assess and manage anxiety disorders using effective evidence-based psychological methods. Previous training packages have largely failed to evaluate skill acquisition. We devised a brief training package for practice nurses to learn how to treat anxiety disorders. Fourteen practice nurses acted as their own controls in a before and one month after training design to determine retention of assessment and management skills. Both were rated 'blind' in videotaped role-played interviews with an actor. With training, there were significant improvements in specific history-taking, explaining anxiety disorders, all aspects of anxiety management (breathing exercise, distraction, exposure), follow-up of patients and overall performance. Overall, 11 practice nurses (79%) were judged to be clinically effective after training compared to none before. After training, all nurses reported that they had used the training package in clinical practice. The findings are discussed in the light of the published literature, and possible future directions for research are suggested.

Effective methods for training general practitioners how to both detect and manage emotional disorders are described. Videofeedback is the most effective method of training. Recent work suggests that not only do training effects persist but also that training can have an impact on patient outcome. It is now essential that skills training is more widely disseminated in primary care. Appropriate models need to be developed for training GPs in the management of a range of common problems.

Objective: Development and evaluation of a method of training primary care providers in psychiatric skills which utilizes videofeedback of real and roleplayed consultations in a group setting.Method: The development of the basic training approach and additional material for teaching specific skills is described. Evaluation has addressed the impact of training on 1) clinician behavior and 2) measures of outcome.Results: Research over a number of years has demonstrated an impact on clinician behavior with some evidence of impact on clinical and economic measures and patient satisfaction.Conclusions: Videofeedback training appears to be most effective when it is provided with a clear model for the professional-patient interaction. Its effectiveness can be further enhanced by delineating sets of component microskills that can be learned using a combination of videotape modeling, role-play, and feedback. Challenges for future research include investment in randomized controlled trials for outcome, developing the training approach for a range of primary care workers, training sufficient group facilitators, and achieving widespread dissemination without subsequent dilution of effectiveness.

Study questionHow effective is supported computerised cognitive behaviour therapy (cCBT) as an adjunct to usual primary care for adults with depression?MethodsThis was a pragmatic, multicentre, three arm, parallel randomised controlled trial with simple randomisation. Treatment allocation was not blinded. Participants were adults with symptoms of depression (score ≥10 on nine item patient health questionnaire, PHQ-9) who were randomised to receive a commercially produced cCBT programme (“Beating the Blues”) or a free to use cCBT programme (MoodGYM) in addition to usual GP care. Participants were supported and encouraged to complete the programme via weekly telephone calls. Control participants were offered usual GP care, with no constraints on the range of treatments that could be accessed. The primary outcome was severity of depression assessed with the PHQ-9 at four months. Secondary outcomes included health related quality of life (measured by SF-36) and psychological wellbeing (measured by CORE-OM) at four, 12, and 24 months and depression at 12 and 24 months.Study answer and limitationsParticipants offered commercial or free to use cCBT experienced no additional improvement in depression compared with usual GP care at four months (odds ratio 1.19 (95% confidence interval 0.75 to 1.88) for Beating the Blues vusual GP care; 0.98 (0.62 to 1.56) for MoodGYM vusual GP care). There was no evidence of an overall difference between either programme compared with usual GP care (0.99 (0.57 to 1.70) and 0.68 (0.42 to 1.10), respectively) at any time point. Commercially provided cCBT conferred no additional benefit over free to use cCBT or usual GP care at any follow-up point. Uptake and use of cCBT was low, despite regular telephone support. Nearly a quarter of participants (24%) had dropped out by four months. The study did not have enough power to detect small differences so these cannot be ruled out. Findings cannot be generalised to cCBT offered with a much higher level of guidance and support. What this study addsSupported cCBT does not substantially improve depression outcomes compared with usual GP care alone. In this study, neither a commercially available nor free to use computerised CBT intervention was superior to usual GP care.Funding, competing interests, data sharing Commissioned and funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project No 06/43/05). The authors have no competing interests. Requests for patient level data will be considered by the REEACT trial management groupTrial registrationCurrent Controlled Trials ISRCTN91947481.

ObjectiveTo test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions.DesignCluster randomised controlled trial.Setting36 general practices in the north west of England.Participants387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial.InterventionsCollaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses.Main outcome measuresThe primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF).Results19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval −0.41 to −0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support.ConclusionsCollaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity.Trial registration ISRCTN80309252.

ObjectiveTo compare the clinical effectiveness of collaborative care with usual care in the management of patients with moderate to severe depression.DesignCluster randomised controlled trial.Setting51 primary care practices in three primary care districts in the United Kingdom.Participants581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression.InterventionsCollaborative care, including depression education, drug management, behavioural activation, relapse prevention, and primary care liaison, was delivered by care managers. Collaborative care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual care was family doctors’ standard clinical practice. Main outcome measuresDepression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months.Results276 participants were allocated to collaborative care and 305 allocated to usual care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving collaborative care than in those receiving usual care at four months, and 1.36 points lower (0.07 to 2.64, P=0.04) at 12 months. Quality of mental health but not physical health was significantly better for collaborative care than for usual care at four months, but not 12 months. Anxiety did not differ between groups. Participants receiving collaborative care were significantly more satisfied with treatment than those receiving usual care. The number needed to treat for one patient to drop below the accepted diagnostic threshold for depression on the PHQ-9 was 8.4 immediately after treatment, and 6.5 at 12 months.ConclusionsCollaborative care has persistent positive effects up to 12 months after initiation of the intervention and is preferred by patients over usual care.Trial registration numberISRCTN32829227.

A letter to the editor is presented in response to an article about computerized cognitive behavioral therapy in the March 14, 2006 issue.