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This study describes coping strategies that patients with heart failure (HF) use to manage adverse drug events (ADEs). The included coping strategies were social support seeking, information seeking, non-adherence and taking alleviating medication. The role of beliefs about medication and ADE perceptions in explaining these coping strategies was assessed using the Self-Regulation Model. We performed a cross-sectional study including 250 HF patients who experienced an ADE. Patients completed validated questionnaires assessing their coping strategies, ADE perceptions and medication beliefs. Social support (60%) and information seeking (32%) were the most commonly used strategies to cope with ADEs. Non-adherence was reported by 7% of the patients. Multivariate linear regression analysis showed that demographics, clinical factors and medication beliefs explained only a small amount of the variance in coping strategies, whereas ADE perceptions explained a substantial amount of variance. Path analysis showed that patients’ perceptions about the timeline, consequences and controllability of ADEs by the health care provider were directly related to their coping behaviour. The effect of patients’ medication beliefs on their coping strategies was consistent with mediation through their ADE perceptions. Our results support the value of the Self-Regulation Model in understanding patients’ coping behaviour with regard to ADEs. [ABSTRACT FROM PUBLISHER]

This study evaluates the kind of aftercare that ischaemic stroke patients receive and the extent that aftercare fulfils the criteria of the 'Dutch Transmural Protocol transient ischaemic attack/cerebrovascular accident'. Fifty-seven patients were interviewed 1 year post-stroke about secondary prevention and aftercare. Forty general practitioners (GPs) completed a questionnaire about guidance and secondary prevention (concerning medication and lifestyle advice). Most patients would like to see their GP more regularly. More aftercare was required than was planned. The use of aspirin remained the same, fewer patients used statins and more used antihypertensives. Of the 40 GPs who participated, 12% did not apply prevention. Blood pressure, glucose and cholesterol were measured in 84%, 28% and 40% of patients. All of these measures were often elevated, but treatment was not given. Lifestyle advice was offered to one-quarter of patients. Considering all of the advice given in the Dutch Protocol, several aspects can be improved in relation to secondary prevention. Too little attention is paid to giving lifestyle advice, stricter medical checkups by GPs are necessary and there is a decrease in use of preventive medication, partly because GPs monitors use of medication inadequately. The use of the Dutch Protocol in aftercare can be improved by a more detailed description of advice. [ABSTRACT FROM AUTHOR]

Objective: To study the incidence, prevalence, and consultation rates of patients with shoulder complaints in general practice in the Netherlands during 10 years following initial presentation. Methods: A primary care database with an average population of 30 000 patients per year aged 18 years or older was used to select patients who consulted their general practitioner (GP) with shoulder complaints in the northern part of the Netherlands in the year 1998. Information about consultations for shoulder complaints was extracted. Incidence and prevalence for men, women, and different age groups were calculated for 9 and 10 years. Results: A total of 526 patients consulted their GP with a new shoulder complaint. During an average follow-up of 7.6 years, these patients consulted their GP 1331 times because of their shoulder complaints (average of 0.33 consultations per year). Almost half of the patients consulted their GP only once. Patients in the 45-64 age category had the highest probability of repeated GP consultations during follow-up. Average incidence was 29.3 per 1000 person-years. Women and patients in the 45-64 age category have the highest incidence. The annual prevalence of shoulder complaints ranged from 41.2 to 48.4 per 1000 person-years, calculated for the period 1998 to 2007, and was higher among women than among men. Conclusion: Although the incidence of shoulder complaints in general practice is as high as 29.3 per 1000 person-years, GPs' workload is generally low, as nearly half of these patients consult their GP only once for their complaint. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to calculate the incidence and prevalence of radiating low back pain, to explore the long-term clinical course of radiating low back pain including the influence of radiculopathy (in a subsample of the study population) and non-radiating low back pain thereon, and to describe general practitioners' (GPs') treatment strategies for radiating low back pain., Design: A historic prospective cohort study., Setting: Dutch general practice., Subjects: Patients over 18 years of age with a first episode of radiating low back pain, registered by the ICPC code L86., Main Outcome Measures: Incidence and prevalence, clinical course of illness, initial diagnoses established by the GPs, and treatment strategies., Results: Mean incidence was 9.4 and mean prevalence was 17.2 per 1000 person years. In total, 390 patients had 1193 contacts with their GPs; 50% had only one contact with their GP. Consultation rates were higher in patients with a history of non-radiating low back pain and in patients with a diagnosis of radiculopathy in the first five years. In this study's subsample of 103 patients, L86 episodes represented radiculopathy in 50% of cases. Medication was prescribed to 64% of patients, mostly NSAIDs. Some 53% of patients were referred, mainly to physiotherapists and neurologists; 9% of patients underwent surgery., Conclusion: Watchful waiting seems to be sufficient general practice care in most cases of radiating low back pain. Further research should be focused on clarifying the relationship between radicular radiating low back pain, non-radicular radiating low back pain, and non-radiating low back pain.

Background: There is hardly evidence on maintenance treatment with antidepressants in primary care. Nevertheless, depression guidelines recommend maintenance treatment i.e. treatment to prevent recurrences, in patients with high risk of recurrence, and many patients use maintenance treatment with antidepressants. This study explores the characteristics of patients on maintenance treatment with antidepressants in general practice, and compares these characteristics with guideline recommendations for maintenance treatment., Methods: We used data (baseline, two-year and four-year follow-up) of primary care respondents with remitted depressive disorder (≥6 months) from the Netherlands Study of Depression and Anxiety (n = 776). Maintenance treatment was defined as the use of an antidepressant for ≥12 months. Multilevel logistic regression was used to describe the association between sociodemographic, clinical and care characteristics and use of maintenance treatment with antidepressants., Results: Older patients, patients with a lower education, those using benzodiazepines or receiving psychological/psychiatric care and patients with a concurrent history of a dysthymic or anxiety disorder more often received maintenance treatment with antidepressants., Limitations: Measurements were not made at the start of an episode, but at predetermined points in time. Diagnoses were based on interview (CIDI) data and could therefore in some cases have been different from the GP diagnosis., Conclusions: Since patients with chronic or recurrent depression do not use maintenance treatment with antidepressants more often, characteristics of patients on maintenance treatment do not fully correspond with guideline recommendations. However, patients on maintenance treatment appear to be those with more severe disorder and/or more comorbidity.

Background: Earlier research showed that healthcare in stroke could be better organized, aiming for improved survival and less comorbidity. Therefore, in 2004 the Dutch College of General Practitioners (NHG) and the Dutch Association of Neurology (NVN) introduced the 'Dutch Transmural Protocol TIA/CVA' (the LTA) to improve survival, minimize the risk of stroke recurrence, and increase quality of life after stroke. This study examines whether survival improved after implementation of the new protocol, and whether there was an increase in contacts with the general practitioner (GP)/nurse practitioner, registration of comorbidity and prescription of medication., Methods: From the primary care database of the Registration Network Groningen (RNG) two cohorts were composed: one cohort compiled before and one after introduction of the LTA. Cohort 1 (n = 131, first stroke 2001-2002) was compared with cohort 2 (n = 132, first stroke 2005-2006) with regard to survival and the secondary outcomes., Results: Comparison of the two cohorts showed no significant improvement in survival. In cohort 2, the number of contacts with the GP was significantly lower and with the nurse practitioner significantly higher, compared with cohort 1. All risk factors for stroke were more prevalent in cohort 2, but were only significant for hypercholesterolemia. In both cohorts more medication was prescribed after stroke, whereas ACE inhibitors were prescribed more frequently only in cohort 2., Conclusion: No major changes in survival and secondary outcomes were apparent after introduction of the LTA. Although, there was a small improvement in secondary prevention, this study shows that optimal treatment after introduction of the LTA has not yet been achieved.

Aim: The present study explored (a) the discharge of breast cancer patients to primary care by specialists, at the end of hospital follow-up and (b) the experiences and views of general practitioners (GPs) regarding transfer of follow-up to the primary care setting., Methods: A cross-sectional survey was performed by sending a self-administered questionnaire to 960 GPs working in the three northern provinces of the Netherlands. Data were analysed using descriptive statistics., Results: Of 949 eligible questionnaires, 502 were returned, providing an adjusted response rate of 53%. In the year before the survey took place, one or more patients aged >60 years, and 5 years after breast-conserving therapy, were discharged to 22% of GPs (n=112) for follow-up. According to 56% of these GPs, transfer of follow-up was communicated by the hospital. The initiative to arrange follow-up visits and mammography appointments was mainly taken by patients. In this survey, 40% of GPs (n=200) were willing to accept exclusive responsibility for follow-up earlier than 5 years after completion of active treatment. Perceived barriers in current and future primary care-based follow-up included: communication with breast cancer specialists, patients' preference for specialist follow-up, GPs' oncology knowledge and skills and the organisation of follow-up in general practice., Conclusions: Primary care-based follow-up might be improved if breast cancer specialists discharge patients more actively to their GPs. Survivorship care plans are needed to facilitate communication across the primary/secondary interface and with patients. Training of GPs and developing administrative tools may be helpful in arranging follow-up care and using guidelines in general practice., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Cardiovascular disease (CVD) is largely preventable and prevention expenditures are relatively low. The randomised controlled SPRING-trial (SPRING-RCT) shows that cardiovascular risk management by practice nurses in general practice with and without self-monitoring both decreases cardiovascular risk, with no additional effect of self-monitoring. For considering future approaches of cardiovascular risk reduction, cost effectiveness analyses of regular care and additional self-monitoring are performed from a societal perspective on data from the SPRING-RCT., Methods: Direct medical and productivity costs are analysed alongside the SPRING-RCT, studying 179 participants (men aged 50-75 years, women aged 55-75 years), with an elevated cardiovascular risk, in 20 general practices in the Netherlands. Standard cardiovascular treatment according to Dutch guidelines is compared with additional counselling based on self-monitoring at home (pedometer, weighing scale and/ or blood pressure device) both by trained practice nurses. Cost-effectiveness is evaluated for both treatment groups and patient categories (age, sex, education)., Results: Costs are €98 and €187 per percentage decrease in 10-year cardiovascular mortality estimation, for the control and intervention group respectively. In both groups lost productivity causes the majority of the costs. The incremental cost-effectiveness ratio is approximately €1100 (95% CI: -5157 to 6150). Self-monitoring may be cost effective for females and higher educated participants, however confidence intervals are wide., Conclusions: In this study population, regular treatment is more cost effective than counselling based on self-monitoring, with the majority of costs caused by lost productivity., Trial Registration: Trialregister.nl identifier: http://NTR2188.

Background: Lower social economic status (SES) is related to an elevated cardiovascular (CV) risk. A pro-active primary prevention CV screening approach in general practice (GP) might be effective in a region with a low mean SES. This approach, supported by a regional GP laboratory, was investigated on feasibility, attendance rate and proportion of persons identified with an elevated risk., Methods: In a region with a low mean SES, men and women aged ≥ 50/55 years, respectively, were invited for cardiovascular risk profiling, based on SCORE 10-year risk of fatal cardiovascular disease and additional risk factors (family history, weight and end organ damage). Screening was performed by laboratory personnel, at the GP practice. Treatment advice was based on Dutch GP guidelines for cardiovascular risk management. Response rates were compared to those in five other practices, using the same screening method., Results: 521 persons received invitations, 354 (68%) were interested, 33 did not attend and 43 were not further analysed because of already known diabetes/cardiovascular disease. Eventually 278 risk profiles were analysed, of which 60% had a low cardiovascular risk (SCORE-risk <5%). From the 40% participants with a SCORE-risk ≥ 5%, 60% did not receive medication yet for hypertension/hypercholesterolemia. In the other five GPs response rates were comparable to the currently described GP., Conclusion: Screening in GP in a low SES area, performed by a laboratory service, was feasible, resulted in high attendance, and identification and treatment advice of many new persons at risk for cardiovascular disease.

Background: In an attempt to control chronic benzodiazepine use and its costs in the Netherlands, health care insurance reimbursement of this medication was stopped on January 1st 2009. This study investigates whether benzodiazepine prescriptions issued by general practitioners changed during the first two years following implementation of this regulation., Methods: Registry study based on data from all benzodiazepine users derived from the Registration Network Groningen. This general practice-based research network collects longitudinal data on the primary care administered to about 30,000 patients. Based on the number of quarterly accumulated prescription days, a comparison was made of benzodiazepine prescriptions issued between 2007/2008 and 2009/2010. Also investigated was which type of user (i.e. short-term or long-term) showed the most change., Results: Information on benzodiazepine prescriptions among 5,200 patients from 16 consecutive trimesters between 2007 and 2010 was available for analysis. A significant reduction in prescription days was observed between 2007/2008 and 2009/2010. Overall, an estimated 1.73 (CI:-1.94 to -1.53; p<0.001) days were less prescribed per trimester after the termination of reimbursement. In particular, short-term users experienced a reduction in prescription days in 2009 and 2010. The number of long-term users decreased by 2.3%, while the number of individuals that did not use increased by 4.2%., Conclusions: A total reduction of almost 14 prescription days was observed over eight trimesters after implementation of the regulation to terminate the reimbursement of benzodiazepines. Short-term users were mainly responsible for this reduction in prescription days in 2009 and 2010. Although long-term users did not alter their benzodiazepine use in 2009 and 2010, the number of long-term users decreased slightly.

Background: Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown., Aim: To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes., Design and Setting: A cross-sectional study in primary care in the Netherlands., Method: A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument., Results: The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively., Conclusion: OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not.

The Groningen Overweight and Lifestyle (GOAL) intervention effectively prevents weight gain. The present study describes a process evaluation in which 214 participants in the intervention group received a structured questionnaire within 7 months (a median of 5 months) after the end of the intervention. The authors investigated the content of the intervention (on basis of the participants' recall), the participants' satisfaction of the intervention, the participants' satisfaction with the nurse practitioners (NPs), and the determinants of the participants' satisfaction. In general, the results show that the content corresponded well with the protocol for the intervention, except for the number of telephone calls and the percentage of participants with individualized goals for a healthy lifestyle. The overall satisfaction of the participants was high, and success and perceived success and a low educational level were important determinants for a higher overall satisfaction grade. Furthermore, the NP was considered to be an expert and motivational to learning and keeping up a healthy lifestyle. The authors therefore conclude that the GOAL study is feasible and indicates that the NP is well equipped to treat these patients. However, it is recommended to reinforce the advice given and the lifestyle goals after the first contact sessions.

Background: Treatment goals for cardiovascular risk management are generally not achieved. Specialized practice nurses are increasingly facilitating the work of general practitioners and self-monitoring devices have been developed as counseling aid. The aim of this study was to compare standard treatment supported by self-monitoring with standard treatment without self-monitoring, both conducted by practice nurses, on cardiovascular risk and separate risk factors., Methods: Men aged 50-75 years and women aged 55-75 years without a history of cardiovascular disease or diabetes, but with a SCORE 10-year risk of cardiovascular mortality ≥ 5% and at least one treatable risk factor (smoking, hypertension, lack of physical activity or overweight), were randomized into two groups. The control group received standard treatment according to guidelines, the intervention group additionally received pro-active counseling and self-monitoring (pedometer, weighing scale and/ or blood pressure device). After one year treatment effect on 179 participants was analyzed., Results: SCORE risk assessment decreased 1.6% (95% CI 1.0-2.2) for the control group and 1.8% (1.2-2.4) for the intervention group, difference between groups was .2% (-.6-1.1). Most risk factors tended to improve in both groups. The number of visits was higher and visits took more time in the intervention group (4.9 (SD2.2) vs. 2.6 (SD1.5) visits p< .001 and 27 (P25 -P75:20-33) vs. 23 (P25 -P75:19-30) minutes/visit p= .048)., Conclusions: In both groups cardiovascular risk decreased significantly after one year of treatment by practice nurses. No additional effect of basing the pro-active counseling on self-monitoring was found, despite the extra time investment., Trial Registration: trialregister.nl NTR2188.

Objective: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient and FP characteristics were related to recognition., Method: A cross-sectional comparison was made between FPs' registration and a structured diagnostic interview, the Composite International Diagnostic Interview, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Seven definitions of recognition were tested using diagnostic codes, medication data, referral data and free text in medical records. Data were derived from the Netherlands Study of Depression and Anxiety. A total of 816 patients were included., Results: Recognition ranged between 9.1% and 85.8%. A broader definition was associated with a higher recognition rate, but led to more false positives. The best definition comprised diagnostic codes for anxiety disorders and symptoms, strong free-text indications, medication and referral to mental health care. Generalized anxiety disorder was best recognized by this definition. Recognition was better among patients with increased severity, comorbid depression and older age., Conclusion: FPs recognized anxiety disorders better than previously reported when all medical record data were taken into account. However, most patients were nonspecifically labeled as having a mental health problem., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: An observational study to examine whether thrombolytic therapy in stroke patients realizes better quality of life outcomes compared to patients without thrombolytic therapy one year after stroke. We also examined whether daily functioning, mental functioning and activities improved after thrombolytic treatment., Methods: A total of 88 stroke patients were interviewed at home one year post-stroke. Health-related quality of life (HRQOL) was assessed using the RAND-36, disability with the Barthel Index, depression and anxiety with the Hospital Anxiety and Depression Scale, and a questionnaire about patient way of life was completed. People aged under 60, moving to a nursing home or with a haemorrhage were excluded., Results: The thrombolysis group (TG) had more severe stroke (higher NIHSS) scores and were younger than the group without thrombolytic therapy (WTG). The primary outcome was HRQOL, which was high and nearly identical in both groups, however the TG had significantly better HRQOL for the 'mental health' and 'vitality' scales. Patients who stopped or reduced their hobbies because of stroke had a significantly worse HRQOL. One year after stroke, more patients in the TG were totally or severely ADL dependent (12% TG and 0% WTG, p = 0.022). The level of dependence decreased in the TG (p = 0.042) and worsened in the WTG (p < 0.001) after one year. Being more dependent is related to diminishing daily occupations in both groups. In the TG the level of dependence had less impact on visiting family and friends and going on holiday. The prevalence of anxiety disorder and depression was low compared to other studies and there is no significant difference between the two groups., Conclusion: No major differences in the primary outcome (HRQOL) could be found between the two groups. In addition, no essential difference could be found in mental functioning and participation. We expected that patients undergoing thrombolytic therapy would have worse quality of life because of the greater initial severity of their stroke. Therefore, thrombolytic therapy seems to be of great importance in achieving better quality of life in ischemic stroke patients who respond to this therapy.

Background: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement., Methods: This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records., Results: 721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes., Conclusion: The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Purpose: This study of Australian and Dutch people with anxiety or depressive disorder aims to examine people's perceived needs and barriers to care, and to identify possible similarities and differences., Methods: Data from the Australian National Survey of Mental Health and Well-Being and the Netherlands Study of Depression and Anxiety were combined into one data set. The Perceived Need for Care Questionnaire was taken in both studies. Logistic regression analyses were performed to check if similarities or differences between Australia and the Netherlands could be observed., Results: In both countries, a large proportion had unfulfilled needs and self-reliance was the most frequently named barrier to receive care. People from the Australian sample (N = 372) were more likely to perceive a need for medication (OR 1.8; 95% CI 1.3-2.5), counselling (OR 1.4; 95% CI 1.0-2.0) and practical support (OR 1.8; 95% CI 1.2-2.7), and people's overall needs in Australia were more often fully met compared with those of the Dutch sample (N = 610). Australians were more often pessimistic about the helpfulness of medication (OR 3.8; 95% CI 1.4-10.7) and skills training (OR 3.0; 95% CI 1.1-8.2) and reported more often financial barriers for not having received (enough) information (OR 2.4; 95% CI 1.1-5.5) or counselling (OR 5.9; 95% CI 2.9-11.9)., Conclusions: In both countries, the vast majority of mental health care needs are not fulfilled. Solutions could be found in improving professionals' skills or better collaboration. Possible explanations for the found differences in perceived need and barriers to care are discussed; these illustrate the value of examining perceived need across nations and suggest substantial commonalities of experience across the two countries.

Background: Whether course trajectories of depressive and anxiety disorders are different, remains an important question for clinical practice and informs future psychiatric nosology. This longitudinal study compares depressive and anxiety disorders in terms of diagnostic and symptom course trajectories, and examines clinical prognostic factors., Methods: Data are from 1209 depressive and/or anxiety patients residing in primary and specialized care settings, participating in the Netherlands Study of Depression and Anxiety. Diagnostic and Life Chart Interviews provided 2-year course information., Results: Course was more favorable for pure depression (n=267, median episode duration = 6 months, 24.5% chronic) than for pure anxiety (n=487, median duration = 16 months, 41.9% chronic). Worst course was observed in the comorbid depression-anxiety group (n=455, median duration > 24 months, 56.8% chronic). Independent predictors of poor diagnostic and symptom trajectory outcomes were severity and duration of index episode, comorbid depression-anxiety, earlier onset age and older age. With only these factors a reasonable discriminative ability (C-statistic 0.72-0.77) was reached in predicting 2-year prognosis., Limitation: Depression and anxiety cases concern prevalent - not incident - cases. This, however, reflects the actual patient population in primary and specialized care settings., Conclusions: Their differential course trajectory justifies separate consideration of pure depression, pure anxiety and comorbid anxiety-depression in clinical practice and psychiatric nosology., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Background: Continuity of end-of-life care for patients receiving palliative care is an important challenge for out-of-hours services in general practice., Aim: To investigate how frequent information is transferred on patients receiving palliative care from GPs to the out-of-hours services, to explore the perceptions of GP's on this information transfer and to study the relation between information transfer and the used GP information systems., Methods: This is a mixed-method design study. The frequency of information transfer to the out-of-hours services was investigated by analyzing a regional out-of-hours database. Barriers and promoting factors for this transfer of information were investigated by using semi-structured interviews among a purposive sample of GPs from the same region. The relation between information transfer and the GP information system was investigated by a postal questionnaire in a national random selection of GPs., Results: When a palliative patient contacted the out-of-hours service, for 20% of these patients, a transfer of information was available and only half of these transfers included an anticipating end-of-life plan. All interviewed GPs considered continuity of care for these patients as important. However, some doubted whether a transfer of information is relevant for the quality of care. There was no relation between the information transfer and the used GP information systems., Conclusion: For only a minority of patients receiving palliative care, a transfer of information including an anticipating management plan was present. There is a large variation in the opinions of GPs on how to organize continuity of end-of-life care.

Background: Care for patients with chronic diseases is challenging and requires multifaceted interventions to appropriately coordinate the entire treatment process. The effect of such interventions on clinical outcomes has been assessed, but evidence of the effect on organization of care is scarce.The aim is to assess the effect of structured diabetes care on organization of care from the perspective of patients and healthcare professionals in routine practice, and to ascertain whether this effect persists, Methods: In a quasi-experimental study the effect of structured care (SC) was compared with care-as-usual (CAU). Questionnaires were sent to healthcare professionals (SC n = 31; CAU n = 11) and to patients (SC n = 301; CAU n = 102). A follow-up questionnaire was sent after formal support of the intervention ended (2007)., Results: SC does have an effect on the organization of care. More cooperation between healthcare professionals, less referrals to secondary care and more education were reported in the SC group as compared to the CAU group. These changes were found both at the healthcare professional and at the patient level. Organizational changes remained after formal support for the intervention support had ended., Conclusion: According to patients and healthcare professionals, structured care does have a positive effect on the organization of care. The use of these two sources of information is important, not only to assess the value of changes in care for the patient and the healthcare provider but also to ascertain the validity of the results found.

Background: Patients with heart failure (HF) often perceive adverse drug events (ADEs), affecting quality of life. For weighing the benefits and burden of medication in HF care, knowledge on patients' perception of ADEs is needed. Our aim was to assess these ADE perceptions and to identify factors related to these perceptions., Methods: A cross-sectional study was performed including HF patients recruited from primary care and outpatient clinics. Patients were included in the analysis if they perceived an ADE in the past 4 weeks. This information was collected using an open-ended question and a symptom checklist. Data on ADE perception were obtained using a modified version of the Revised Illness Perception Questionnaire. Demographic, clinical, and ADE characteristics were collected by self-administered questionnaire and chart review. The relations between these factors and ADE perceptions were analyzed using regression analyses., Results: In total, 261 HF patients perceived an ADE and completed the questionnaire. Patients reported 814 ADEs, of which 26% of the patients reported dizziness and 24% reported dry mouth as being the most prevalent. Almost half of the patients (46%) perceived their ADE as something serious, with major consequences for their daily life (40%) and reported to be worried (36%) about the ADE. Patients perceived the ADE as a chronic problem (91%), and the majority believed more in the ability of the health care provider to control the ADE (61%) than in their own ability (46%). Demographic and clinical variables had a limited contribution to the explained variance of ADE perceptions after adjusting for ADE characteristics, such as perceived severity., Conclusion: Patients with HF perceive particular negative consequences and emotional distress of symptomatic ADE. Open communication between patients and providers with attention for patients ADE perceptions would be valuable during the decision process of ADE management and may result in a regimen aligned with patients' preferences and needs.

Background: Annually, 41,000 people in the Netherlands have strokes. This has multiple physical and psychosocial consequences. Most patients return home after discharge from hospital. Quality aftercare by general practitioners is important to support patients at home. The purpose of this study is to examine the wellbeing of patients who returned home immediately after discharge from hospital, one year post stroke, in comparison with the general Dutch population of the same age and to determine factors that could influence wellbeing., Methods: All the stroke patients from the Department of Neurology, Martini Hospital Groningen in the period November 2006 to October 2007 were included. People aged under 65 years or with haemorrhaging were excluded. All the patients (N=57) were interviewed at home using the following questionnaires: Barthel Index, SF-36, HADS, CSI and a questionnaire about their way of life., Results: 31% of the patients in this study experienced a decrease in functional status after one year. Nevertheless, there was no significant difference between the median Barthel Index value at discharge from hospital and one year post stroke. ADL independence correlated with a better quality of life. The health-related quality of life was high. Stroke patients have almost the same quality of life as the 'average' Dutch elderly population. Where patients can no longer fully participate in society, their perceived quality of life is also lower. In this study there is an indication of a high prevalence of depression and anxiety disorders in stroke patients. This negatively affects the quality of life a year after stroke. Although caregiver strain was low for the partners of stroke patients, a reduced quality of life is correlated to greater burden., Conclusions: This study provides valuable insight into the wellbeing of patients living at home one year post stroke. Physical functioning and quality of life are comparable to the general population of the same age, but improvements in mental functioning can be envisaged. In addition, more attention should be paid to maintaining the patients' activities. The wellbeing of these stroke patients could be increased further if greater attention is paid to these aspects of life. This seems to be applicable to general practice.

Background: Depression is a common illness, often treated in primary care. Many studies have reported undertreatment with antidepressants in primary care. Recently, some studies also reported overtreatment with antidepressants. The present study was designed to assess whether treatment with antidepressants in primary care is in accordance with current guidelines, with a special focus on overtreatment., Methodology: We used baseline data of primary care respondents from the Netherlands Study of Depression and Anxiety (NESDA) (n = 1610). Seventy-nine patients with treatment in secondary care were excluded. We assessed justification for treatment with antidepressant according to the Dutch primary care guidelines for depression and for anxiety disorders. Use of antidepressants was based on drug-container inspection or, if unavailable, on self-report. Results were recalculated to the original population of primary care patients from which the participants in NESDA were selected (n = 10,677)., Principal Findings: Of 1531 included primary care patients, 199 (13%) used an antidepressant, of whom 188 (94.5%) (possibly) justified. After recalculating these numbers to the original population (n = 10,677), we found 908 (95% CI 823 to 994) antidepressant users. Forty-nine (95% CI 20 to 78) of them (5.4%) had no current justification for an antidepressant, but 27 of them (54.5%) had a justified reason for an antidepressant at some earlier point in their life., Conclusions: We found that overtreatment with antidepressants in primary care is not a frequent problem. Too long continuation of treatment seems to explain the largest proportion of overtreatment as opposed to inappropriate initiation of treatment.

Objective: To describe the medical consumption [general practitioner (GP) consultation, referrals, medication consumption] of patients with shoulder complaints in general practice., Methods: Data were obtained from a primary-care medical registration network. All patients aged ≥18 years with new shoulder complaints who consulted their general practitioner in 1998 were included, and were followed 10 years beyond the initial consultation., Results: A total of 526 incident cases were identified (average age 47 years, 65% women and average follow-up 7.6 years). Nearly half of the patients consulted their GP only once. For 79% of those patients, a wait-and-see policy or a prescription for NSAIDs sufficed. During follow-up, 65% of all patients were prescribed medication. Medication consumption was significantly higher among men than women, and higher for the 45- to 64-year age group compared with the younger group. A total of 199 patients were referred, of which 84% was to a physiotherapist and 16% to secondary care. Only two patients had surgery, performed by an orthopaedic surgeon. The GP recorded a diagnosis in only 14% of patients; rotator cuff disorder being the most common., Conclusions: Nearly half of patients with a new shoulder complaint consult their GP only once. Medical consumption in general practice is highest for male shoulder patients and the 45- to 64-year age group. Shoulder problems are mainly an issue for primary care.

Objective: To evaluate care received for anxiety and depression, to identify which patient-, GP- and practice factors obstruct delivery of care in accordance with Dutch College of General Practitioners' (NHG) practice guidelines, and to evaluate the costs and effects of guideline-concordant care., Design: Descriptive study., Methods: During the baseline assessment of the Netherlands study of depression and anxiety--which has followed a large number of adults with and without psychiatric complaints since 2004--various questionnaires and diagnostic interviews were completed. At one year follow-up, the severity of symptoms of anxiety and depression, overall functioning or dysfunction, healthcare use and absenteeism from employment over the past year were assessed. Data from electronic medical patient records were studied to determine whether NHG practice guidelines had been followed., Results: Of the 721 patients with an anxiety or depressive disorder, 57% (n = 413) indicated receiving some form of care; two-thirds of this group received appropriate care according to NHG practice guidelines (n = 281). At patient level the severity of depressive symptoms, the self-evaluated need for care, a high level of education and accessibility of care were most strongly associated with guideline adherence; at general practitioner level, collaboration with other mental health professionals was most strongly associated with guideline adherence. On average, all patients had symptoms that were less serious than a year previously, irrespective of which care they had received. Guideline-concordant care was significantly more expensive., Conclusion: Half of the patients who had not received care did not think that they needed it. Of those who had received care, those with more severe symptoms and greatest need for care were most likely to have received guideline-concordant care. Both patients and general practitioners seemed well able to assess whether care was needed or not.

Objective: To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care., Design: Analysis of data from the Netherlands Study of Depression and Anxiety (NESDA)., Participants: Seven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included., Measures: Diagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners., Results: Two hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%-CI = 1.05-1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%-CI = 1.84-4.85; p < 0.001), counseling (OR = 2.25; 95%-CI = 1.29-3.95; p = 0.005) or a referral (OR = 1.83; 95%-CI = 1.09-3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%-CI = 0.11-0.98; p = 0.04) of receiving guideline-concordant care., Conclusions: This study shows that education level, accessibility of care and patients' perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs' communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary care.

Objective: Hospitals in The Netherlands have recently made certain performance data public, allowing patients to choose the location of their care. The objective of this study is to assess (a) patient preferences and experiences concerning the transition between primary and secondary health care, (b) patients' needs for choice and information and how these are influenced by personal and morbidity factors., Methods: Two different types of questionnaires were used. The first questionnaire concerns the importance that patients attach to the care provided. The second questionnaire concerns the actual experiences of the patient with the care provided. For the selection of patients, we used the databases of the registration networks of the Departments of General Practice of the Universities of Groningen and Leiden. The questionnaires were returned by 513 patients (Importance 69%) and 1404 patients (Experience 65%)., Results: Many patients prefer the GP advising them regarding which hospital or specialist they should be referred to: a quarter of the patients preferred that the GP decided for them. Patients with a curable condition and patients aged between 25 and 65, highly educated and with stable personal characteristics as measured by a purposive scale, more often wished to use information from internet or newspapers to make a decision. The amount of information that was needed on illness or treatment varied greatly. Young people, older people, and those with less stable personal characteristics more often desired only practical information., Conclusions: In spite of making performance data of different health care institutions public, only a limited number of patients want to use this information on a limited number of health problems., Practice Implications: Care providers should take differences into account concerning patients' need for information on their illness., (2009 Elsevier Ireland Ltd. All rights reserved.)

A major problem in the analysis of attrition of cohorts in studies on mental health problems is that data on those who do not participate at the outset of a study are largely unavailable. It is not known how underlying psychopathology affects the first stages of screening where non-response and selectivity are usually highest. This article presents results of one of the centres of the Netherlands Study of Depression and Anxiety (NESDA), a longitudinal study aimed at describing the long-term course and consequences of depression and anxiety disorders. The aim is to describe the different ways of attrition during the first NESDA-wave in a cohort of patients aged 18-65 years of the Registration Network Groningen and to analyse whether attrition is related to gender, age and psychopathology as recorded in general practice. The attrition of the study cohort (n = 8475) was highest during the first stages, eventually leading to a population of 169 patients only who participated in the full NESDA-programme. Probabilities of transition from one stage of the screening process to the next were regressed on selected background variables using binary logistic regression. Correlates of participation were being female and being older (>40). Psychopathology was an important variable in the formation of the initial sample cohort, but only had a weak influence on patient response to the screening questionnaire. Study design factors had a stronger impact on the changing composition of the cohort at each screening stage compared to patient factors.

Background: Many anxiety and depression patients receive no care, resulting in unnecessary suffering and high costs. Specific beliefs and the absence of a perceived need for care are major reasons for not receiving care. This study aims to determine the specific perceived need for care in primary care patients with anxiety and depression, and examine to what extent these different needs are met., Methods: Cross-sectional data were derived from The Netherlands Study of Depression and Anxiety (NESDA). In 622 primary care patients with a current (6-month recency) diagnosis of depression and/or anxiety disorder who recognised their mental health problem themselves, the perceived need for mental health care was measured by the Perceived Need for Care Questionnaire (PNCQ). Possible determinants were measured in the same interview by means of a questionnaire., Results: Most patients with anxiety or depression expressed a need for counselling or information. Medication, practical support, skills training and a referral were less often perceived to be needed. Multiple logistic regression analyses revealed that after controlling for age, clinical status and disability, patients' confidence in professional help and their evaluation of received care positively influenced their perception of a need for medication and counselling., Conclusions: Although no conclusions can be made about what type of care was specifically not wanted, patients with anxiety or depression mostly want to receive information and counselling. Health professionals should be aware of the fact that there are differences in perceived need for care between subgroups of patients, based on their beliefs and their evaluation of care.

Background: Lifestyle interventions targeting prevention of weight gain may have better long-term success than when aimed at weight loss. Limited evidence exists about such an approach in the primary care setting., Design: An RTC was conducted., Setting/participants: Participants were 457 overweight or obese patients (BMI=25-40 kg/m(2), mean age 56 years, 52% women) with either hypertension or dyslipidemia, or both, from 11 general practice locations in The Netherlands., Intervention: In the intervention group, four individual visits to a nurse practitioner (NP) and one feedback session by telephone were scheduled for lifestyle counseling with guidance of the NP using a standardized computerized software program. The control group received usual care from their general practitioner (GP)., Main Outcome Measures: Changes in body weight, waist circumference, blood pressure, and blood lipids after 1 year (dropout <10%). Data were collected in 2006 and 2007. Statistical analyses were conducted in 2007 and 2008., Results: There were more weight losers and stabilizers in the NP group than in the general practitioner usual care (GP-UC) group (77% vs 65%; p<0.05). In men, mean weight losses were 2.3% for the NP group and 0.1% for the GP-UC group (p<0.05). Significant reductions occurred also in waist circumference but not in blood pressure, blood lipids, and fasting glucose. In women, mean weight losses were in both groups 1.6%. In the NP group, obese people lost more weight (-3.0%) than the non-obese (-1.3%; p<0.05)., Conclusions: Standardized computer-guided counseling by NPs may be an effective strategy to support weight-gain prevention and weight loss in primary care, in the current trial, particularly among men., Trial Registration: The study was registered with the Netherlands Trial Register (NTR), www.trialregister.nl, study no. TC 1365.

Background: Relatives who are bereaved by suicide likely consult their GP when they feel the need for professional help. GPs may play a key role in establishing who is at risk for adverse consequences of the loss as they are familiar with relatives' possible psychiatric vulnerabilities. The availability of evidence-based services for relatives of suicide victims is limited. Successful implementation of services needs analysis of key factors considered critical in the achievement of changes. We investigated GPs' management of help requests of relatives bereaved by suicide and examined determinants of GPs willingness to refer for evidence-based follow-up care., Methods: A cross-sectional survey among 488 GPs in the northern part of The Netherlands., Results: A 44% response was achieved (n = 214) during the last 3 years, 38 (18%) were exposed to suicide, 21 (10%) to help requests without being exposed to suicide and 52 (24%) to both suicide and help requests. Out of 106 requests, 69 (65%) were handled by the GP; 60 (57%) were either directly or additionally referred, principally for mental health care. Suicide exposure and female gender were associated with the doctor's perception that follow-up care following a loss through suicide is useful. The perception that help is useful increased the likelihood of GPs' referral for evidence-based follow-up care., Conclusions: GPs support the availability of evidence-based follow-up care for relatives of suicide victims. To modify GPs' key role in referring relatives for it, GPs should be well informed of its usefulness and to whom.

The Netherlands Study of Depression and Anxiety (NESDA) is a multi-site naturalistic cohort study to: (1) describe the long-term course and consequences of depressive and anxiety disorders, and (2) to integrate biological and psychosocial research paradigms within an epidemiological approach in order to examine (interaction between) predictors of the long-term course and consequences. Its design is an eight-year longitudinal cohort study among 2981 participants aged 18 through 65 years. The sample consists of 1701 persons with a current (six-month recency) diagnosis of depression and/or anxiety disorder, 907 persons with life-time diagnoses or at risk because of a family history or subthreshold depressive or anxiety symptoms, and 373 healthy controls. Recruitment took place in the general population, in general practices (through a three-stage screening procedure), and in mental health organizations in order to recruit persons reflecting various settings and developmental stages of psychopathology. During a four-hour baseline assessment including written questionnaires, interviews, a medical examination, a cognitive computer task and collection of blood and saliva samples, extensive information was gathered about key (mental) health outcomes and demographic, psychosocial, clinical, biological and genetic determinants. Detailed assessments will be repeated after one, two, four and eight years of follow-up. The findings of NESDA are expected to provide more detailed insight into (predictors of) the long-term course of depressive and anxiety disorders in adults. Besides its scientific relevance, this may contribute to more effective prevention and treatment of depressive and anxiety disorders.

Objective: To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients' psychological problems., Methods: Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs' awareness of the patient's psychological problems and their communication as outcome measures, the GPs' workload as a predictor, and GP and patient characteristics as confounders., Results: GPs' workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients' psychological problems., Conclusion: Patients' feelings of distress are more important for GPs' communication and their awareness of patients' psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems., Practice Implications: We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs' training. Additionally, attention for gender differences and stress management is recommended in GPs' training.

Background: The extra workload induced by patients with mental health problems may sometimes cause GPs to be reluctant to become involved in mental health care. It is known that dealing with patients' mental health problems is more time consuming in specific situations such as in consultations. But it is unclear if GPs who are more often involved in patients' mental health problems, have a higher workload than other GPs. Therefore we investigated the following: Is the attention GPs pay to their patients' mental health problems related to their subjective and objective workload?, Methods: Secondary analyses were made using data from the Second Dutch National Survey of General Practice, a cross sectional study conducted in the Netherlands in 2000-2002. A nationally representative selection of 195 GPs from 104 general practices participated in this National Survey. Data from: 1) a GP questionnaire; 2) a detailed log of the GP's time use during a week and; 3) an electronic medical registration system, including all patients' contacts during a year, were used. Multiple regression analyses were conducted with the GP's workload as an outcome measure, and the GP's attention for mental health problems as a predictor. GP, patient, and practice characteristics were included in analyses as potential confounders., Results: Results show that GPs with a broader perception of their role towards mental health care do not have more working hours or patient contacts than GPs with a more limited perception of their role. Neither are they more exhausted or dissatisfied with the available time. Also the number of patient contacts in which a psychological or social diagnosis is made is not related to the GP's objective or subjective workload., Conclusion: The GP's attention for a patient's mental health problems is not related to their workload. The GP's extra workload when dealing in a consultation with patients' mental health problems, as is demonstrated in earlier research, is not automatically translated into a higher overall workload. This study does not confirm GPs' complaints that mental health care is one of the components of their job that consumes a lot of their time and energy. Several explanations for these results are discussed.

This contribution reports on the acceptability and feasibility to nurses and patients of an intervention to ameliorate minor depression among patients with chronic physical diseases. Elderly patients with chronic obstructive pulmonary disease (COPD) and type II Diabetes Mellitus were recruited from 10 general practices. All eligible patients were screened. Twenty-nine patients with minor depression gave their informed consent to participate in this feasibility study. The nurses spent an average of 70 min per visit. Our intervention appeared feasible and acceptable to patients and nurses. For the nurses, it provided an additional tool for a well-known problem. The majority of the patients regarded the intervention as worthwhile and effective. Patients had difficulties in understanding the link between physical complaints and symptoms of depression. The intervention has been further improved on the basis of our experiences, and is now ready to be tested in an effectiveness study.

Background: General practitioners' (GPs) ability to recognize, diagnose and treat depression improved significantly after a comprehensive, 20-h training programme. This study aims to evaluate in more detail the effects of the training on GPs' pharmacotherapy of depression and related issues., Methods: A pretest-posttest design was used. Both in the pre- and post-training phase, a sample was drawn from consecutive patients of the 17 participating GPs. In the pre-training phase we identified a sample of 31 cases with an ICD-10 depression who received an antidepressant from their GP. The sample was followed for 1 year. Outcome measures were: type of antidepressant, dosage, duration and number of target instructions given by the GP. Then we trained the GPs. In the post-training phase, we identified a new sample (n = 47) from their practices and measured the same outcomes., Results: Improvements were seen in choice for modern antidepressant, adequate dosage, adequate duration, and number of target instructions given., Limitations: Observed changes can be due to a period effect, inherent in a pre-post design., Conclusions: A post-academic hands-on training of GPs can improve depression pharmacotherapy according to clinical guidelines with respect to choice of a modern antidepressant, adequate dosage, adequate duration and psychoeducation.

Background: We developed a comprehensive, 20-hour training programme for primary-care physicians, that sought to improve their ability to detect, diagnose and manage depression. We evaluated the effects of physician training on patient outcomes, using a pre-post design., Methods: In the pre-training phase of the study, we sampled 1834 consecutive patients of 17 primary-care physicians and evaluated 518 of these patients for the presence of depression. We measured outcomes of all patients with depression at 3 months and 1 year. The outcome measures were: severity of psychopathology; duration of depressive episode; and level of daily functioning. After the 17 physicians completed the training, we drew a new sample from their practices (498 of 1785 consecutive patients were evaluated for depression) and measured outcomes for the depressed patients., Results: We found an effect of the training on short-term outcome, particularly for patients with a recent-onset depression. At 3-month follow-up depressed patients whose physicians had received training had less severe psychopathology and patients with recent-onset depression also showed higher levels of daily functioning than patients of the same physicians prior to the training. The patients with a recent-onset depression that was recognized by trained physicians had shorter depressive episodes, but this was not statistically significant. At 1-year follow-up, all training effects had faded away., Conclusions: Training primary-care physicians to recognize, diagnose and manage depression can improve short-term patient outcomes, especially for patients with a recent onset of depression. Patients suffering from a recurrent or chronic depression may need more specific interventions, both for acute treatment and long-term management.

The purpose of this pretest-posttest study was to evaluate effects of a training program designed to improve primary care physicians' (PCPs) ability to recognize mental health problems (MHP) and to diagnose and manage depression according to clinical guidelines. The primary care settings were in the northern part of The Netherlands. There were eight intensive, hands-on training sessions of 2.5 hours, each of which three were targeting depression (7.5 hours). In the pretraining phase we screened 1778 consecutive patients of 17 PCPs with the 12-item General Health Questionnaire (GHQ-12) and interviewed a stratified sample of 518 patients about presence of current depression with the Primary Health Care version of the Composite International Diagnostic Interview (CIDI-PHC). PCPs registered patient's mental health (status, severity, diagnosis) and treatment prescribed. Then we trained the PCPs. In the posttraining phase, we screened a new group of 1724 consecutive patients of the same PCPs and a new stratified sample of 498 patients went through the same interview and rating procedures as patients in the pretraining phase. Knowledge about depression was assessed pre- and posttraining. PCPs' knowledge of depression improved significantly. Recognition of MHP and accuracy of depression diagnosis improved, but was not statistically significant. The proportion of patients receiving treatment according to the clinical guidelines increased significantly. It was observed that training PCPs improves the management of depression.

Objective: To examine to what extent postgraduate training of general practitioners (GPs) with the Intervention Study Primary Care (INSTEL) programme improved detection, diagnosis, and treatment of depression, and whether the course of depression was influenced favourably., Design: Prospective, comparative., Setting: Academic Hospital Groningen, discipline group Psychiatry and General Practice, Groningen, the Netherlands., Method: General practitioners active in ten practices in Groningen and surrounds were trained in recognition and treatment of depression. The first group consisted of ten GPs who had not participated in psychiatrically oriented research before, the second group of seven GPs who had participated in such research. Both before and after the training, a group of patients aged 18-65 years visiting these GPs' office hours were examined by the investigators for presence of depression with the aid of questionnaires. The GPs recorded of each patient whether or not they found him/her depressed, and they mentioned the treatment. The researchers assessed the outcomes of depressed patients shortly after the index consultation and at 3 and 12-month follow-up., Results: Before the training a questionnaire was completed by 1778 patients, of whom 179 were depressed; after the training a questionnaire was completed by 1724 patients, of whom 155 were depressed. Detection and diagnosis of depression improved in the first group of GPs, but not in the second group. Treatment improved for patients in both groups. In terms of symptoms, illness duration, daily functioning, and absence from work patients recovered slightly faster from their depression after the training, although the effects were weak, not always statistically significant (p < 0.05), and mostly limited to the subgroup of recognized depressions with a recent onset. At the 12-month follow-up the pre-post differences were not statistically significant., Conclusion: The postgraduate training with the INSTEL programme appears to be an effective intervention that improves treatment and somewhat speeds up recovery in recent onset cases.

Objective: To establish the prevalence of depression and other psychiatric disorders in the contact population of primary care physicians (PCPs) in several countries., Design: Descriptive., Setting: World Health Organization (WHO), Geneva, Switzerland., Method: The WHO carried out a study in 15 centers in 14 different countries, including the Groningen centre in the Netherlands. This study comprised interviewing 5438 patients with the primary health care version of the 'Composite international diagnostic interview' (CIDI). The PCPs also evaluated their patients' somatic and psychic health., Results: Depression was found to be seen at all centres, according to the CIDI results as well as according to the physicians. Most patients with a depression were treated by the PCPs themselves; only a small proportion were referred. As regards pharmacotherapy, in most centres tranquillizers were prescribed more often than antidepressive agents. Groningen differed from the other centres in that a larger proportion of depressive patients attended the PCPs for a psychological reason for encounter, and in that the patients' somatic health was classified as much better. The Groningen PCPs referred to institutes for mental health care more often than the PCPs in most other centres., Conclusion: Depression was diagnosed in all participating countries, both by PCPs and with the aid of the CIDI results.

This article addresses the issues of recognition and labelling of psychological disorders (PDs) by general practitioners (GPs), and the association of recognition with management and outcome. Nearly 2000 attenders of 25 GPs were screened with the GHQ and a stratified sample of 296 patients was examined twice, using the Present State Examination (PSE) and Groningen Social Disability Schedule (GSDS). Prevalence rates of PDs according to the GHQ, GP and PSE were 46%, 26% and 15% respectively. For the 1450 'new' patients, i.e. patients who had no PD diagnosed by their GP in the 12 months prior to the enrollment visit, these rates were 38%, 14%, and 10%. GPs missed half of the PSE cases and typically assigned non-specific diagnoses to recognized cases. Depressions were more readily recognized than anxiety disorders, and the detection rates for severe disorders were higher than those for less severe disorders. Recognition was strongly associated with management and outcome. Recognized as compared to non-recognized cases were more likely to receive mental health interventions from their GP and had better outcomes in terms of both psychopathology and social functioning. Initial severity, psychological reasons for encounter, recency of onset, diagnostic category, and psychiatric comorbidity were related to both better recognition and outcome. However, these variables could not account for the association of recognition with management and outcome, but some did modify the association. A causal model of the relationships is presented and possible reasons for non-recognition and for the beneficial effects of recognition are discussed.