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BACKGROUND: Only half of all depressions are diagnosed in Primary Health Care (PHC). Depression can remain undetected for a long time and entail high costs for care and low quality of life for the individuals. Drop in clinic is a common form of organizing health care; however the visits are short and focus on solving the most urgent problems. The aim of this study was to investigate the prevalence and severity of depression among women visiting the GPs' drop in clinic and to identify possible clues for depression among women. METHODS: The two-stage screening method with 'high risk feedback' was used. Beck's Depression Inventory (BDI) was used to screen 155 women visiting two GPs' drop in clinic. Women who screened positive (BDI score > or =10) were invited by the GP to a repeat visit. Major depression (MDD) was diagnosed according to DSM-IV criteria and the severity was assessed with Montgomery-Asberg Depression Rating Scale (MADRS). Women with BDI score <10 constituted a control group. Demographic characteristics were obtained by questionnaire. Chart notations were examined with regard to symptoms mentioned at the index visit and were categorized as somatic or mental. RESULTS: The two-stage method worked well with a low rate of withdrawals in the second step, when the GP invited the women to a repeat visit. The prevalence of depression was 22.4% (95% CI 15.6-29.2). The severity was mild in 43%, moderate in 53% and severe in 3%. The depressed women mentioned mental symptoms significantly more often (69%) than the controls (15%) and were to a higher extent sick-listed for a longer period than 14 days. Nearly one third of the depressed women did not mention mental symptoms. The majority of the women who screened as false positive for depression had crisis reactions and needed further care from health professionals in PHC. Referrals to a psychiatrist were few and revealed often psychiatric co-morbidity. CONCLUSION: The prevalence of previously undiagnosed depression among women visiting GPs' drop in clinic was high. Clues for depression were identified in the depressed women's symptom presentation; they often mention mental symptoms when they visit the GP for somatic reasons e.g. respiratory infections. We suggest that GPs do selective screening for depression when women mention mental symptoms and offer to schedule a repeat visit for follow-up rather than just recommending that the patient return if the mental symptoms do not disappear. [ABSTRACT FROM AUTHOR]

Objective: This study explores the effectiveness of using the International Classification of Functioning, Disability and Health (ICF) as a coding framework to document work-related disability information in sick leave certificates, focusing on depression and fibromyalgia in Sweden., Design: A qualitative ICF linking study was conducted, mapping information from 200 certificates per diagnosis to ICF., Methods: ICF linking rules were followed strictly. The coverage of ICF and ICF Core Sets was evaluated, proposing additional ICF categories when relevant categories were not included. Saturation of ICF categories was considered achieved if no new categories appeared in the last 5 certificates., Results: The study found high ICF coverage (85% for depression, 78% for fibromyalgia) in capturing work-related disability information. However, there was limited coverage in ICF Core Sets due to an excess of ICF categories in the Core Sets. Also, 2 additional relevant ICF categories for depression and 3 for fibromyalgia were identified., Conclusion: This study confirms that the International Classification of Functioning, Disability and Health is suitable for coding work-related disability in sick leave certificates. However, the identified limitations in ICF Core Sets highlights the need for context-specific subsets to enhance their relevance for depression and fibromyalgia in work-related disability.

Introduction: The International Classification of Functioning, Disability and Health is the WHO coding scheme for functioning-related data. Clear and unambiguous information regarding patients' work-related disabilities is important not only for the assessment of entitlement to paid sickness benefits but also for planning rehabilitation and return to work. The objective was to validate the content of ICF and ICF Core Sets for information on work-related disability in sick leave due to depression and long-term musculoskeletal pain. Specific aims: To describe to what extent (1) such data could be linked to ICF and (2) the result of the ICF linking in terms of ICF categories was represented in relevant ICF Core Sets., Methods: An ICF-linking study following the ICF-linking rules. A random sample of sick leave certificates issued in primary care for either depression ( n  = 25) or long-term musculoskeletal pain ( n  = 34) was collected from a community with 55,000 inhabitants in Stockholm County, Sweden., Results: The results of the ICF linking consisted of codings for (1) ICF categories and (2) other health information not possible to link to ICF. The ICF categories were compared to ICF Core Sets for coverage. The majority of the meaning units, 83% for depression and 75% for long-term musculoskeletal pain, were linked to ICF categories. The Comprehensive ICF Core Set for depression covered 14/16 (88%) of the ICF categories derived from the ICF linking. The corresponding figures were lower for both the Brief ICF Core Set for depression 7/16 (44%) and ICF Core Set for disability evaluation in social security 12/20 (60%)., Conclusion: The results indicates that ICF is a feasible code scheme for categorising information on work-related disability in sick leave certificates for depression and long-term musculoskeletal pain. As expected, the Comprehensive ICF Core Set for depression covered the ICF categories derived from the certificates for depression to a high degree. However, the results indicate that (1) sleep- and memory functions should be added to the Brief ICF Core Set for depression, and (2) energy-, attention- and sleep functions should be added to the ICF Core Set for disability evaluation in social security when used in this context., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Fresk, Grooten, Brodin, Backlund, Arrelöv, Skånér and Kiessling.)

Background: The purpose was to test the effectiveness of two transdiagnostic group interventions compared to care as usual (CAU) for patients with anxiety, depressive or stress-related disorders within a primary health care context., Objectives: To compare the effects of cognitive-based-behavioural therapy (CBT) and multimodal intervention (MMI) on the quality of life and relief of psychological symptoms of patients with common mental disorders or problems attending primary health care centre., Methods: Patients (n = 278), aged 18-65 years, were referred to the study by the GPs and 245 were randomized to CAU or one of two group interventions in addition to CAU: (i) group CBT administered by psychologists and (ii) group MMI administered by assistant nurses. The primary outcome measure was the Mental Component Summary score of short form 36. Secondary outcome measures were Perceived Stress Scale and Self-Rating Scale for Affective Syndromes. The data were analysed using intention-to-treat with a linear mixed model., Results: On the primary outcome measure, the mean improvement based on mixed model analyses across post- and follow-up assessment was significantly larger for the MMI group than for the CBT (4.0; P = 0.020) and CAU (7.5; P = .001) groups. Participants receiving CBT were significantly more improved than those in the CAU group. On four of the secondary outcome measures, the MMI group was significantly more improved than the CBT and CAU groups. The course of improvement did not differ between the CBT group and the CAU group on these measures., Conclusions: Transdiagnostic group treatment can be effective for patients with common mental disorders when delivered in a primary care setting. The group format and transdiagnostic approach fit well with the requirements of primary care., (© The Author 2014. Published by Oxford University Press.)

Objective: To investigate whether interventions that have positive effects on psychological symptoms and quality of life compared with usual care would also reduce days on sick leave., Design: A randomized controlled trial., Setting: A large primary health care centre in Stockholm, Sweden. Intervention. Patients with common mental disorders were recruited by their GPs and randomized into one of two group interventions that took place in addition to usual care. These group interventions were: (a) group cognitive behavioural therapy (CBT), and (b) group multimodal intervention (MMI). Both types of intervention had previously shown significant effects on quality of life, and MMI had also shown significant effects on psychological symptoms., Patients: Of the 245 randomized patients, 164 were employed and had taken sick leave periods of at least two weeks in length during the study period of two years. They comprised the study group., Main Outcome Measures: The odds, compared with usual care, for being sick-listed at different times relative to the date of randomization., Results: The mean number of days on sick leave increased steadily in the two years before randomization and decreased in the two years afterwards, showing the same pattern for all three groups .The CBT and MMI interventions did not show the expected lower odds for sick-listing compared with usual care during the two-year follow-up., Conclusion: Reduction in psychological symptoms and increased well-being did not seem to be enough to reduce sickness absence for patients with common mental problems in primary care. The possibility of adding workplace-oriented interventions is discussed.

Background: Data regarding mortality among depressed patients in Swedish primary care is limited., Objectives: We compared mortality in a cohort of depressed and non-depressed patients at long-term follow-up and compared these values with standardized mortality rates (SMRs) in the Swedish population. Hazards ratios (HRs) for the relationship between death and depression, psychosocial factors and lifestyle were analysed, and we explored the proportion of unnatural causes of deaths., Methods: Mortality was studied in a cohort of 124 depressed and 280 non-depressed patients 12 years after being diagnosed with depression in primary care. Mortality and the mortality rates and SMRs in depressed and non-depressed patients were compared by gender. Cox regression was applied to calculate HRs for the risk of dying for explanatory variables, including depression, psychosocial factors and lifestyle., Results: A larger number of depressed patients, 11% (n = 14), compared with non-depressed patients, 4% (n = 12), died (P = 0.008), with significantly higher values among depressed men (P = 0.014). SMRs did not differ from those of the Swedish population. Depression was the only variable associated with a significantly elevated risk of death (HR, 3.34; 95% CI, 1.38-8.08). Nearly one-third of deaths had unnatural causes when alcohol-related deaths were included., Conclusion: This study underlines the importance of careful follow-up of all depressed patients' mental and physical health and the intervention on unhealthy lifestyles. Large primary care database studies are needed to explore the association between depression, co-morbid somatic diseases, lifestyle and mortality.

Aim: We investigated whether the risk estimates of General Practitioners (GPs) and their treatment decisions mutually influence each other and whether factors not related to the patient's risk, such as the gender and length in clinical practice, interact., Background: The quantitative assessment of the absolute risk of developing coronary heart disease (CHD) and the decision to start treatment with lipid-lowering drugs are crucial tasks in the primary prevention of CHD., Methods: Nine clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to three groups of 90 randomly selected GPs in Stockholm. One group (R) was asked to estimate the risk of CHD within 10 years on a visual analogue scale. A second group (R1D) was asked to estimate the risk and to specify whether they would recommend a pharmacological lipid-lowering treatment. A third group (D) only to indicate whether they would recommend treatment., Results: Response rate ranged from 42.2% to 45.6%. The median risk estimates were higher in the R group than in the R1D group (difference not statistically significant). R1D group showed higher proportions of correct decisions to start treatment compared with the R group (86.2% versus 77.5%, P50.19). More correct decisions were made by female doctors (OR 1.77, 95% CI 1.19-2.61, P50.004) and by less experienced doctors (OR 0.97, 95% CI 0.95-0.99, P50.016)., Conclusions: The task of making CHD risk estimates and the task of making decisions whether to start lipid-lowering treatment do not seem to influence each other. The gender of physicians and the length of clinical experience seem to affect treatment decisions. Female GPs and less experienced GPs are more likely to make correct decisions. However, the relatively low response rate to the questionnaires may limit the generalizability of these results.

Background: In the period 2004-2009, national and regional initiatives were developed in Sweden to improve the quality of sickness certificates. Parameters for assessing the quality of sickness certificates in primary health care have been proposed. The aim of this study was to measure the quality of sickness certification in primary health care by means of assessing sickness certificates issued between 2004 and 2009 in Stockholm., Methods: This was a retrospective study using data retrieved from sickness certificates contained in the electronic patient records of 21 primary health care centres in Stockholm County covering six consecutive years. A total number of 236 441 certificates were used in the current study. Seven quality parameters were chosen as outcome measures. Descriptive statistics and regression models with time, sex and age group as explanatory variables were used., Results: During the study period, the quality of the sickness certification practice improved as the number of days on first certification decreased and the proportion of duly completely and acceptable certificates increased. Assessment of need for vocational rehabilitation and giving a prognosis for return to work were not significantly improved during the same period. Time was the most influential variable., Conclusions: The quality of sickness certification practice improved for most of the parameters, although additional efforts to improve the quality of sickness certificates are needed. Measures, such as reminders, compulsory certificate fields and structured guidance, could be useful tools to achieve this objective.

Background: The purpose of this study was to test the feasibility of International Classification of Functioning, Disability and Health (ICF) and to explore the distribution, including gender differences, of health problems and disabilities as reflected in long-term sickness absence certificates., Methods: A total of 433 patients with long sick-listing periods, 267 women and 166 men, were included in the study. All certificates exceeding 28 days of sick-listing sent to the local office of the Swedish Social Insurance Administration of a municipality in the Stockholm area were collected during four weeks in 2004-2005. ICD-10 medical diagnosis codes in the certificates were retrieved and free text information on disabilities in body function, body structure or activity and participation were coded according to ICF short version., Results: In 89.8% of the certificates there were descriptions of disabilities that readily could be classified according to ICF. In a reliability test 123/131 (94%) items of randomly chosen free text information were identically classified by two of the authors. On average 2.4 disability categories (range 0-9) were found per patient; the most frequent were 'Sensation of pain' (35.1% of the patients), 'Emotional functions' (34.1%), 'Energy and drive functions' (22.4%), and 'Sleep functions' (16.9%). The dominating ICD-10 diagnostic groups were 'Mental and behavioural disorders' (34.4%) and 'Diseases of the musculoskeletal system and connective tissue' (32.8%). 'Reaction to severe stress and adjustment disorders' (14.7%), and 'Depressive episode' (11.5%) were the most frequent diagnostic codes. Disabilities in mental functions and activity/participation were more commonly described among women, while disabilities related to the musculoskeletal system were more frequent among men., Conclusions: Both ICD-10 diagnoses and ICF categories were dominated by mental and musculoskeletal health problems, but there seems to be gender differences, and ICF classification as a complement to ICD-10 could provide a better understanding of the consequences of diseases and how individual patients can cope with their health problems. ICF is feasible for secondary classifying of free text descriptions of disabilities stated in sick-leave certificates and seems to be useful as a complement to ICD-10 for sick-listing management and research.

Background: Psychosocial stress may account for the higher prevalence of depression in women and in individuals with a low educational background. The aim of this study was to analyse the association between depression and socio-demographic data, psychosocial stressors and lifestyle circumstances from a gender perspective in a relatively affluent primary care setting., Methods: Patients, aged 18- 75 years, visiting a drop-in clinic at a primary care health centre were screened with Beck's Depression Inventory (BDI). The physicians used also targeted screening with BDI. A questionnaire on socio-demographic data, psychosocial stressors and use of alcohol and tobacco was distributed. Among patients, who scored BDI ≥ 10, DSM-IV-criteria were used to diagnose depression. Of the 404 participants, 48 men and 76 women were diagnosed with depression. The reference group consisted of patients with BDI score <10, 187 men and 93 women. Age-adjusted odds ratios (ORs) with 95% confidence intervals (CI) as being depressed were calculated for the psychosocial stressors and lifestyle circumstances, separately for men and women. Multiple logistic regression analyses were used to determine the age-adjusted main effect models for men and women., Results: The same three psychosocial stressors: feeling very stressed, perceived poor physical health and being dissatisfied with one's family situation were associated with depression equally in men and women. The negative predictive values of the main effect models in men and women were 90.7% and 76.5%, respectively. Being dissatisfied with one's work situation had high ORs in both men and women. Unemployment and smoking were associated with depression in men only., Conclusions: Three questions, frequently asked by physicians, which involve patient's family and working situation as well as perceived stress and physical health, could be used as depression indicators in early detection of depression in men and women in primary health care.

Background: Anger attacks and alcohol use may mask depressive symptoms in men. Only the Gotland Male Depression Scale (GS) includes such items., Aims: To study the usefulness of the GS and Beck Depression Inventory (BDI) in detecting depression among men in primary care., Methods: At a family doctor's drop-in clinic in Stockholm, Sweden, all men were invited into the study 2 days a week (opportunistic screening). On other days, the men who mentioned mental symptoms were invited (targeted screening). The men filled in BDI, GS and a social questionnaire. The doctor invited the men with BDI > or = 10 and /or GS > or = 13 to a repeat visit. The outcome was depression diagnosed according to DSM-IV and the severity was assessed with the Montgomery-Asberg Depression Rating Scale., Results: 223 men were recruited, 190 by opportunistic and 33 by targeted screening. Seventeen per cent of the men reported an alcohol consumption that might put them at risk. In the opportunistic screening, 23% scored BDI > or = 10 and 14% scored GS > or = 13. The prevalence of depression in the opportunistic screening was 10.5%. The proportion of depressed men in the targeted screening was 60.6%. In total, 40 men were depressed, 63% had a mild and 35% moderate depression. The correlation between the scales was 0.80. The GS identified no additional cases., Conclusions: Clinical depression was quite common among those men who often had a high alcohol consumption, indicating an advantage for the GS when screening for depression among men. In primary care, a targeted screening procedure seems to be the most feasible method.

Background: Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA., Methods: A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created., Results: Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention., Conclusions: Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.

Background: Quantitative assessment of an individual's absolute cardiovascular risk is essential for primary prevention. Although risk-scoring tools have been developed for this task, risk estimates are usually made subjectively. We investigated whether general practitioners (GPs), internists and cardiologists differ in their quantitative estimates of cardiovascular risk and their recommendations about lipid-lowering treatment for the same set of patients., Methods: Mail survey. Nine written clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to 90 randomly selected GPs and to the same number of internists and cardiologists in Sicily. The doctors were then asked to estimate the 10-year coronary risk in each case and to decide whether they would recommend a lipid-lowering treatment., Results: In the majority of the nine cases, the cardiologists' risk estimates were significantly lower than those of the other two groups. A higher proportion of internists (mean value 0.68) decided to start treatment than GPs (0.54) or cardiologists (0.57). In all three groups, the doctors' willingness to begin treatment was over 90% when their risk estimate was above 20%, and less than 50% when it fell below this level. Internists were more prone to treat than the other two groups even when their patients' estimated risk was below 20%., Conclusion: When presented with the same set of clinical cases, GPs, internists and cardiologists make different quantitative risk estimates and come to different conclusions about the need for lipid-lowering treatment. This may result in over- or under-prescription of lipid-lowering drugs and inconsistencies in the care provided by different categories of doctors.

Background: Data from 2 previous studies were reanalyzed, one on judgments regarding drug treatment of hyperlipidemia and the other on diagnosing heart failure. The original MH model and the extended MH model were compared with logistic regression (LR) in terms of fit to actual judgments, number of cues, and the extent to which the cues were consistent with clinical guidelines., Results: There was a slightly better fit with LR compared with MH. The extended MH model gave a significantly better fit than the original MH model in the drug treatment task. In the diagnostic task, the number of cues was significantly lower in the MH models compared to LR, whereas in the therapeutic task, LR could be less or more frugal than the matching heuristic models depending on the significance level chosen for inclusion of cues. For the original MH model, but not for the extended MH model or LR, the most important cues in the drug treatment task were often used in a direction contrary to treatment guidelines., Conclusions: The extended MH model represents an improvement in that prevalence of cue values is adequately taken into account, which in turn may result in better fit and in better agreement with medical guidelines in the evaluation of cues.

Background: Only half of all depressions are diagnosed in Primary Health Care (PHC). Depression can remain undetected for a long time and entail high costs for care and low quality of life for the individuals. Drop in clinic is a common form of organizing health care; however the visits are short and focus on solving the most urgent problems. The aim of this study was to investigate the prevalence and severity of depression among women visiting the GPs' drop in clinic and to identify possible clues for depression among women., Methods: The two-stage screening method with "high risk feedback" was used. Beck's Depression Inventory (BDI) was used to screen 155 women visiting two GPs' drop in clinic. Women who screened positive (BDI score > or =10) were invited by the GP to a repeat visit. Major depression (MDD) was diagnosed according to DSM-IV criteria and the severity was assessed with Montgomery-Asberg Depression Rating Scale (MADRS). Women with BDI score <10 constituted a control group. Demographic characteristics were obtained by questionnaire. Chart notations were examined with regard to symptoms mentioned at the index visit and were categorized as somatic or mental., Results: The two-stage method worked well with a low rate of withdrawals in the second step, when the GP invited the women to a repeat visit. The prevalence of depression was 22.4% (95% CI 15.6-29.2). The severity was mild in 43%, moderate in 53% and severe in 3%. The depressed women mentioned mental symptoms significantly more often (69%) than the controls (15%) and were to a higher extent sick-listed for a longer period than 14 days. Nearly one third of the depressed women did not mention mental symptoms. The majority of the women who screened as false positive for depression had crisis reactions and needed further care from health professionals in PHC. Referrals to a psychiatrist were few and revealed often psychiatric co-morbidity., Conclusion: The prevalence of previously undiagnosed depression among women visiting GPs' drop in clinic was high. Clues for depression were identified in the depressed women's symptom presentation; they often mention mental symptoms when they visit the GP for somatic reasons e.g. respiratory infections. We suggest that GPs do selective screening for depression when women mention mental symptoms and offer to schedule a repeat visit for follow-up rather than just recommending that the patient return if the mental symptoms do not disappear.