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.

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.

Increasing access to contraception in New Zealand: assessing the impact of a new funding initiative.

AIM: This paper offers a grassroots view of the impact of a recent government initiative designed to increase access to contraception and improve health and social outcomes for women in New Zealand. METHOD: District health board and primary health organisation project leads were contacted to request information on how each region had chosen to configure contraception services under the new contract in August 2019, a month after the rollout of the initiative, and again in August 2020. In addition, feedback from individual general practitioners was sought via social media groups. RESULTS: There is significant variation in regional funding and provision of contraception services. Further, complex eligibility criteria can create unnecessary barriers to access for women. CONCLUSION: Variation in funding and access to contraception continues to be a feature of service provision in New Zealand and may have been exacerbated by the recent Ministry of Health funding initiative. This perpetuates inequity, particularly for vulnerable women. Urgent consideration should be given to a whole-of-system approach with contraception being free at the point of access for all women in New Zealand.

A brief treatment for fear of heights.

Objective To assess the effectiveness of a novel imaginal intervention for people with acrophobia. Methods The design was a randomized controlled trial with concealed randomization and blinded to other participants' intervention. The intervention was a single novel imaginal intervention session or a 15-min meditation. The setting was in Auckland, New Zealand. The participants were a convenience sample of the public with a score >29 on the Heights Interpretation Questionnaire (HIQ), a questionnaire validated against actual height exposure. The primary outcomes were the proportion of participants with a score <26 on the HIQ at eight weeks and difference between the HIQ scores between the two arms of the study. Results Ninety-eight participants (92%) returned their questionnaire and were included in the intention to treat analysis. The HIQ score <26 was 34.6% (18/52) in the intervention group and 15.2% (7/46) in the control group RR = 2.26, 95% CI (1.05, 4.95) and p = 0.028. The numbers needed to treat is six 95% CI (3 to 36). Participants with scores <26 report their fear of heights is very much improved. There was a 4.5-point difference in the HIQ score at eight weeks (p = 0.055) on the multiple regression analysis. Conclusions This is the first randomized trial of this novel imaginal intervention which is probably effective, brief, easily learnt, and safe. It may be worth considering doing this prior to some of the longer or more expensive exposure therapies. This study will be of interest to family doctors, psychiatrists, and psychologists.

A systematic review and meta-analysis of treatments for acrophobia.

OBJECTIVE: To review the literature on the comparative efficacy of psychological, behavioural and medical therapies for acrophobia (fear of heights). DATA SOURCES: Multiple databases were searched through the Cochrane Common Mental Disorders review group on 1 December 2015. DATA SYNTHESIS: The data were extracted independently and were pooled using RevMan version 5.3.5. The main outcome measures were changes from baseline on questionnaires for measurement of fear of heights, such as the Acrophobia Questionnaire (AQ), Attitude Towards Height Questionnaire (ATHQ), and behavioural avoidance tests. Individual and pooled analyses were conducted. Sixteen studies were included. Analysis of pooled outcomes showed that desensitisation (DS) measured by the post-test AQ anxiety score (standardised mean difference [SMD], -1.24; 95% CI, -1.88 to -0.60) and in vivo exposure (IVE) were effective in the short term compared with control (SMD, -0.74; 95% CI, -1.22 to -0.25). IVE was not effective in the long term (SMD, -0.34; 95%CI -0.76 to 0.08) and there were no follow-up data for DS. Virtual reality exposure (VRE) therapy was effective when assessed with the ATHQ but not the AQ. Augmentation of VRE with medication was promising. The number needed to treat (NNT) ranged from 1.4 (95% CI, 1.0 to 2.2) for IVE therapy with oppositional actions (a psychological process) versus waitlist control to an NNT of 6.0 (95% CI, 2.8 to 35.5) for the rapid phobia cure (a neurolinguistic programming technique) versus a mindfulness exercise as the control activity. It was often unclear if there were biases in the included studies. CONCLUSIONS AND RELEVANCE: A range of therapies are effective for acrophobia in the short term but not in the long term. Many of the comparative studies showed equivalence between therapies, but this finding may be due to a type II statistical error. The quality of reporting was poor in most studies.

Neonatal invasive pneumococcal disease: New Zealand experience in the era of pneumococcal vaccination.

BACKGROUND: Invasive pneumococcal disease (IPD) became a notifiable disease in New Zealand in 2008, and in the same year pneumococcal conjugate vaccine (PCV) was added to the childhood immunisation schedule. DESIGN: This was a retrospective study of IPD in infants aged <90 days reported to the national notifiable disease database, EpiSurv, from 1 January 2009 to 31 December 2013. All cases had Streptococcus pneumoniae isolated from a normally sterile site. MAIN OUTCOME MEASURES: IPD incidence was calculated for babies aged <90 and <30 days using the number of national IPD cases with a denominator of annual infant live births. Clinical, demographic and outcome data were reviewed for infants aged less than seven days (early onset). RESULTS: There were 29 cases of IPD in infants aged <90 days and 19 cases in infants aged <30 days. Of the nine early-onset cases, six occurred within the first 48 h. Six of the early-onset cases were infants of NZ Maori ethnicity. One infant died six hours after birth. Three infants developed long-term neurological or respiratory sequelae. Isolates from five of the early-onset cases were S. pneumoniae serotypes not covered by the PCV in use at the time of infection. Maternal vaccination with 23-valent pneumococcal vaccine would have covered 84% (16 of 19) of serotypes responsible for the cases in infants <30 days old. CONCLUSION: Strategies such as maternal vaccination or accelerated neonatal vaccination may be beneficial to protect neonates at high risk of IPD.

Antidepressants for treatment of depression in primary care: a systematic review and meta-analysis.

INTRODUCTION Evidence for the effectiveness of drug treatment for depression in primary care settings remains limited, with little information on newer antidepressant classes. AIM To update an earlier Cochrane review on the effectiveness of antidepressants in primary care to include newer antidepressant classes, and to examine the efficacy of individual agents. METHODS Selection criteria included antidepressant studies with a randomly assigned placebo group where half or more subjects were recruited from primary care. The Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) group searched multiple databases to identify eligible studies. Data extraction was performed independently by two reviewers. Data were analysed using Revman version 5.3.5. RESULTS In total, 17 papers and 22 comparisons were included for analysis. Significant benefits in terms of response were found for tricyclic antidepressants (TCA) with a relative risk (RR) = 1.23 (95% CI, 1.01-1.48), and serotonin selective reuptake inhibitors (SSRI) with a RR = 1.33 (95% CI, 1.20-1.48). Mianserin was effective for continuous outcomes. Numbers needed to treat (NNT) for TCA = 8.5; SSRI = 6.5; and venlafaxine = 6. Most studies were industry-funded and of a brief duration (≤ 8 weeks). There was evidence of publication bias. There were no studies comparing newer antidepressants against placebo. CONCLUSION Antidepressants such as TCA, SSRI, SNRI (serotonin-norepinephrine reuptake inhibitor) and NaSSA (noradrenergic and specific serotonergic antidepressant) classes appear to be effective in primary care when compared with placebo. However, in view of the potential for publication bias and that only four studies were not funded by industry, caution is needed when considering their use in primary care.