Objectives: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. Design: Qualitative study. Setting: 20 general practices in the West Midlands and south east England. Participants: 20 general practitioners and 35 consulting patients. Main outcome measures: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. Results: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor9s decision, and relationship factors. All the misunderstandings were associated with lack of patients9 participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors9 decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients9 ideas about medicines for successful prescribing. Conclusions: Patients9 participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.

https://www.bmj.com/content/bmj/320/7233/484.full.pdf

Misunderstandings in prescribing decisions in general practice: qualitative study

The evidence for bringing behavioral health services into primary care can be confusing. Studies are quite varied in the types of programs assessed, what impacts are assessed, what kind of therapy is offered, for what populations, and on how broad a scale. By organizing the evidence into categories: whether the program is coordinated, co-located or integrated, whether for a targeted or non-targeted patient population, offering specified or unspecified behavioral health services, in a small scale or extensive implementation, programs can be compared more easily. By noting what sorts of impacts are reportedimproved access to services, clinical outcome, maintained improvement^ improved compliance, patient satisfaction, provider satisfaction, cost effectiveness or medical cost offset-the most comprehensive overall assessment of this important approach to patients' needs can be encouraged.

Integrated Primary Care: Organizing the Evidence.

OBJECTIVES: The aim of this study was to determine both the clinical and cost-effectiveness of usual general practitioner (GP) care compared with two types of brief psychological therapy (non-directive counselling and cognitive-behaviour therapy) in the management of depression as well as mixed anxiety and depression in the primary care setting. DESIGN: The design was principally a pragmatic randomised controlled trial, but was accompanied by two additional allocation methods allowing patient preference: the option of a specific choice of treatment (preference allocation) and the option to be randomised between the psychological therapies only. Of the 464 patients allocated to the three treatments, 197 were randomised between the three treatments, 137 chose a specific treatment, and 130 were randomised between the psychological therapies only. The patients underwent follow-up assessments at 4 and 12 months. SETTING: The study was conducted in 24 general practices in Greater Manchester and London. SUBJECTS: A total of 464 eligible patients, aged 18 years and over, were referred by 73 GPs and allocated to one of the psychological therapies or usual GP care for depressive symptoms. INTERVENTIONS: The interventions consisted of brief psychological therapy (12 sessions maximum) or usual GP care. Non-directive counselling was provided by counsellors who were qualified for accreditation by the British Association for Counselling. Cognitive-behaviour therapy was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies. Usual GP care included discussions with patients and the prescription of medication, but GPs were asked to refrain from referring patients for psychological intervention for at least 4 months. Most therapy sessions took place on a weekly basis in the general practices. By the 12-month follow-up, GP care in some cases did include referral to mental healthcare specialists. MAIN OUTCOME MEASURES: The clinical outcomes included depressive symptoms, general psychiatric symptoms, social function and patient satisfaction. The economic outcomes included direct and indirect costs and quality of life. Assessments were carried out at baseline during face-to-face interviews as well as at 4 and 12 months in person or by post. RESULTS: At 4 months, both psychological therapies had reduced depressive symptoms to a significantly greater extent than usual GP care. Patients in the psychological therapy groups exhibited mean scores on the Beck Depression Inventory that were 4-5 points lower than the mean score of patients in the usual GP care group, a difference that was also clinically significant. These differences did not generalize to other measures of outcome. There was no significant difference in outcome between the two psychological therapies when they were compared directly using all 260 patients randomised to a psychological therapy by either randomised allocation method. At 12 months, the patients in all three groups had improved to the same extent. The lack of a significant difference between the treatment groups at this point resulted from greater improvement of the patients in the GP care group between the 4- and 12-month follow-ups. At 4 months, patients in both psychological therapy groups were more satisfied with their treatment than those in the usual GP care group. However, by 12 months, patients who had received non-directive counselling were more satisfied than those in either of the other two groups. There were few differences in the baseline characteristics of patients who were randomised or expressed a treatment preference, and no differences in outcome between these patients. Similar outcomes were found for patients who chose either psychological therapy. Again, there were no significant differences between the two groups at 4 or 12 months. Patients who chose counselling were more satisfied with treatment than those who chose c

/pdf/randomised-controlled-trial-of-non-directive-counselling-30ayzsbmh4.pdf

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care

Psychological therapies provided in primary care are usually briefer than in secondary care. There has been no recent comprehensive review comparing their effectiveness for common mental health problems. We aimed to compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders. Meta-analysis and meta-regression of randomized controlled trials of brief psychological therapies of adult patients with anxiety, depression or mixed common mental health problems treated in primary care compared to primary care treatment as usual. Thirty-four studies, involving 3962 patients, were included. Most were of brief cognitive behaviour therapy (CBT; n = 13), counselling (n = 8) or problem solving therapy (PST; n = 12). There was differential effectiveness between studies of CBT, with studies of CBT for anxiety disorders having a pooled effect size [d -1.06, 95% confidence interval (CI) -1.31 to -0.80] greater than that of studies of CBT for depression (d -0.33, 95% CI -0.60 to -0.06) or studies of CBT for mixed anxiety and depression (d -0.26, 95% CI -0.44 to -0.08). Counselling for depression and mixed anxiety and depression (d -0.32, 95% CI -0.52 to -0.11) and problem solving therapy (PST) for depression and mixed anxiety and depression (d -0.21, 95% CI -0.37 to -0.05) were also effective. Controlling for diagnosis, meta-regression found no difference between CBT, counselling and PST. Brief CBT, counselling and PST are all effective treatments in primary care, but effect sizes are low compared to longer length treatments. The exception is brief CBT for anxiety, which has comparable effect sizes.

/pdf/brief-psychological-therapies-for-anxiety-and-depression-in-2u2c5e7kc9.pdf

Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression

In a prospective (controlled) trial, the result in 18 patients receiving eight, weekly half-hour sessions of brief problem-oriented dynamic psychotherapy was compared with the result in an equal number receiving eight, weekly half-hour sessions of family practitioner therapy and in another 20 receiving no additional therapy. The subjects were drawn from patients at ten suburban family practices in Sydney. They had had psychological complaints for at least six months. No differences between the three treatment groups were found in the final outcome, either in a symptom severity and social dysfunction factor or in a physical disability and medication factor.

Brief psychotherapy in family practice. A controlled prospective intervention trial.

A controlled trial study is described in which 50 consecutive potential referrals for psychological treatment from one general practice were randomly allocated either to behavioural treatment or no-treatment conditions. Treatment-group patients received treatment from a clinical psychologist working within the practice; the control-group patients continued to be managed by their general practitioner. The patients' use of NHS resources was assessed during the treatment period (or its equivalent for the control group) and at a follow-up comparison point, when the patients' subjective ratings of their progress were also obtained. Between referral and the end of treatment the treated group received significantly less psychotropic medication than the control group. This difference was not, however, maintained at the longer-term follow-up. No differences in general practice consultation rates, in the subjective ratings of psychological distress, in control orientation or life satisfaction were found between the two groups, but the level of patient satisfaction was high. Implications for the design of future studies and for psychological health care delivery systems are discussed.

Louise Earll

Papers

Clinical psychology in general practice: a controlled trial evaluation