Paul Walters

Community studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings. This pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care. 81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire. Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant’s physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant’s mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient’s self efficacy to solve their problems. Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation. This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care. ISRCTN21615909.

At one time, it was asserted that the ‘worried well’ were treated in primary care, while true mental illnesses were seen by the mental illness services. This was not true when it was asserted, and is even less true now. The great majority of patients with common mental disorders are cared for within primary care, and many of those with severe mental illnesses are only seen in primary care. ‘Stepped care’ is a model for distributing clinical problems between the services, and ‘shared care’ refers to the care of patients seen by both primary care and specialist mental health services. Many other workers in primary care now assist GPs with the treatment of mental disorders, and special administrative arrangements within primary care are necessary to ensure that clinical services are available to those with special needs. In summary, mental disorders in primary care: ♦ Are an important public health problem ♦ Frequently present with somatic symptoms ♦ Are more likely to be detected if the doctor has better communication skills ♦ Those with disabling physical illnesses are also at greater risk ♦ Are on average less severe than those seen in specialist care

Asthma and depression are common health problems in primary care. Evidence of a relationship between asthma and depression is conflicting. Objectives: to determine 1. The incidence rate and incidence rate ratio of depression in primary care patients with asthma compared to those without asthma, and 2. The standardized mortality ratio of depressed compared to non-depressed patients with asthma. A historical cohort and nested case control study using data derived from the United Kingdom General Practice Research Database. Participants: 11,275 incident cases of asthma recorded between 1/1/95 and 31/12/96 age, sex and practice matched with non-cases from the database (ratio 1∶1) and followed up through the database for 10 years. 1,660 cases were matched by date of asthma diagnosis with 1,660 controls. Main outcome measures: number of cases diagnosed with depression, the number of deaths over the study period. The rate of depression in patients with asthma was 22.4/1,000 person years and without asthma 13.8 /1,000 person years. The incident rate ratio (adjusted for age, sex, practice, diabetes, cardiovascular disease, cerebrovascular disease, smoking) was 1.59 (95% CI 1.48–1.71). The increased rate of depression was not associated with asthma severity or oral corticosteroid use. It was associated with the number of consultations (odds ratio per visit 1.09; 95% CI 1.07–1.11). The age and sex adjusted standardized mortality ratio for depressed patients with asthma was 1.87 (95% CI: 1.54–2.27). Asthma is associated with depression. This was not related to asthma severity or oral corticosteroid use but was related to service use. This suggests that a diagnosis of depression is related to health seeking behavior in patients with asthma. There is an increased mortality rate in depressed patients with asthma. The cause of this needs further exploration. Consideration should be given to case-finding for depression in this population.

Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression.

This is a major international textbook for psychiatrists and other professionals working in the field of mental healthcare. With contributions from opinion-leaders from around the globe, this book will appeal to those in training as well as to those further along the career path seeking a comprehensive and up-to-date overview of effective clinical practice backed by research evidence. The book is divided into cohesive sections moving from coverage of the tools and skills of the trade, through descriptions of the major psychiatric disorders and on to consider special topics and issues surrounding service organization. The final important section provides a comprehensive review of treatments covering all of the major modalities. Previously established as the Essentials of Postgraduate Psychiatry, this new and completely revised edition is the only book to provide this depth and breadth of coverage in an accessible, yet authoritative manner.

Background Antidepressant prescribing should reflect need. The Quality and Outcomes Framework has provided an opportunity to explore factors affecting antidepressant prescribing in UK general practice. Aims To explore the relationship between physical illness, social deprivation, ethnicity, practice characteristics and the volume of antidepressants prescribed in primary care. Method This was an ecological study using data derived from the Quality and Outcomes Framework, the Informatics Collaboratory of the Social Sciences, and Prescribing Analyses and CosT data for 2004–2005. Associations were examined using linear regression modelling. Results Socio-economic status, ethnic density, asthma, chronic obstructive pulmonary disease and epilepsy explained 44% of the variance in the volume of antidepressants prescribed. Conclusions Lower volumes of antidepressants are prescribed in areas with high densities of Black or Asian people. This may suggest disparities in provision of care. Chronic respiratory disease and epilepsy may have a more important association with depression in primary care than previously thought.

Context  Many patients in primary care somatise psychological distress. Training general practitioners (GPs) to manage somatisation has been shown to lead to improvements in their management of these patients. However, the training has been intensive and conducted by psychiatrists, making it impractical for widespread use. The aim of this research was to determine the effectiveness of a teaching package in improving the ability of GP registrars to manage patients who somatise, when taught by GP vocational course tutors within the constraints of a general practice vocational training scheme. Methods  This was a before‐and‐after training evaluation of GP registrars' skills. A total of 22 GP registrars and 6 GP course organisers were recruited from 3 GP vocational training schemes. The GP trainees had 2 videotaped consultations with trained actors role‐playing patients with somatised depression, before and 1 month after training. Results  There was a significant overall improvement in the ability of GP registrars to manage patients who somatise (mean scores on a 4‐point Likert scale: pre‐training 1.4 [standard deviation, SD, 0.6]; post‐training 2.2 [SD 0.9]; P = 0.002). General practice registrars improved their ability to use a negotiating style of consultation (skill present in 8/22 pre‐training, 16/22 post‐training; P = 0.02) and also demonstrated more empathy during the ‘consultation’ after training (mean scores on a 5‐point Likert scale: pre‐training 2.3 [SD 1.0]; post‐training 3.0 [SD 0.8]; P = 0.03). Conclusions  Using a structured training package, it is possible for GP vocational course tutors to successfully teach GP registrars to manage patients who somatise psychological distress. Given limited resources for teaching in terms of cost and time, this training package could have important implications for training medical staff.

Despite current debate on the methodology of existing research into depression and anxiety disorders, there is still general agreement that recognition rates of these conditions in primary care could be improved. This review examines the factors that influence recognition of these disorders from both the patients' perspective and the primary care givers' perspective. Approaches and methods for improving recognition in primary care, including guidelines, mental health skills training, screening, and increasing public awareness, are considered in detail.