Case-finding for common mental disorders of anxiety and depression in primary care: an external validation of routinely collected data.

BACKGROUND: The robustness of epidemiological research using routinely collected primary care electronic data to support policy and practice for common mental disorders (CMD) anxiety and depression would be greatly enhanced by appropriate validation of diagnostic codes and algorithms for data extraction. We aimed to create a robust research platform for CMD using population-based, routinely collected primary care electronic data. METHODS: We developed a set of Read code lists (diagnosis, symptoms, treatments) for the identification of anxiety and depression in the General Practice Database (GPD) within the Secure Anonymised Information Linkage Databank at Swansea University, and assessed 12 algorithms for Read codes to define cases according to various criteria. Annual incidence rates were calculated per 1000 person years at risk (PYAR) to assess recording practice for these CMD between January 1(st) 2000 and December 31(st) 2009. We anonymously linked the 2799 MHI-5 Caerphilly Health and Social Needs Survey (CHSNS) respondents aged 18 to 74 years to their routinely collected GP data in SAIL. We estimated the sensitivity, specificity and positive predictive value of the various algorithms using the MHI-5 as the gold standard. RESULTS: The incidence of combined depression/anxiety diagnoses remained stable over the ten-year period in a population of over 500,000 but symptoms increased from 6.5 to 20.7 per 1000 PYAR. A 'historical' GP diagnosis for depression/anxiety currently treated plus a current diagnosis (treated or untreated) resulted in a specificity of 0.96, sensitivity 0.29 and PPV 0.76. Adding current symptom codes improved sensitivity (0.32) with a marginal effect on specificity (0.95) and PPV (0.74). CONCLUSIONS: We have developed an algorithm with a high specificity and PPV of detecting cases of anxiety and depression from routine GP data that incorporates symptom codes to reflect GP coding behaviour. We have demonstrated that using diagnosis and current treatment alone to identify cases for depression and anxiety using routinely collected primary care data will miss a number of true cases given changes in GP recording behaviour. The Read code lists plus the developed algorithms will be applicable to other routinely collected primary care datasets, creating a platform for future e-cohort research into these conditions.

Narrating uncertainties about treatment of mental health conditions.

BACKGROUND: Integration of patient views in mental health service planning is in its infancy despite service provision being clearly dominated by narratives from professional consultations and medical records. We wished to clarify perceptions of uncertainty about mental health conditions from a range of provider and user perspectives (patients, carers, parents, mental health service providers) and understand the role of narratives in mental health research. AIMS: (1) To explore the utility of qualitative research methods, particularly narrative content analysis in mental health research, and (2) identify aspects of uncertainty in mental health service users and providers. MATERIAL: Four hundred and six free text responses were considered as one element of an existing questionnaire about uncertainties about mental health treatments, collected from mental healthcare users and providers through charities, the Mental Health Research Network in Wales, health professionals and websites. Free text responses were analysed using narrative content analysis, an elaborate and rigorous research technique that involves groups of analysts working independently and together over extended group sessions. FINDINGS: Three main themes emerged across respondent groups: "medication and treatment options", "objectification and marginalisation of patient" and "integrity of service delivery". Within these, patients embraced the opportunity to write about their illness at length, whilst carers' and parents' main concerns were about how patients were dealing with their illnesses, the services they were getting and the side effects of treatments. Carers and patients' parents perceived themselves to be the 'go-between', carrying messages between patients and professionals, in order to enable services to function. Mental health service providers and professionals considered uncertainties surrounding medication and treatment from an 'evidence-base' perspective, concentrating on medication choices and the adoption of new approaches to care rather than patient need and expectation. Patients wanted to know what alternatives were available to the drug regimes they were on and felt their opinions were rarely listened to. As a consequence patients felt marginalised by the health systems there to support them and by society as a whole. CONCLUSIONS: Narrative content analysis can help distil large amounts of free text data and enable their successful interpretation. Listening to patients' voices should become an integral part of routine service evaluation and may help bring patient expectation more in line with service organisation and delivery towards an optimal delivery of care.

A qualitative study of help seeking and primary care consultation prior to suicide.

BACKGROUND: Many suicides may be preventable through medical intervention, but many people do not seek help from a medical practitioner prior to suicide. Little is known about how consulting decisions are made at this time. AIM: To explore how distressed individuals and members of their lay networks had made decisions to seek or not to seek help from a medical practitioner in the period leading up to suicide. DESIGN OF STUDY: Qualitative analysis of psychological autopsy data. SETTING: One large English county. METHOD: Semi-structured interviews with close relatives or friends of suicide victims were conducted as part of a psychological autopsy study. Sixty-six interviews were transcribed verbatim and analysed using a thematic approach. RESULTS: Relatives and friends often played a key role in determining whether or not suicidal individuals sought medical help. Half the sample had consulted in their final month and many were persuaded to do so by a relative or friend. Of those who did not consult, some were characterised as help-resisters but many others had omitted to do so because no-one around them was aware of the seriousness of their distress or considered it to be medically significant. A range of lay interventions and coping strategies was identified, including seeking non-medical help. CONCLUSION: Greater attention needs to be given to the potential role of lay networks in managing psychological distress and preventing suicide. A balanced approach to suicide prevention is recommended that builds on lay knowledge and combines medical and non-medical strategies.

Access to health care prior to suicide: findings from a psychological autopsy study.

Previous research has suggested that progress towards suicide reduction targets may be achieved by improving the ability of general practitioners to recognise and treat mental illness. Using data from a study of suicide completers who were not in contact with specialist mental health services, we found that the rate of detection and treatment of mental health problems in primary care was high. The major barrier to receipt of care for mental health problems prior to suicide was non-consultation. The study also shows that detection and management in primary care does not necessarily result in prevention of suicide. Implications for public education, access to primary care services and the potential for suicide prevention are considered.

Changes in regional cerebral blood flow with venlafaxine in the treatment of major depression.

OBJECTIVE: Neuroimaging studies reveal abnormalities of regional cerebral blood flow (rCBF) in major depression. In this study the authors prospectively investigated rCBF and clinical response to venlafaxine, a novel antidepressant. METHOD: A trial of venlafaxine was performed with seven patients referred with ICD-10 major depression. At entry and 6-week follow-up, the Beck Depression Inventory and Hamilton Depression Rating Scale were administered and rCBF was measured by means of single photon emission computed tomography with [(99m)Tc]hexamethylpropyleneamine oxime. Blood flow changes were explored with statistical parametric mapping. RESULTS: The subjects showed significant improvement after treatment. Statistical parametric mapping analysis revealed increased rCBF bilaterally in the thalamus and decreased rCBF in the left occipital lobe, right cerebellum, and temporal cortex bilaterally. CONCLUSIONS: These data confirm limbic cortical rCBF changes associated with effective antidepressant treatment.

Study of psychiatric admission patterns before and after out-patient psychotherapy in a district service setting.

There is a need for evidence to demonstrate the clinical and economic effectiveness of psychotherapy as a component of mental health service delivery. A naturalistic cohort study was carried out in a specialist psychotherapy department in a district mental health service. Thirty-six patients were identified with hospital admissions in the study period who had also received a course of outpatient psychotherapy. There was a significant decrease in hospital in-patient usage temporally associated with receipt of psychotherapy and associated cost savings. Out-patient psychotherapy leads to less in-patient bed usage and significant health-care savings among previously hospitalized psychiatric patients (approximately 6700 pounds sterling per patient).

The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders

BACKGROUND: Recent anthropological studies have documented the importance of understanding the relation of culture to the experience of mental illness. The use of interviews that elicit explanatory models has facilitated such research, but currently available interviews are lengthy and impractical for epidemiological studies. This paper is a preliminary report on the development of a brief instrument to elicit explanatory models for use in field work. METHOD: The development of the SEMI, a short interview to elicit explanatory models is described. The interview explores the subject's cultural background, nature of presenting problem, help-seeking behaviour, interaction with physician/healer and beliefs related to mental illness. RESULTS: The SEMI was employed to study the explanatory models of subjects with common mental disorders among Whites, African-Caribbean and Asians living in London and was also used in Harare, Zimbabwe. Data from its use in four different ethnic groups is presented with the aim of demonstrating its capacity to show up differences in these varied settings. CONCLUSIONS: The simplicity and brevity of the SEMI allow for its use in field studies in different cultures, data can be used to provide variables for use in quantitative analysis and provide qualitative descriptions.(Au)