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Background Guidelines on the management of depression recommend that practitioners use patient-reported outcome measures for the follow-up monitoring of symptoms, but there is a lack of evidence of benefit in terms of patient outcomes. Objective To test using the Patient Health Questionnaire-9 questionnaire as a patient-reported outcome measure for monitoring depression, training practitioners in interpreting scores and giving patients feedback. Design Parallel-group, cluster-randomised superiority trial; 1 : 1 allocation to intervention and control. Setting UK primary care (141 group general practices in England and Wales). Inclusion criteria Patients aged ≥ 18 years with a new episode of depressive disorder or symptoms, recruited mainly through medical record searches, plus opportunistically in consultations. Exclusions Current depression treatment, dementia, psychosis, substance misuse and risk of suicide. Intervention Administration of the Patient Health Questionnaire-9 questionnaire with patient feedback soon after diagnosis, and at follow-up 10–35 days later, compared with usual care. Primary outcome Beck Depression Inventory, 2nd edition, symptom scores at 12 weeks. Secondary outcomes Beck Depression Inventory, 2nd edition, scores at 26 weeks; antidepressant drug treatment and mental health service contacts; social functioning (Work and Social Adjustment Scale) and quality of life (EuroQol 5-Dimension, five-level) at 12 and 26 weeks; service use over 26 weeks to calculate NHS costs; patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale); and adverse events. Sample size The original target sample of 676 patients recruited was reduced to 554 due to finding a significant correlation between baseline and follow-up values for the primary outcome measure. Randomisation Remote computerised randomisation with minimisation by recruiting university, small/large practice and urban/rural location. Blinding Blinding of participants was impossible given the open cluster design, but self-report outcome measures prevented observer bias. Analysis was blind to allocation. Analysis Linear mixed models were used, adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering including practice as random effect. Quality of life and costs were analysed over 26 weeks. Qualitative interviews Practitioner and patient interviews were conducted to reflect on trial processes and use of the Patient Health Questionnaire-9 using the Normalization Process Theory framework. Results Three hundred and two patients were recruited in intervention arm practices and 227 patients were recruited in control practices. Primary outcome data were collected for 252 (83.4%) and 195 (85.9%), respectively. No significant difference in Beck Depression Inventory, 2nd edition, score was found at 12 weeks (adjusted mean difference –0.46, 95% confidence interval –2.16 to 1.26). Nor were significant differences found in Beck Depression Inventory, 2nd Edition, score at 26 weeks, social functioning, patient satisfaction or adverse events. EuroQol-5 Dimensions, five-level version, quality-of-life scores favoured the intervention arm at 26 weeks (adjusted mean difference 0.053, 95% confidence interval 0.013 to 0.093). However, quality-adjusted life-years over 26 weeks were not significantly greater (difference 0.0013, 95% confidence interval –0.0157 to 0.0182). Costs were lower in the intervention arm but, again, not significantly (–£163, 95% confidence interval –£349 to £28). Cost-effectiveness and cost–utility analyses, therefore, suggested that the intervention was dominant over usual care, but with considerable uncertainty around the point estimates. Patients valued using the Patient Health Questionnaire-9 to compare scores at baseline and follow-up, whereas practitioner views were more mixed, with some considering it too time-consuming. Conclusions We found no evidence of improved depression management or outcome at 12 weeks from using the Patient Health Questionnaire-9, but patients’ quality of life was better at 26 weeks, perhaps because feedback of Patient Health Questionnaire-9 scores increased their awareness of improvement in their depression and reduced their anxiety. Further research in primary care should evaluate patient-reported outcome measures including anxiety symptoms, administered remotely, with algorithms delivering clear recommendations for changes in treatment. Study registration This study is registered as IRAS250225 and ISRCTN17299295. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 17. See the NIHR Funding and Awards website for further award information. Plain language summary Depression is common, can be disabling and costs the nation billions. The National Health Service recommends general practitioners who treat people with depression use symptom questionnaires to help assess whether those people are getting better over time. A symptom questionnaire is one type of patient-reported outcome measure. Patient-reported outcome measures appear to benefit people having therapy and mental health care, but this approach has not been tested thoroughly in general practice. Most people with depression are treated in general practice, so it is important to test patient-reported outcome measures there, too. In this study, we tested whether using a patient-reported outcome measure helps people with depression get better more quickly. The study was a ‘randomised controlled trial’ in general practices, split into two groups. In one group, people with depression completed the Patient Health Questionnaire, or ‘PHQ-9’, patient-reported outcome measure, which measures nine symptoms of depression. In the other group, people with depression were treated as usual without the Patient Health Questionnaire-9. We fed the results of the Patient Health Questionnaire-9 back to the people with depression themselves to show them how severe their depression was and asked them to discuss the results with the practitioners looking after them. We found no differences between the patient-reported outcome measure group and the control group in their level of depression; their work or social life; their satisfaction with care from their practice; or their use of medicines, therapy or specialist care for depression. However, we did find that their quality of life was improved at 6 months, and the costs of the National Health Service services they used were lower. Using the Patient Health Questionnaire-9 can improve patients’ quality of life, perhaps by making them more aware of improvement in their depression symptoms, and less anxious as a result. Future research should test using a patient-reported outcome measure that includes anxiety and processing the answers through a computer to give practitioners clearer advice on possible changes to treatment for depression. Scientific summary Some text in this chapter has been adapted from the study protocol published as: Kendrick T, Moore M, Leydon G, et al. Patient-reported outcome measures for monitoring primary care patients with depression (PROMDEP): study protocol for a randomised controlled trial. Trials 2020;21:441. https://doi.org/10.1186/s13063-020-04344-9. This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. Background Depression is common and costly. It can lead to chronic disability, poor quality of life, suicide, and high service use and costs. National Institute for Health and Care Excellence guidelines recommend different treatments for more severe and less severe depression, but general practitioners, who treat more the majority of people with depression in primary care, are often inaccurate in their global clinical assessments of depression severity, and treatment is not targeted to patients most likely to benefit. The National Institute for Health and Care Excellence recommends that practitioners consider using validated patient-reported outcome measures to inform treatment at diagnosis and follow-up of people with depression, but there is insufficient evidence that these measures improve depression management and outcomes for patients in primary care. Aim and objectives The aim of the study was to answer the research question: What is the effectiveness and cost-effectiveness of assessing primary care patients with depression or low mood soon after diagnosis and again at follow-up 10–35 days later, using the Patient Health Questionnaire-9 combined with patient feedback and practitioner guidance on treatment? The objectives were to (1) carry out a cluster-randomised controlled trial to compare the intervention with usual care; (2) provide intervention arm patients with written feedback on their Patient Health Questionnaire-9 scores, indicating evidence-based treatments relevant to the level of severity of depression to discuss with practitioners; (3) train practitioners to interpret Patient Health Questionnaire-9 scores and their implications for choice of treatment, taking into account contextual factors; (4) follow up participants for 26 weeks, with research assessments at 12 and 26 weeks; (5) determine the primary outcome of depressive symptoms on the Beck Depression Inventory, 2nd edition, at 12-week follow-up; (6) examine secondary outcomes, including depressive symptoms on the Beck Depression Inventory, 2nd edition, at 26 weeks, and social functioning and quality of life at both 12- and 26-week follow-ups; (7) measure patient satisfaction, adverse events, antidepressant treatment, secondary care contacts, service use, and costs over 26 weeks’ follow-up, and perform cost-effectiveness and cost–utility analyses; and (8) carry out a qualitative process analysis to explore participants’ reflections on the use of the Patient Health Questionnaire-9 and the potential for implementing it in practice. Methods The study design was a parallel-group, cluster-randomised superiority trial with 1 : 1 allocation to intervention and control arms. The setting was UK primary care (141 group general practices in England and Wales). Inclusion criteria were age ≥ 18 years with a new episode of depressive disorder or symptoms. Patients were recruited mainly through regular medical records searches but also opportunistically at consultations for new episodes of depression. Exclusion criteria were current treatment for depression; dementia; psychosis; substance misuse; or a significant risk of suicide. The intervention was administration of the Patient Health Questionnaire-9 questionnaire as a PROM soon after diagnosis and at follow-up 10–35 days later. Patients were given written feedback on their Patient Health Questionnaire-9 scores and potential treatments to discuss with their general practitioners. Practitioners were trained in interpreting Patient Health Questionnaire-9 scores and taking them into account in treatment decisions. The primary outcome was depressive symptoms on the Beck Depression Inventory, 2nd edition, at 12 weeks. Secondary outcomes were Beck Depression Inventory, 2nd edition, scores at 26 weeks; social functioning (on the Work and Social Adjustment Scale) and quality of life (on the EuroQol-5 Dimensions, five-level) at 12 and 26 weeks; service use including antidepressant treatment and primary and secondary care contacts over 26 weeks to calculate NHS costs; and patient satisfaction at 26 weeks (on the Medical Informant Satisfaction Scale). For our sample size calculation, we assumed a baseline mean Beck Depression Inventory, 2nd edition, score of 24.0 with a standard deviation of 10.0 (derived from a feasibility study), and mean scores at 12-week follow-up of 14.0 in the intervention arm and 17.0 in the control arm. The anticipated difference of 3.0 points (effect size of 0.3) represented the minimum clinically important difference on the Beck Depression Inventory, 2nd edition. At the 5% level of significance, to have 90% power to detect that difference we calculated we needed 235 patients analysed per arm. We aimed to recruit a mean of six patients per practice and assumed an intracluster correlation coefficient of 0.03 (from the feasibility study), which gave a cluster design effect of 1.15, meaning we needed 270 per arm. We assumed a 20% loss to follow-up at 12 weeks, so the total sample size needed was 270 × 2/0.8 and our original target sample size was a total of 676 patients recruited, from 113 practices, by three recruitment centres (the University of Southampton, the University of Liverpool and University College London). We subsequently revised the target sample size on finding a significant correlation coefficient of > 0.5 between baseline and follow-up values for the primary outcome, which meant that we needed only 222 patients analysed per arm and, therefore, a target sample size of 554 patients recruited (revised 10 June 2021). Cluster randomisation of practices to intervention and control arms was carried out remotely by a Clinical Trials Unit statistician using computerised sequence generation, with minimisation by recruiting centre, size of practice and urban or rural location. Blinding of participating practitioners and patients to allocation was impossible given the nature of the intervention and the cluster-randomised design, but self-report outcome measures were used to prevent researcher rating bias, and statistical analysis was blind to allocation. Differences between intervention and control arms in the outcomes of depressive symptoms, social functioning and quality of life measured at 12- and 26-week follow-up were analysed using linear mixed models, adjusting for baseline depression; duration of depression; history of depression; baseline anxiety; sociodemographic factors (gender, age, socioeconomic position, housing, education, marital status and dependants), and clustering including a random effect for practice. Patient satisfaction, quality of life (quality-adjusted life-years) and costs were compared between the arms over the 26 weeks’ study follow-up period. Differences between the arms in the process of care for depression were also analysed, including patients’ self-reported use of antidepressants at the 12- and 26-week follow-up points, and medication and contacts with mental health services (community mental health nurses, counsellors, psychologists, psychiatrists, other therapists and social workers) recorded in practice medical records over the 26 weeks’ follow-up. A health economic evaluation was undertaken from an NHS and Personal Social Services perspective. The outcomes were expressed as incremental cost per point improvement in the Beck Depression Inventory, 2nd edition, clinical outcome (cost-effectiveness analysis), and incremental cost per quality-adjusted life-year gained (cost–utility analysis). The primary analysis at 26 weeks used a generalised linear mixed model to estimate the differences in costs and quality-adjusted life-years (using the EuroQol-5 Dimensions, five-level to calculate patient utilities), adjusted for baseline quality of life; baseline anxiety; sociodemographic factors; and practice as a random effect. Incremental cost-effectiveness ratios and a cost-effectiveness acceptability curve were generated using non-parametric bootstrapping. Qualitative interviews with participating practitioners and patients in both arms were conducted to reflect on their involvement in the trial and analysed using reflexive thematic analysis. Intervention arm participants were asked about barriers, facilitators, benefits and problems related to using the Patient Health Questionnaire-9, including questions derived from the normalisation process theory framework. Results Practices and patients As the number of patients recruited per practice was smaller than anticipated, we recruited significantly more than our target of 113 practices, eventually reaching a total of 189, but 48 practices subsequently withdrew (24 in each arm), so the final number of active practices was 141: 72 intervention and 69 control (28 above our original target). Practice characteristics were well balanced by arm. Of 11,468 patients approached in consultations or through mailed invitations, 1058 (9.2%) returned reply slips about the study: 574 (10.6% of those approached) in the intervention arm and 484 (8.0% of those approached) in the control arm. After the exclusion of patients declining to participate, ineligible at screening or uncontactable, 529 patients were assessed at baseline: 302 (5.5% of those approached) in the intervention arm and 227 (3.8% of those approached) in the control arm. The ratio of intervention to control arm patients recruited was, therefore, 1.3 to 1, which may have reflected lower motivation to take part among control arm practices. Of 529 patients recruited, 453 (85.6%) were followed up at 12 weeks: 254 intervention arm (84.1%) and 199 control arm (87.7%) patients. At the 26-week point, 414 patients (78.3%) were followed up: 230 intervention arm (76.2%) and 184 control arm (81.1%). Medical records data were collected for 259 intervention arm patients (85.8%) and 201 control arm patients (88.5%). The mean BDI-II score for depressive symptoms at baseline was higher in the intervention arm, at 24.1 (standard deviation 8.89) than in the control arm, at 22.4 (standard deviation 9.52). Baseline anxiety and quality-of-life scores were also worse in the intervention arm. Control arm patients were more likely to have had two or more previous depressive episodes. Demographic characteristics were relatively well balanced. Clinical outcomes At the 12-week follow-up, the mean Beck Depression Inventory, 2nd edition, score was 18.5 (standard deviation 10.2) in the intervention arm and 16.9 (standard deviation 10.3) in the control arm. The adjusted mean score was slightly lower in the intervention arm, but this was not statistically significant (mean adjusted difference –0.46, 95% confidence interval –2.16 to 1.26; p = 0.60). At 26 weeks, the mean Beck Depression Inventory, 2nd edition, scores were 15.1 (standard deviation 10.8) in the intervention arm and 14.7 (standard deviation 10.6) in the control arm (mean adjusted difference –1.63, 95% confidence interval –3.48 to 0.21; p = 0.08). Social functioning on the Work and Social Adjustment Scale and Medical Informant Satisfaction Scale satisfaction with care scores favoured the intervention, but the differences found were not statistically significant. A post hoc analysis at 26 weeks showed similar proportions improving by ≥ 50% on the Beck Depression Inventory, 2nd edition, in the intervention and control arms (45.1% vs. 37.3%), but the proportion remitting to a score of

Background: Palliative care aims to provide holistic support for people with life-limiting illness, responding to psychological, social and spiritual needs, as well as to clinical and physical. In the United Kingdom, hospice day services (including day care, group interventions, group activities, and social events for palliative care outpatients) aim to provide opportunities for patients to gain social support, which is thought to improve their quality of life. Objectives: This research explored social support within hospice day services, to explain in detail how and why social support obtained within a hospice day service could be beneficial to palliative care patients. Design: Qualitative research using observations of hospice day services and interviews with service providers. Methods: Data collection involved nineteen interviews with hospice service providers ( n = 19) and researcher observations of hospice day services. The findings detail how patient and hospice context interact to produce mechanisms that lead to outcomes beyond the hospice day service. Results: Practical, clinical and social aspects of the hospice day service are important for patients feeling welcome and safe in the setting. The opportunity to connect with other people and work towards personal goals can boost self-confidence for patients who have lost access to meaningful activity. New friendships between patients encourages reciprocal support and feelings of belonging. It is beneficial to have permission to speak freely about topics deemed inappropriate elsewhere, because honest communication is helpful in accepting and adapting to their circumstances. Conclusion: Hospice day services facilitate group settings for reciprocal social support. This research proposes an initial programme theory that can be further developed and tested. It explains how and why, in some contexts, social support increases personal and practical resources to cope with illness and death, leading to changes outside of the hospice (to mood, interpersonal interactions and behaviour) that could improve quality of life.

Abstract Introduction Our aim is to explore the ways in which a patient and a general practitioner (GP) negotiate knowledge claims stemming from different epistemic domains while dealing with a mismatch between experiential and biomedical knowledge during the clinical consultation. We interpret their interaction in relation to the sociocultural context in which their negotiation is embedded and identify factors facilitating their successful negotiation (a medical error is avoided). Methods Based on a narrative analysis of a verbatim transcript of a complete naturally occurring primary care consultation, we explore the moment‐to‐moment unfolding of talk between the patient and the GP (two women). Findings The patient experiences symptoms of what she interprets as a thyroid condition, and indirectly asks for medication. She presents her case by drawing on experiential knowledge (‘it feels like my metabolism has shut down’) and biomedical knowledge (while suggesting a diagnosis and a diagnostic test). The GP informs her that her thyroid blood tests are normal and uses biomedical knowledge to explain why she turns down the patient's request. This stages a potential conflict between the patient's embodied experiential knowledge and the doctor's biomedical knowledge. However, during their encounter, the patient and the GP manage to co‐construct the patient's illness story and make shared decisions about further actions. Conclusion The transition from potential conflict to consensus is a result of the mutual efforts of two parties: a patient who persistently claims experiential as well as biomedical knowledge while at the same time deferring to the GP's professional knowledge, and a GP who maintains her epistemic authority while also acknowledging the patient's experiential and biomedical knowledge. Patient and Public Contribution Our empirical data are sourced from a data archive and patients were not involved in the design or conduct of the study, but our study is based on a naturally occurring clinical consultation with a patient.

Introduction: The first primary care consultation for patients with depression can have long-term consequences for patients, but little is known about treatment decisions at this visit. The aim of this study was to explore the treatment of patients presenting in primary care with a new episode of depression and the drivers behind GPs' treatment decisions at the initial consultation. Materials and Methods: A random sample of GPs in Auckland was invited to participate. A qualitative study was undertaken using semi-structured interviews. Interview transcripts were analyzed using a general inductive approach. Results: Twenty-one GPs were interviewed. We identified three themes as drivers of treatment decisions at the first visit: characteristics of GPs, characteristics of patients, and characteristics of treatment options. Drivers for prescribing were severe depression and time constraints. A driver for non-pharmacological treatment was a strong doctor–patient relationship. Limited time, skill, and training were associated with low confidence using talking therapies. Access to counseling was reported as poor. There was a very wide range of approaches taken. GPs described preferring antidepressants less and talking therapies more with Mčori patients. Behavioral activation was used least despite its ease of use and it being one of the most effective treatments for depression. Conclusion: Treatment of depression at the first visit varies widely between practitioners. GPs report multiple barriers to the provision of talking therapies. A move to a more standardized approach may lead to more equitable care. This is the first study to report findings about the initial primary care consultation for depression.

Objectives: To assess the causes and risk factors of post-traumatic stress disorder (PTSD) in adult asylum seekers and refugees. To explore whether the causes and risk factors of PTSD between male and female adult refugees/asylum seekers are different. Study design: Systematic review of current literature. Data Sources: PubMed, Web of Science, Scopus and Google Scholar up until February 2019. Method: A structured, systematic search was conducted of the relevant databases. Papers were excluded if they failed to meet the inclusion and exclusion criteria. Afterwards, a qualitative assessment was performed on the selected papers. Results: 12 Studies were included for the final analysis. All papers were either case studies/reports or cross-sectional studies. Traumatic events experienced by refugees/asylum seekers are the most frequently reported pre-migration causes of PTSD development, while acculturative stress is the most common post-migration stressor. There were mixed reports regarding the causes of PTSD between both genders of refugees/asylum seekers. Conclusions: This review’s findings have potential clinical application in terms of helping clinicians to risk stratify refugees/asylum seekers for PTSD development and thus aid in embarking on earlier intervention measures. However, more rigorous research similar to this study is needed for it to be implemented into clinical practice.

To address the unmet need for accessible mental health services for refugees and asylum seekers in high-income countries, the PROSPER study is testing implementation of the World Health Organization Problem Management Plus (PM+) intervention. Incorporating task-sharing strategies, the intervention is delivered by Peer Lay Therapists with lived experience of seeking asylum or migration. The PM+ training adopts a cascade apprenticeship model, where Master Trainers train and supervise Wellbeing Mentors; who subsequently train and supervise the Peer Lay Therapists. We describe application of this training and supervision approach in PROSPER, drawing on Master Trainer and Wellbeing Mentor perspectives. We then reflect on our experiences, highlighting logistical challenges when working with refugee and asylum-seeking Peer Lay Therapists, the strategies to promote their ongoing engagement and the opportunities for team and personal growth. A core learning point has been the role of straddling the intervention and research components of the PROSPER study. Based on our experiences, we make recommendations for others adopting a task-sharing approach by training refugees and asylum seekers as Peer Lay Therapists in high-income countries, so that this might inform service programming and/or associated research activity.

Abstract The stressful experiences that many asylum seekers and refugees (AS&R) are exposed to during forced migration, and during resettlement in host countries, can have a profound impact on their mental health. Comparatively less research attention has been allocated to exploring other indices of quality of life (QoL) in AS&R populations. This review aimed to (i) synthesize the predictors and correlates of QoL of AS&R populations in high-income countries, and (ii) to identify the methodological strengths and weaknesses of this body of research. Fourteen databases were systematically searched (Medline, PsychINFO, CINAHL, Cochrane Library, Health Technology Assessment, National Health Service Economic Evaluation, Educational Resource Index and Abstracts, BiblioMap, Scopus, Social Sciences Citation Index, Evidence Aid, DARE, Web of Science and PubMed). Eligibility criteria included: adults seeking asylum or refuge in a high-income country, primary quantitative data, the use of a measure based on the WHO’s definition of QoL, published in a peer-reviewed journal. A narrative synthesis approach was used, and the quality was assessed using the AXIS tool for cross-sectional studies and the CASP tool for longitudinal studies. Of the 13.656 papers identified, 23 met the eligibility criteria. A wide range of factors were found to have significant associations with QoL. Both positive and negative correlates of QoL were largely dominated by social (e.g. social networks) and mental health factors (e.g. depression). Although all of the cross-sectional studies met over half of the quality criteria, only 12 met 75% or more of these criteria. For the longitudinal studies, for all but one study lacked statistical precision and the results cannot be applied to the local population. Key findings across the various forms of QoL (overall, physical, psychological, social and environmental) were that having established social networks and social integration were associated with higher QoL, whereas having mental disorders (i.e. PTSD or depression) was strongly associated with reduced QoL. More research is needed into physical and environmental predictors and correlates of QoL. The findings of the review can be used to inform policies and interventions aimed at supporting AS&R and promoting the integration and wellbeing of these populations.

Abstract Background Benefits to patients from reduced depression have been shown from monitoring progress with patient-reported outcome measures (PROMs) in psychological therapy and mental health settings. This approach has not yet been researched in the United Kingdom for primary care, which is where most people with depression are treated in the United Kingdom. Methods This is a parallel-group cluster randomised trial with 1:1 allocation to intervention and control. Patients who are age 18+ years, with a new episode of depressive disorder/symptoms, meet the inclusion criteria. Patients with current depression treatment, comorbid dementia/psychosis/substance misuse/suicidal ideas are excluded. The intervention includes the Administration of Patient Health Questionnaire (PHQ-9) as a PROM within 2 weeks of diagnosis and at follow-up 4 weeks later. General practitioners are trained in interpreting scores and asked to take them into account in their treatment decisions. Patients are given written feedback on scores and suggested treatments. The primary outcome measure is Depression on the Beck Depression Inventory BDI-II at 12 weeks. Secondary outcomes include BDI-II at 26 weeks, changes in drug treatments and referrals, social functioning (Work & Social Adjustment Scale) and quality of life (EQ-5D) at 12 and 26 weeks, service use over 26 weeks (modified Client Services Receipt Inventory) to calculate NHS costs, and patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale). The sample includes 676 total participants from 113 practices across three centres. Randomisation is achieved by computerised sequence generation. Blinding is impossible given the nature of the intervention (self-report outcome measures prevent rating bias). Differences at 12 and 26 weeks between intervention and controls in depression, social functioning and quality of life are analysed using linear mixed models, adjusted for socio-demographics, baseline depression, anxiety, and clustering, while including practice as a random effect. Patient satisfaction, quality of life (QALYs) and costs over 26 weeks will be compared between arms. Qualitative process analysis includes interviews with 15–20 GP/NPs and 15–20 patients per arm to reflect trial results and implementation issues, using Normalization Process Theory as a theoretical framework. Discussion If PROMs are helpful in improving patient outcomes for depression even to a small extent, then they are likely to be good value for money, given their low cost. The benefits could be considerable, given that depression is common, disabling, and costly. Trial registration ISRCTN no: 17299295 . Registered 1st October 2018.

Abstract Background Around one in ten adults take antidepressants for depression in England, and their long-term use is increasing. Some need them to prevent relapse, but 30–50% could possibly stop them without relapsing and avoid adverse effects and complications of long-term use. However, stopping is not always easy due to withdrawal symptoms and a fear of relapse of depression. When general practitioners review patients on long-term antidepressants and recommend to those who are suitable to stop the medication, only 6–8% are able to stop. The Reviewing long-term antidepressant use by careful monitoring in everyday practice (REDUCE) research programme aims to identify safe and cost-effective ways of helping patients taking long-term antidepressants taper off treatment when appropriate. Methods Design: REDUCE is a two-arm, 1:1 parallel group randomised controlled trial, with randomisation clustered by participating family practices. Setting: England and north Wales. Population: patients taking antidepressants for longer than 1 year for a first episode of depression or longer than 2 years for repeated episodes of depression who are no longer depressed and want to try to taper off their antidepressant use. Intervention: provision of ‘ADvisor’ internet programmes to general practitioners or nurse practitioners and to patients designed to support antidepressant withdrawal, plus three patient telephone calls from a psychological wellbeing practitioner. The control arm receives usual care. Blinding of patients, practitioners and researchers is not possible in an open pragmatic trial, but statistical and health economic data analysts will remain blind to allocation. Outcome measures: the primary outcome is self-reported nine-item Patient Health Questionnaire at 6 months for depressive symptoms. Secondary outcomes: depressive symptoms at other follow-up time points, anxiety, discontinuation of antidepressants, social functioning, wellbeing, enablement, quality of life, satisfaction, and use of health services for costs. Sample size: 402 patients (201 intervention and 201 controls) from 134 general practices recruited over 15–18 months, and followed-up at 3, 6, 9 and 12 months. A qualitative process evaluation will be conducted through interviews with 15–20 patients and 15–20 practitioners in each arm to explore why the interventions were effective or not, depending on the results. Discussion Helping patients reduce and stop antidepressants is often challenging for practitioners and time-consuming for very busy primary care practices. If REDUCE provides evidence showing that access to internet and telephone support enables more patients to stop treatment without increasing depression we will try to implement the intervention throughout the National Health Service, publishing practical guidance for professionals and advice for patients to follow, publicised through patient support groups. Trial registration ISRCTN:12417565 . Registered on 7 October 2019.

Abstract Background Asylum seekers and refugees (AS&Rs) experience impaired mental health and wellbeing, related to stresses in their country of origin, experiences in transit and reception on arrival, including significant barriers to accessing mainstream services. Their contact with health care is often crisis-driven and mediated through non-governmental organisations (NGOs). Problem Management Plus (PM+) is a psychosocial intervention recommended by the World Health Organisation to address distress experienced by adults affected by humanitarian crises. We are investigating its application for the first time in a high-income country. Methods In a pilot randomised controlled trial (RCT), PM+ will be delivered to AS&Rs in contact with NGOs in Liverpool City Region, UK by lay therapists who have lived experience of forced migration. Following systematic review and stakeholder engagement, PM+ has been adapted to the local context, and lay therapists have been trained in its delivery. We will assess the feasibility of conducting a three-arm RCT of five 90-min sessions of PM+, delivered individually or in groups by lay therapists to AS&Rs experiencing emotional distress and functional impairment, compared with each other and with usual support offered by local NGOs. Distress and impairment at baseline will be measured by the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule (WHO-DAS). We aim to recruit 105 participants, 35 per arm. Primary health outcomes are anxiety and depressive symptoms at 3 months, measured by HADS. Secondary outcomes include subjective wellbeing, functional status, progress on identified problems, presence of post-traumatic stress disorder and depressive disorder and service usage. Longer-term impact will be assessed at 6 months post baseline, on the same parameters. We will assess the feasibility of conducting a full RCT in relation to the following elements: recruitment and retention of lay therapists and study participants; fidelity of delivery of PM+; and suitability of the study measures, including any linguistic or cultural barriers. Discussion We will use these findings to specify the parameters for a full RCT to test the effectiveness and cost-effectiveness of PM+ in reducing emotional distress and health inequalities, and improving functional ability and wellbeing, amongst asylum seekers and refugees. Trial registration ISRCTN, ID: ISRCTN15214107 . Registered on 10 September 2019.

Background Target-D, a new person-centred e-health platform matching depression care to symptom severity prognosis (minimal/mild, moderate or severe) has demonstrated greater improvement in depressive symptoms than usual care plus attention control. The aim of this study was to evaluate the cost-effectiveness of Target-D compared to usual care from a health sector and partial societal perspective across 3-month and 12-month follow-up. Methods and findings A cost-utility analysis was conducted alongside the Target-D randomised controlled trial; which involved 1,868 participants attending 14 general practices in metropolitan Melbourne, Australia. Data on costs were collected using a resource use questionnaire administered concurrently with all other outcome measures at baseline, 3-month and 12-month follow-up. Intervention costs were assessed using financial records compiled during the trial. All costs were expressed in Australian dollars (A$) for the 2018–19 financial year. QALY outcomes were derived using the Assessment of Quality of Life-8D (AQoL-8D) questionnaire. On a per person basis, the Target-D intervention cost between $14 (minimal/mild prognostic group) and $676 (severe group). Health sector and societal costs were not significantly different between trial arms at both 3 and 12 months. Relative to a A$50,000 per QALY willingness-to-pay threshold, the probability of Target-D being cost-effective under a health sector perspective was 81% at 3 months and 96% at 12 months. From a societal perspective, the probability of cost-effectiveness was 30% at 3 months and 80% at 12 months. Conclusions Target-D is likely to represent good value for money for health care decision makers. Further evaluation of QALY outcomes should accompany any routine roll-out to assess comparability of results to those observed in the trial. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000537459).

BackgroundThe number of people receiving antidepressants has increased in the past 3 decades, mainly because of people staying on them longer. However, in many cases long-term treatment is not evidence based and risks increasing side effects. Additionally, prompting general practitioners (GPs) to review medication does not improve the rate of appropriate discontinuation. Therefore, GPs and other health professionals may need help to support patients discontinuing antidepressants in primary care. ObjectiveThis study aims to develop a digital intervention to support practitioners in helping patients discontinue inappropriate long-term antidepressants (as part of a wider intervention package including a patient digital intervention and patient telephone support). MethodsA prototype digital intervention called Advisor for Health Professionals (ADvisor HP) was planned and developed using theory, evidence, and a person-based approach. The following elements informed development: a literature review and qualitative synthesis, an in-depth qualitative study, the development of guiding principles for design elements, and theoretical behavioral analyses. The intervention was then optimized through think-aloud qualitative interviews with health professionals while they were using the prototype intervention. ResultsThink-aloud qualitative interviews with 19 health professionals suggested that the digital intervention contained useful information and was readily accessible to practitioners. The development work highlighted a need for further guidance on drug tapering schedules for practitioners and clarity about who is responsible for broaching the subject of discontinuation. Practitioners highlighted the need to have information in easily and quickly accessible formats because of time constraints in day-to-day practice. Some GPs felt that some information was already known to them but understood why this was included. Practitioners differed in their ideas about how they would use ADvisor HP in practice, with some preferring to read the resource in its entirety and others wanting to dip in and out as needed. Changes were made to the wording and structure of the intervention in response to the feedback provided. ConclusionsADvisor HP is a digital intervention that has been developed using theory, evidence, and a person-based approach. The optimization work suggests that practitioners may find this tool to be useful in supporting the reduction of long-term antidepressant use. Further quantitative and qualitative evaluation through a randomized controlled trial is needed to examine the feasibility, effectiveness, and cost-effectiveness of the intervention.

Background: Day care services support older people living with long-term conditions (LTC’s). Aims: The aims of the study were to determine outcomes in terms of loneliness and health-related quality of life for older people with LTCs attending day care services in the United Kingdom. Methods: Newly referred older people with LTCs to day care services in North West of England and Wales were invited to participate. The EQ-5D-3L and De Jong Loneliness questionnaires were completed at recruitment, 6 and 12 weeks. Results: Ninty-four older people (64% female), age range 65–99 years; mean number of LTCs 4.3 (range: 2–9) were recruited. About 52% lived alone and 36% lived in one of the 20% most deprived local authorities in England and Wales. Outcomes over 12 weeks were comparable for paid, blended, and for volunteer-led services. Conclusion: Following the Covid-19 pandemic, it is increasingly urgent to support older people with LTCs who may have lost physical and cognitive function during lockdown and to support their recovery. Our study suggests that volunteers can provide services and complement the care provided by paid staff, freeing up resources and enabling increasing numbers of older people to be supported.

Background: In 2019, a literature review indicated that more than half of people who try to come off antidepressants experience withdrawal effects. Both the National Institute of Health and Care Excellence and the Royal College of Psychiatrists updated their positions in line with that review, and Public Health England published a 152-page report called Dependence and withdrawal associated with some prescribed medicines: an evidence review . The report made several recommendations relevant to general practice. Method: In order to facilitate implementation of these recommendations, an online survey was designed to explore United Kingdom general practitioner (GP) experiences, opinions, knowledge and needs in relation to depression, ADs and withdrawal. A total of 66 GPs had completed the survey when COVID-19 occurred. Results: In keeping with previous findings, this small sample of GPs had a predominantly psycho-social perspective on the causes of, and treatments for, depression. They broadly considered ADs effective for moderate/severe depression and ineffective for minimal/mild depression, for which they preferred psychological therapies and social prescribing. There was a marked lack of consistency in GPs’ knowledge about the incidence and duration of withdrawal effects. Only a minority (29%) felt their knowledge about withdrawal was ‘adequate’ and fewer (17%) believed this about their ‘Ability to distinguish between withdrawal effects and return of the original problem (e.g. depression)’. Two-thirds (68%) would like more training on these matters. Conclusion: It is hoped that even this small sample will be helpful when designing, and seeking funding for, GP training programmes, and when implementing the PHE recommendations for support services, based in the primary care system, for the millions of people contemplating or initiating withdrawal from ADs every year in the UK.

Background: Despite a growing number of prescriptions for antidepressants (over 70 million in 2018), there is uncertainty about when people with depression might benefit from antidepressant medication and concern that antidepressants are prescribed unnecessarily. Objectives: The main objective of the PANDA (What are the indications for Prescribing ANtiDepressAnts that will lead to a clinical benefit?) research programme was to provide more guidance about when antidepressants are likely to benefit people with depression. We aimed to estimate the minimal clinically important difference for commonly used self-administered scales for depression and anxiety, and to understand more about how patients respond to such assessments. We carried out an observational study of patients with depressive symptoms and a placebo-controlled randomised controlled trial of sertraline versus placebo to estimate the treatment effect in UK primary care. The hypothesis was that the severity and duration of symptoms were related to treatment response. Design: The programme consisted of three phases. The first phase relied on the secondary analysis of existing data extracted from published trials. The second phase was the PANDA cohort study of patients with depressive symptoms who presented to primary care and were followed up 2, 4 and 6 weeks after a baseline assessment. Both quantitative and qualitative methods were used in the analysis. The third phase was a multicentre randomised placebo-controlled double-blind trial of sertraline versus placebo in patients presenting to primary care with depressive symptoms. Setting: UK primary care in Bristol, London, Liverpool and York. Participants: Patients aged 18–74 years who were experiencing depressive symptoms in primary care. Eligibility for the PANDA randomised controlled trial included that there was uncertainty about the benefits about treatment with an antidepressant. Interventions: In the PANDA randomised controlled trial, patients were individually randomised to 100 mg daily of sertraline or an identical placebo. The PANDA cohort study was an observational study. Main outcome measures: Depressive symptoms measured using the Patient Health Questionnaire were the primary outcome for the randomised controlled trial. Other outcomes included anxiety symptoms using the Generalised Anxiety Disorder-7; depressive symptoms using the Beck Depression Inventory, version 2; health-related quality of life; self-reported improvement; and cost-effectiveness. Results: The secondary analysis of existing randomised controlled trials [GENetic and clinical Predictors Of treatment response in Depression (GenPod), TREAting Depression with physical activity (TREAD) and Clinical effectiveness and cost-effectiveness of cognitive Behavioural Therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care (CoBalT)] found evidence that the minimal clinically important difference increased as the initial severity of depressive symptoms rose. Our estimates of minimal clinically important difference were a 17% and 18% reduction in Beck Depression Inventory scores for GenPod and TREAD, respectively. In CoBalT, a 32% reduction corresponded to the minimal clinically important difference but the participants in this study had depression that had not responded to antidepressants. In the PANDA study cohort, and from our analyses in existing data, we found that the minimal clinically important difference varies considerably with the initial severity of depressive and anxiety symptoms. Expressing the minimal clinically important difference as a percentage reduction reduces this variation at higher scores, but at low scores the percentage reduction increased substantially. The results from the qualitative studies pointed out many limitations of the Patient Health Questionnaire-9 items in assessing change and recovery from depression. In the PANDA randomised controlled trial, there was no evidence that sertraline resulted in a reduction in depressive symptoms within 6 weeks of randomisation, but there was some evidence of a reduction by 12 weeks. However, sertraline led to a reduction in anxiety symptoms, an improvement of mental health-related quality of life and an increased likelihood of reporting improvement. The mean Patient Health Questionnaire-9 items score at 6 weeks was 7.98 (standard deviation 5.63) in the sertraline group and 8.76 (standard deviation 5.86) in the placebo group (5% relative reduction, 95% confidence interval –7% to 15%; p = 0.41). Of the secondary outcomes, there was strong evidence that sertraline reduced anxiety symptoms (Generalised Anxiety Disorder-7 score reduced by 17% (95% confidence interval 9% to 25%; p = 0.00005). Sertraline had a high probability (> 90%) of being cost-effective at 12 weeks. The PANDA randomised controlled trial found no evidence that treatment response or cost-effectiveness was related to severity or duration of depressive symptoms. The minimal clinically important difference estimates suggested that sertraline’s effect on anxiety, but not on depression, was likely to be clinically important. Limitations: The results from the randomised controlled trial and the estimates of minimal clinically important difference were not sufficiently precise to provide specific clinical guidance for individuals. We had low power in testing whether or not initial severity and duration of depressive symptoms are related to treatment response. Conclusions: The results of the trial support the use of sertraline and probably other selective serotonin reuptake inhibitors because of their action in reducing anxiety symptoms and the likelihood of longer-term benefit on depressive symptoms. Sertraline could be prescribed for anxiety symptoms that commonly occur with depression and many patients will experience a clinical benefit. The Patient Health Questionnaire-9 items and similar self-administered scales should not be used on their own to assess clinical outcome, but should be supplemented with further clinical assessment. Future work: We need to examine the longer-term effects of antidepressant treatment. We need more precise estimates of the treatment effects and minimal clinically important difference at different severities to provide more specific guidance for individuals. However, the methods we have developed provide an approach towards providing such detailed guidance. Trial registration: Current Controlled Trials ISRCTN84544741 and EudraCT number 2013-003440-22. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 10. See the NIHR Journals Library website for further project information.

Abstract The current political crisis, conflicts and riots in many Middle Eastern and African countries have led to massive migration waves towards Europe. European countries, receiving these migratory waves as first port of entry (POE) over the past few years, were confronted with several challenges as a result of the sheer volume of newly arriving refugees. This humanitarian refugee crisis represents the biggest displacement crisis of a generation. Although the refugee crisis created significant challenges for all national healthcare systems across Europe, limited attention has been given to the role of primary health care (PHC) to facilitate an integrated delivery of care by enhancing care provision to refugees upon arrival, on transit or even for longer periods. Evidence-based interventions, encompassing elements of patient-centredness, shared decision-making and compassionate care, could contribute to the assessment of refugee healthcare needs and to the development and the implementation of training programmes for rapid capacity-building for the needs of these vulnerable groups and in the context of integrated PHC care. This article reports on methods used for enhancing PHC for refugees through rapid capacity-building actions in the context of a structured European project under the auspices of the European Commission and funded under the 3rd Health Programme by the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The methods include the assessment of the health needs of all the people reaching Europe during the study period, and the identification, development, and testing of educational tools. The developed tools were evaluated following implementation in selected European primary care settings.

Background: Migration in Europe is increasing at an unprecedented rate. There is an urgent need to develop ‘migrant-sensitive healthcare systems’. However, there are many barriers to healthcare for migrants. Despite Greece’s recent, significant experiences of inward migration during a period of economic austerity, little is known about Greek primary care service providers’ experiences of delivering care to migrants. Objectives: To identify service providers’ views on the barriers to migrant healthcare. Methods: Qualitative study involving six participatory learning and action (PLA) focus group sessions with nine service providers. Data generation was informed by normalization process theory (NPT). Thematic analysis was applied to identify barriers to efficient migrant healthcare. Results: Three main provider and system-related barriers emerged: (a) emphasis on major challenges in healthcare provision, (b) low perceived control and effectiveness to support migrant healthcare, and (c) attention to impoverished local population. Conclusion: The study identified major provider and system-related barriers in the provision of primary healthcare to migrants. It is important for the healthcare system in Greece to provide appropriate supports for communication in cross-cultural consultations for its diversifying population.

Abstract Background Depressive symptoms are usually managed within primary care and antidepressant medication constitutes the first-line treatment. It remains unclear at present which people are more likely to benefit from antidepressant medication. This paper describes the protocol for a randomised controlled trial (PANDA) to investigate the severity and duration of depressive symptoms that are associated with a clinically significant response to sertraline compared to placebo, in people presenting to primary care with depression. Methods/design PANDA is a randomised, double blind, placebo controlled trial in which participants are individually randomised to sertraline or placebo. Eligible participants are those who are between the ages of 18 to 74; have presented to primary care with depression or low mood during the past 2 years; have not received antidepressant or anti-anxiety medication in the 8 weeks prior to enrolment in the trial and there is clinical equipoise about the benefits of selective serotonin reuptake inhibitor (SSRI) medication. Participants who consent to participate in the trial are randomised to receive either sertraline or matching placebo, starting at 50 mg daily for 1 week, increasing to 100 mg daily for up to 11 weeks (with the option of increasing to 150 mg if required). Participants, general practitioners (GPs) and the research team will be blind to treatment allocation. The primary outcome will be depressive symptoms measured by the Patient Health Questionnaire-9 (PHQ-9) at 6 weeks post randomisation, measured as a continuous outcome. Secondary outcomes include depressive symptoms measured with the PHQ-9 at 2 and 12 weeks as a continuous outcome and at 2, 6 and 12 weeks as a binary outcome; follow-up scores on depressive symptoms measured with the Beck Depression Inventory-II, anxiety symptoms measured by the Generalized Anxiety Disorder-7 and quality of life measured with the Euroqol-5D-5L and Short Form-12; emotional processing task scores measured at baseline, 2 and 6 weeks; and costs associated with healthcare use, time off work and personal costs. Discussion The PANDA trial uses a simple self-administered measure to establish the severity and duration of depressive symptoms associated with a clinically significant response to sertraline. The evidence from the trial will inform primary care prescribing practice by identifying which patients are more likely to benefit from antidepressants. Trial registration Controlled Trials ISRCTN Registry, ISRCTN84544741 . Registered on 20 March 2014. EudraCT Number: 2013-003440-22; Protocol Number: 13/0413 (version 6.1).

Abstract Background Depression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months’ time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care. Methods The Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group. Discussion To our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR 12616000537459 ). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data.

Background: The ongoing refugee crisis has revealed the need for enhancing primary health care (PHC) professionals’ skills and training. Objectives: The aim was to strengthen PHC professionals in European countries in the provision of high-quality care for refugees and migrants by offering a concise modular training that was based on the needs of the refugees and PHC professionals as shown by prior research in the EUR-HUMAN project. Methods: We developed, piloted, and evaluated an online capacity building course of 8 stand-alone modules containing information about acute health issues of refugees, legal issues, provider–patient communication and cultural aspects of health and illness, mental health, sexual and reproductive health, child health, chronic diseases, health promotion, and prevention. The English course template was translated into seven languages and adapted to the local contexts of six countries. Pre- and post-completion knowledge tests were administered to effectively assess the progress and knowledge increase of participants so as to issue CME certificates. An online evaluation survey post completion was used to assess the acceptability and practicability of the course from the participant perspective. These data were analyzed descriptively. Results: A total of 390 participants registered for the online course in 6 countries with 175 completing all modules of the course, 47.7 % of them medical doctors. The mean time for completion was 10.77 hours. In total, 123 participants completed the online evaluation survey; the modules on acute health needs, legal issues (both 44.1%), and provider–patient communication/cultural issues (52.9%) were found particularly important for the daily practice. A majority expressed a will to promote the online course among their peers. Conclusion: This course is a promising learning tool for PHC professionals and when relevant supportive conditions are met. The course has the potential to empower PHC professionals in their work with refugees and other migrants.

Objective: To identify the associations among quality of life (QoL), social determinants and psychological distress in primary care in two cities in Brazil. Methods: A cross-sectional study with 1,466 patients from 2009 to 2010. The statistical analysis used the t-test to compare the variables of interest to the study. Results: The prevalence of Common Mental Disorders (CMD3), severe forms of Common Mental Disorders (CMD5), anxiety and depression were 20.5%, 32%, 37% and 25.1% respectively. Thes presence of psychological distress is associated with worse QoL among the patients studied, especially those older than 40 years of age. In cases of CMD3, those with higher income and educational levels presented higher QoL in the psychical and psychological domains. For the cases of probable anxiety, those with higher educational levels presented lower scores on the physical and social relationship scores. Conclusion: Psychological distress can be associated with a worse QoL among those studied and can be influenced by socioeconomic conditions. Therefore, it is important to structure patient-centered help, which should also include patients’ social contexts.

Mental health problems are common in primary health care, particularly anxiety and depression. This study aims to estimate the prevalence of common mental disorders and their associations with socio-demographic characteristics in primary care in Brazil (Family Health Strategy). It involved a multicenter cross-sectional study with patients from Rio de Janeiro, São Paulo, Fortaleza (Ceará State) and Porto Alegre (Rio Grande do Sul State), assessed using the General Health Questionnaire (GHQ-12) and the Hospital Anxiety and Depression Scale (HAD). The rate of mental disorders in patients from Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre were found to be, respectively, 51.9%, 53.3%, 64.3% and 57.7% with significant differences between Porto Alegre and Fortaleza compared to Rio de Janeiro after adjusting for confounders. Prevalence proportions of mental problems were especially common for females, the unemployed, those with less education and those with lower incomes. In the context of the Brazilian government's moves towards developing primary health care and reorganizing mental health policies it is relevant to consider common mental disorders as a priority alongside other chronic health conditions.

The objective of this study was to identify the association between emotional distress and social support networks with quality of life in primary care patients. This was a cross-sectional study involving 1,466 patients in the cities of São Paulo and Rio de Janeiro, Brazil, in 2009/2010. The General Health Questionnaire, the Hospital Anxiety and Depression Scale and the brief version of the World Health Organization Quality of Life Instrument were used. The Social Support Network Index classified patients with the highest and lowest index as socially integrated or isolated. A bivariate analysis and four multiple linear regressions were conducted for each quality of life outcome. The means scores for the physical, psychological, social relations, and environment domains were, respectively, 64.7; 64.2; 68.5 and 49.1. In the multivariate analysis, the psychological domain was negatively associated with isolation, whereas the social relations and environment domains were positively associated with integration. Integration and isolation proved to be important factors for those in emotional distress as they minimize or maximize negative effects on quality of life.