Amount and frequency of psychotherapy as predictors of treatment outcome for adult depression: A meta-regression analysis.

BACKGROUND: It is not clear whether the amount and frequency of psychotherapy is associated with treatment effects for adult depression. We investigated whether a number of indicators of the amount and frequency of psychotherapy were related to the treatment effects in randomized controlled trials (RCTs) comparing individual, face-to-face psychotherapy to a control group (e.g., care-as-usual [CAU] or waitlist condition [WL]). METHODS: Four databases were systematically searched, and meta-regression analyses conducted to assess the relationship between the effect size (Hedges' g) of the treatment and number of sessions, duration of psychotherapy, total contact time with the therapist, and number of sessions per week. RESULTS: We included 176 studies (210 comparisons) with 15,158 participants. We did not find a relationship between the effect size, and number of sessions, or total contact time. There was a small negative association between duration of treatment and the effect size, an additional week of treatment was related to a 0.014 decrease in the effect size. In addition, there was a strong association between number of sessions per week and the effect size, an increase from one to two sessions per week was related to an effect size higher by 0.596. Both associations were no longer significant when controlling for characteristics of studies. LIMITATIONS: The current findings are correlational, future research should thus address this question in an RCT. CONCLUSIONS: We should deliver brief therapies, and thus shorten waiting lists. More sessions, if necessary, should be delivered with higher frequency and over a shorter period of time.

Health and Wellness Coaching for 5-Year Projected Cardiovascular Health: A Randomized Controlled Trial.

Background and Objectives: Evidence of effective multifactorial lifestyle interventions for primary stroke prevention is lacking, despite the significant contribution of lifestyle to stroke burden. We aimed to determine the efficacy of health and wellness coaching (HWC) for primary stroke and cardiovascular disease (CVD) prevention in adults at a moderate-to-high CVD risk. Methods: This was a parallel, 2-arm, open-label, single-blinded, phase III randomized controlled trial to determine the efficacy of HWC for primary stroke prevention in individuals 30 years and older with a 5-year CVD risk ≥10% as measured by 5-year absolute CVD risk (as measured by the PREDICT tool) at 9 months post-randomization. Eligible participants were those with a 5-year CVD risk ≥10%, with no history of stroke, transient ischemic attack, or myocardial infarction. The relative risk reduction (RRR) and odds ratios (OR) were evaluated separately in those at moderate (10%-14%) 5-year CVD risk and those at high risk (≥15%) at baseline. The Life's Simple 7 (LS7) score for lifestyle-related CVD risk, as the indicator of cardiovascular health, was a key secondary outcome. Results: Of a total of 320 participants, 161 were randomized to the HWC group and 159 to the usual care (UC) group. HWC resulted in a statistically significant RRR of -10.9 (95% CI -21.0 to -0.9) in 5-year CVD risk in the higher CVD risk group but no change in the moderate risk group. An improvement in the total LS7 score was seen in the HWC group compared with the UC group (absolute difference = 0.485, 95% CI [0.073 to 0.897], p = 0.02). Improvement in blood pressure scores was statistically significantly greater in the HWC group than in the UC group for those at high risk of CVD (OR 2.28 [95% CI 1.12 to 4.63] and 1.55 [0.80 to 3.01], respectively). No statistically significant differences in mood scores, medication adherence, quality of life, and satisfaction with life scores over time or between groups were seen. Discussion: Health and wellness coaching resulted in a significant RRR in the 5-year CVD risk compared with UC at 9 months post-randomization in patients with a high baseline CVD risk. There was no improvement in CVD risk in the moderate risk group; hence, this study did not meet the primary hypothesis. However, this treatment effect is clinically significant (number needed to treat was 43). The findings suggest that HWC has potential if further refined to improve lifestyle risk factors of stroke.

Usability and feasibility of PreventS-MD web app for stroke prevention.

BACKGROUND: Most strokes and cardiovascular diseases (CVDs) are potentially preventable if their risk factors are identified and well controlled. Digital platforms, such as the PreventS-MD web app (PreventS-MD) may aid health care professionals (HCPs) in assessing and managing risk factors and promoting lifestyle changes for their patients. METHODS: This is a mixed-methods cross-sectional two-phase survey using a largely positivist (quantitative and qualitative) framework. During Phase 1, a prototype of PreventS-MD was tested internationally by 59 of 69 consenting HCPs of different backgrounds, age, sex, working experience, and specialties using hypothetical data. Collected comments/suggestions from the study HCPs in Phase 1 were reviewed and implemented. In Phase 2, a near-final version of PreventS-MD was developed and tested by 58 of 72 consenting HCPs using both hypothetical and real patient (n = 10) data. Qualitative semi-structured interviews with real patients (n = 10) were conducted, and 1 month adherence to the preventive recommendations was assessed by self-reporting. The four System Usability Scale (SUS) groups of scores (0-50 unacceptable; 51-68 poor; 68-80.3 good; >80.3 excellent) were used to determine usability of PreventS-MD. FINDINGS: Ninety-nine HCPs from 27 countries (45% from low- to middle-income countries) participated in the study, and out of them, 10 HCPs were involved in the development of PreventS before the study, and therefore were not involved in the survey. Of the remaining 89 HCPs, 69 consented to the first phase of the survey, and 59 of them completed the first phase of the survey (response rate 86%), and 58 completed the second phase of the survey (response rate 84%). The SUS scores supported good usability of the prototype (mean score = 80.2; 95% CI [77.0-84.0]) and excellent usability of the final version of PreventS-MD (mean score = 81.7; 95% CI [79.1-84.3]) in the field. Scores were not affected by the age, sex, working experience, or specialty of the HCPs. One-month follow-up of the patients confirmed the high level of satisfaction/acceptability of PreventS-MD and (100%) adherence to the recommendations. INTERPRETATION: The PreventS-MD web app has a high level of usability, feasibility, and satisfaction by HCPs and individuals at risk of stroke/CVD. Individuals at risk of stroke/CVD demonstrated a high level of confidence and motivation in following and adhering to preventive recommendations generated by PreventS-MD.

Trends in the primary healthcare nursing workforce in managing diabetes from two sample surveys in 2006-2008 and 2016 in Auckland, New Zealand.

AIM: To examine trends in the primary healthcare nursing workforce and their community management of diabetes. METHOD: Two representative surveys were carried out in 2006-2008 and 2016 among all primary healthcare nurses in Auckland. Nurses were randomly selected, and 26% (n=287) and 24% (n=336) completed a self-administered questionnaire and telephone survey. Biographical information, knowledge of diabetes, how valued nurses felt and diabetes care for patients was provided. RESULTS: Between surveys, numbers of practice nurses have significantly increased, and specialist nurse numbers decreased, while district nurse numbers remained the same. In 2016, practice nurses were younger, more ethnically diverse, more likely to undertake education and had increased knowledge of diabetes and diabetes-related complications (including stroke) compared to nurses in 2006-2008. More nurses consulted patients, conducted foot examinations, addressed serum glucose, medication management, tobacco use and followed up care independently of doctors. In 2016, only 37% of nurses felt sufficiently knowledgeable to discuss medications with patients, <20% could state that hypertension, smoking and dyslipidaemia were major risk factors for complications, and less nurses felt valued. CONCLUSION: Practice nurses have increased their capacity in diabetes management following global trends and require more support in meeting the complex healthcare needs of people with diabetes.

Burns Depression Scale Today (BDST): A validation study of BDST against the reference standard of PHQ-9.

Background: Case finding for low mood is essential in primary care, but it is time-consuming using current depression inventories. The Burns Depression Scale Today (BDST) is a short, simple inventory which assesses mood for today, and we aimed to validate it in this study. Materials and Methods: Consecutive patients with emotional distress seen in a single primary care clinic by one of the authors over 22 months were eligible for this retrospective audit (N = 160). Multiple visits (N = 421) from the same patient were included in the study. The index test was BDST, which assesses the patient's mood for today. The reference standard was the 9-item Patient Health Questionnaire (PHQ-9), which assesses mood over the past 2 weeks. PHQ-9 had a cut-off point of ≥10 and BDST had a cut-off point of ≥6 for a significant mood issue. Results: The median age of patients was 35 years, and 63% of the cohort were women. The median BDST score was 8, indicative of moderately low mood, and the median PHQ-9 score was 15, indicative of moderately severe depression. For patients with a BDST score ≥6, the likelihood ratio of a positive test was 2.67. The sensitivity was 85% (95% confidence interval [CI]: 89%-96%) and the specificity was 68% (95% CI: 60%-76%). The area under the curve was 84% (95% CI: 80%-87%). Conclusion: This audit validates BDST against PHQ-9 and finds it an excellent case-finding tool compared to PHQ-9. This is the first validation study of BDST.

Psychological treatment of adult depression in primary care compared with outpatient mental health care: A meta-analysis.

BACKGROUND: It is not yet known whether psychological treatments of depression in primary care have comparable effects to treatments in specialized mental health care. We conducted a meta-analysis comparing randomized controlled trials in primary and specialized care. METHODS: We selected studies from an existing database of randomized trials of psychological treatments of depression in adults, which was built through searches in PubMed, PsychINFO, Embase and the Cochrane Library. Random effects meta-analyses were conducted to examine the effects of therapies and mixed effects subgroup analyses were used to compare the effects in primary and specialized care. RESULTS: We included 52 trials (7984 patients) in primary care and compared them with 50 trials (3685 patients) in specialized care. The main effect of therapies in primary care was g = 0.43 (95 % CI: 0.32; 0.53; PI: -0.18; 1.03). The overall effects were significantly smaller than those in specialized care (p = 0.006), but this was no longer significant after adjustment for differences between the two settings. The proportion of patients responding to treatment was comparable in primary (0.38; 95 % CI: 0.33; 0.43) and specialized care (0.34; 95 % CI: 0.28; 0.41; p = 0.41), but higher in control conditions in primary care (0.25; 95 % CI: 0.22; 0.28) compared to specialized care (0.16; 95 % CI: 0.12; 0.20; p < 0.001). DISCUSSION: Psychological treatments are effective in primary care, but somewhat less than in specialized care. Response rates in control conditions in primary care are higher than in specialized care, which may point at a transient nature of depression in primary care.

Emoqol-100: Development and validation of a single question for low mood in primary care. A retrospective audit.

BACKGROUND: Patients with depression need to be diagnosed and managed effectively in primary care. However, current inventories for case-finding low mood are time-consuming when considering the limited time available during appointments. AIM: To validate the diagnostic accuracy of a single question on the emotional quality of life (Emoqol-100) as a measure of depression in symptomatic patients. DESIGN & SETTING: A retrospective clinical audit, validating the Emoqol-100 compared with the 9-item Patient Health Questionnaire (PHQ-9) and Burns Depression Scale Today (BDST) in South Auckland, New Zealand. METHOD: Consecutive patients with suspected low mood, seen over 22 months in a single primary care clinic by one of the authors, were eligible for this retrospective audit (n = 160). The index test was the verbally asked Emoqol-100: 'How is your emotional quality of life now, with 100 being perfect and 0 being the worst imaginable?' The reference standard was the PHQ-9 (n = 426 visits) with a cut-off point of ≥10 or BDST (n = 513 visits) with a cut-off point of ≥6. RESULTS: The Emoqol-100 range 0-20 had a likelihood ratio (LR) of 25.2 for low mood compared with the BDST as the reference standard; and for Emoqol-100 scores of 21-40, 41-60, 61-80, and 81-100 the LRs were 3.6, 1.7, 0.35, and 0.09, respectively. For the PHQ-9, these were 10.1, 2.9, 1.3, 0.40, and 0.2, respectively. Any score ≤60 was associated with a low mood. CONCLUSION: The Emoqol-100 appears to have high validity, so when it is low (≤60), it is suggestive of a high PHQ-9 or BDST score, and a mood issue probably exists. Emoqol-100 could be helpful for busy primary care professionals and other clinicians.

Bridging the gap between primary and secondary care: a utilisation evaluation of an otolaryngology GPwSI programme.

Introduction Counties Manukau Health Otolaryngology programme for general practitioners with special interest (GPwSI) was developed to provide a group of GPs with tools to manage low complexity, secondary otolaryngology (ORL) problems in their local communities. After clinical triaging, the medical records were retrieved to assess patient outcomes from community (GPwSI) review. This programme provides an example of how the aims of the Health NZ reforms may work in practice, by bridging primary and secondary services. Aim To assess whether the GPwSI programme provides patients with suitable specialty care in the community, compared to a specialised, hospital outpatient otolaryngology clinic (OPC). Methods This is a retrospective study of patients with an assigned priority of three (non-urgent) referred to Middlemore Hospital for a first specialist assessment (FSA) during 2018-19. Results Of the 6231 patients referred, one-fifth (22%) were directed to the GPwSI service, and the remainder (78%) were arranged to be seen in the OPC. GPwSI patients were more likely to be seen for their FSA earlier than OPC patients (RR 1.55, 95% CI 1.46-1.64, P Discussion Patients being seen through the GPwSI programme are suitably managed in the community, more efficiently than if they were to be seen in an outpatient specialist clinic.

Post-consultation acute respiratory tract infection recovery: a latent class-informed analysis of individual patient data.

BACKGROUND: There is a lack of evidence regarding post-consultation symptom trajectories for patients with respiratory tract infections (RTIs) and whether patient characteristics can be used to predict illness duration. AIM: To describe symptom trajectories in patients with RTIs, and assess baseline characteristics and adverse events associated with trajectories. DESIGN AND SETTING: The study included data about 9103 adults and children from 12 primary care studies. METHOD: A latent class-informed regression analysis of individual patient data from randomised controlled trials and observational cohort studies was undertaken. Post-consultation symptom trajectory (severity and duration), re-consultation with same or worsening illness, and admission to hospital were assessed. RESULTS: In total, 90% of participants recovered from all symptoms by 28 days, regardless of antibiotic prescribing strategy (none, immediate, and delayed antibiotics). For studies of RTI with cough as a dominant symptom (n = 5314), four trajectories were identified: 'rapid (6 days)' (90% of participants recovered within 6 days) in 52.0%; 'intermediate (10 days)' (28.9%); 'slow progressive improvement (27 days)' (12.5%); and 'slow improvement with initial high symptom burden (27 days)' (6.6%). For cough, being aged 16-64 years (odds ratio [OR] 2.57, 95% confidence interval [CI] = 1.72 to 3.85 compared with <16 years), higher presenting illness baseline severity (OR 1.51, 95% CI = 1.12 to 2.03), presence of lung disease (OR 1.78, 95% CI = 1.44 to 2.21), and median and above illness duration before consultation (≥7 days) (OR 1.99, 95% CI = 1.68 to 2.37) were associated with slower recovery (>10 days) compared with faster recovery (≤10 days). Re-consultations and admissions to hospital for cough were higher in those with slower recovery (ORs: 2.15, 95% CI = 1.78 to 2.60 and 7.42, 95% CI = 3.49 to 15.78, respectively). CONCLUSION: Older patients presenting with more severe, longer pre-consultation symptoms and chronic lung disease should be advised they are more likely to experience longer post-consultation illness durations, and that recovery rates are similar with and without antibiotics.

The first consultation with a depressed patient: A qualitative study of GPs' approaches to diagnosis.

Background: The first consultation with a depressed patient is important because many patients do not return for subsequent visits. Therefore, the first consultation provides a unique opportunity for diagnosis (if required) and treatment, but there are risks of both under and over-diagnosis. Aim: To understand how general practitioners utilize diagnosis when patients present with a new episode of depression. Method: We approached a random selection of twenty-one general practitioners (GPs) in Auckland, New Zealand and asked them to participate in a semi-structured telephone interview. The interviews explored "the first consultation for a depressed/distressed patient" were undertaken to theme saturation. Interviews were hand-written and later transcribed. Results: We identified three major themes in GPs' approach to diagnosis. The issue of diagnosis was underpinned by a complex understanding of depression and the GP role. GPs did not always make a formal diagnosis, but the experience of a patient's distress/depression was understood by drawing on a range of factors and resources. These included time, screening tools, clinician experience, and patient affect. GPs were careful about how they communicated a diagnosis, both in their documentation and in their conversations with patients. Conclusion: At an initial appointment, the distressed/depressed patient can present to their GP with various symptoms and differing degrees of distress. GPs draw upon a variety of skills and resources to negotiate these complexities. The value of a diagnosis was questioned and issues such as impairment may be more useful concepts for GPs. This is the first study to report the findings of the first visit.

Treatment of depression in the first primary care consultation: A qualitative study.

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 Maori 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.

Nurse's contribution to the diabetes annual review and funded programmes in Auckland, New Zealand.

AIMS: Examine trends in nurse's contribution to diabetes funded programmes,estimate total nurse consultations, and document the division of diabetes care between doctors and nurses in general practice. METHODS: All primary health care nurses in Auckland were identified in 2006-8 and 2016 and 26% and 24% were randomly surveyed, achieving response rates of 86%and 73%, respectively. Participants completed a self-administered and telephone questionnaire detailing their contribution to diabetes funded programmes. RESULTS: In response to more people with diabetes, significantly more nurses in 2016 consulted patients, provided follow-up care, completed Diabetes Annual Reviews independently of doctors (48%), accessed more educational resources (including theinternet) and 63% felt supported, compared with 27% and 55% of nurses respectively,in 2006-8. The main reason nurses surveyed did not participate in diabetes reviews was because designated nurses conducted them, with more reporting this in 2016 (55%) compared to 32% in 2006-8. Most nurses in the 2016 survey addressed cardiovascular risk such as blood pressure, smoking cessation, physical activity and nutrition during the review. CONCLUSIONS: Nurses conducted more diabetes consultations and reviews, addressed cardiovascular risk in 2016 and reported increased support for participating in diabetes reviews within general practice, compared with nurses in 2006-8.

Developing a national primary care research network: a qualitative study of stakeholder views.

Introduction Primary care research is critical to address Aotearoa New Zealand's (NZ) health sector challenges. These include health inequities, workforce issues and the need for evaluation of health system changes. Internationally, primary care data are routinely collected and used to understand these issues by primary care research and surveillance networks (PCRN). NZ currently has no such infrastructure. Aim To explore health sector stakeholders' views on the utility of, and critical elements needed for, a national PCRN in NZ. Methods Twenty semi-structured interviews and a focus group were conducted with key stakeholders, representing different perspectives within the health sector, including Hauora Maori providers. Data were analysed thematically. Results Six themes were identified that included both challenges within current primary care research and ideas for a future network. The themes were: disconnection between research, practice and policy; desire for better infrastructure; improving health equity for Maori and other groups who experience inequity; responding to the research needs of communities; reciprocity between research and practice; and the need for data to allow evidence-informed decision-making. Improving health equity for Maori was identified as a critical function for a national PCRN. Discussion Stakeholders identified challenges in conducting primary care research and translating research into practice and policy in NZ. Stakeholders from across the health sector supported a national PCRN and identified what its function should be and how it could operate. These views were used to develop a set of recommendations to guide the development of a national PCRN.

Emoqol 100, an ultra ultra-brief mood case-finding tool: A diagnostic accuracy study.

BACKGROUND: Case-finding for low mood in primary care can be time-consuming using current depression inventories. AIM: To assess the diagnostic accuracy, of a single verbally administered question on the emotional quality of life (Emoqol 100), for low mood in patients with symptoms of distress in an ambulatory care setting. DESIGN AND SETTING: Eligible patients were consecutive patients seen by one of the authors over 13 months with possible distress/low mood. The index test was the verbally asked Emoqol 100, which is the patient's emotional quality of life now, with 100 being perfect emotional health and 0 being the worst imaginable. The reference standard is the written version of the PHQ-9 with a cut point of ≥10. METHODS: A retrospective audit of consecutive consultations in a single primary care clinic. RESULTS: One hundred two patients were seen during the study period, of which 76 met the eligibility criteria for this audit, and there were 215 test results. For a cut point of <50 on the Emoqol 100 and the PHQ-9 ≥10 the sensitivity was 47% (95% CI 39-54), and the specificity was 93% (95% CI 86-100). The positive predictive value was 95%, and the negative predictive value was 37%. CONCLUSION: This is the first accuracy estimation of the Emoqol 100. It appears to have a high specificity which means when it is positive (<50) it is a good estimate of a high PHQ-9, i.e. a mood issue probably exists. The test will be helpful for busy primary care clinicians as it takes less than 15 seconds to verbally administer.

The inequity of access to health: a case study of patients with gout in one general practice.

AIM: Gout is a health equity issue for Maori and Pacific peoples because disparities in quality of care exist. This study aims to describe domains of access that may contribute to the optimisation of gout care and, therefore, address health inequity. METHODS: The practice management system at one general practice in Auckland was used to identify enrolled patients with gout, using disease codes and medication lists. Barriers to access for the cohort were investigated using staff knowledge and the practice management system. The general practice is uniquely situated within an urban marae (traditional meeting house) complex serving a predominantly Maori community. This enables a focus on domains of access other than cultural safety. RESULTS: Of 3,095 people enrolled at the practice, 268 were identified as having gout. Of these, 94% had at least one other long-term health condition. The majority of people with gout enrolled at the practice have employment roles incongruent with the clinic's opening hours. CONCLUSIONS: Social circumstances, such as employment and availability of transport, should be actively discussed with all patients and recorded in the practice management system. Reorientation of health services, including hours of access, is evidentially required to ensure optimal management of gout and possibly other health conditions.