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Contains fulltext : 217004.pdf (Publisher’s version ) (Closed access) Achtergrond: Voorschrijven van antidepressiva (ad) is sinds 1980 sterk toegenomen, vooral selectieve serotonineheropnameremmers (ssri's), en voor steeds langere tijd. Toch worden, vooral buiten de beroepsgroep, ad nog steeds bekritiseerd en betwijfelt men hun nut. Doel: Verklaren van toename en bieden van een perspectief op oorzaken en oplossingen van de controverse, aanzet tot debat. Methode: Essay met genuanceerde en kritische presentatie van feiten en argumenten van voor- en tegenstanders. Resultaten: Toename is het gevolg van 1. toegenomen veiligheid en gebruiksgemak, 2. toegenomen hulpvraag voor en herkenning van depressie in de huisartspraktijk, 3. uitbreiding indicatiecriteria, 4. effectieve marketingstrategieën, en 5. effectiviteit van ad in de acute fase en bij preventie van terugval/recidief in continuerings- en onderhoudsfasen. Critici wijzen op: 1. beperkte meerwaarde van ad in acute fase t.o.v. placebo, 2. veel uitvallers en mensen zonder respons, 3. terugval/recidiefpreventie met ad in continuerings- en onderhoudsfasen werkt alleen bij patiënten met goede respons op ad in acute fase, 4. terugval/recidief na discontinuering ad vaak onthoudingsverschijnselen, en 5. publicatiebias, selectieve rapportage, selectieve patiëntselectie en suboptimale blindering, leidend tot overschatting voordelen en onderschatting nadelen. Factoren die controverse onderhouden, zijn: 1. critici wijzen op de netto-effectiviteit en voorstanders op de bruto-effectiviteit (dus inclusief spontaan herstel en placebo-effect); 2. hardnekkigheid van beschadigd vertrouwen in industriegefinancierde rct's; 3. gebrek aan rct’s met relevante langetermijnuitkomstmetingen; 4. ideologische posities, versterkt door belangenconflicten en selectieve citaties; 5. maatschappelijk klimaat. Conclusie: Hoewel het lastig zal zijn om deels ideologisch ingegeven posities tot elkaar te brengen, zien wij mogelijkheden. Drie factoren zijn daarbij van groot belang: polderen (welke data overtuigen de tegenpartij), responspredictie en rct's met functionele uitkomstdata over de lange termijn. 10 p.

Objective: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient and FP characteristics were related to recognition. Method: A cross-sectional comparison was made between FPs' registration and a structured diagnostic interview, the Composite International Diagnostic Interview, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Seven definitions of recognition were tested using diagnostic codes, medication data, referral data and free text in medical records. Data were derived from the Netherlands Study of Depression and Anxiety. A total of 816 patients were included. Results: Recognition ranged between 9.1% and 85.8%. A broader definition was associated with a higher recognition rate, but led to more false positives. The best definition comprised diagnostic codes for anxiety disorders and symptoms, strong free-text indications, medication and referral to mental health care. Generalized anxiety disorder was best recognized by this definition. Recognition was better among patients with increased severity, comorbid depression and older age. Conclusion: FPs recognized anxiety disorders better than previously reported when all medical record data were taken into account. However, most patients were nonspecifically labeled as having a mental health problem. © 2012 Elsevier Inc.

Although children with emotional or behavioural problems are at increased risk of future problems, knowledge of factors associated with persistence and change in child problems, once these problems exist, is limited. Using repeated measures analyses of variance, the present study investigated the association of parental problem recognition, professional and informal service use, and sociodemographic factors with change in child problems over a one-year period, in a sample of 360 children and adolescents with emotional and behavioural problems. Higher overall problem levels were found in children (aged 4–11 years at baseline) versus adolescents (aged 12–17 years), in boys, and in children with less educated parents, which indicates the need to address preventive actions at these groups. Although rates of service use were low, children who had been in contact with general practitioners or mental health services had higher overall problem levels, suggesting that children who need it most end up receiving professional care. Although child emotional and behavioural problems decreased significantly over time, this change was not associated with utilisation of professional or informal services. Our findings imply the need for methodologically sound research into the effectiveness of professional and informal services for child emotional and behavioural problems.

Objectives and Methods: Electronic momentary assessment was employed to substantiate the relevance of psychological functioning in chronic pain. More than 7100 electronic diaries from 80 patients with varying IASP classified types of chronic pain served to investigate to what extent fear-avoidance, cognitive and spousal solicitous and punishing pain responses explained fluctuations in pain intensity and whether patients with pre-chronic, recently chronic and persistently chronic pain differed in this regard. Results: Psychological pain responses explained 40% of the total variance in pain intensity: almost 24% concerned pain variance that occurred between the CPD patients and 16% pertained to pain variance due to momentary differences within these patients. Separately tested fear-avoidance and cognitive responses each explained about 28% of the total pain variance, while spousal responses explained 9%. Catastrophizing emerged as the strongest pain predictor, followed by pain-related fear and bodily vigilance. Results did not differ with the duration of chronicity. Discussion: Exaggerated negative interpretations of pain, and fear that movement will induce or increase pain strongly predicted CPD pain intensity. Spousal responses—assessed only when the spouse was with the patient who at that moment was in actual pain—may more strongly affect immobility due to pain than pain intensity per se (see part II of the study). The findings substantiate the importance of catastrophizing, fear and vigilance identified primarily in low back pain and extend this to other forms of chronic pain. The compelling evidence of momentary within-patients differences underscores that these must be accounted for in chronic pain research and practice.

Background GPs report that patients’ psychosocial problems play a part in 20% of all consultations. GPs state that these consultations are more time-consuming and the perceived burden on the GP is higher. Aim To investigate whether GPs’ workload in consultations is related to psychological or social problems of patients. Design of study A cross-sectional national survey in general practice, conducted in the Netherlands from 2000–2002. Setting One hundred and four general practices in the Netherlands. Method Videotaped consultations (n = 1392) of a representative sample of 142 GPs were used. Consultations were categorised in three groups: consultations with a diagnosis in the International Classification of Primary Care chapter P ‘psychological’ or Z ‘social’ (n = 138), a somatic diagnosis but with a psychological background according to the GP (n = 309), or a somatic diagnosis and background (n = 945). Workload measures were consultation length, number of diagnoses and GPs’ assessment of sufficiency of patient time. Results Consultations in which patients’ mental health problems play a part (as a diagnosis or in the background) take more time and involve more diagnoses, and the GP is more heavily burdened with feelings of insufficiency of patient time. In consultations with a somatic diagnosis but psychological background, GPs more often experienced a lack of time compared to consultations with a psychological or social diagnosis. Conclusion Consultations in which the GP notices psychosocial problems make heavier demands on the GP’s workload than other consultations. Patients’ somatic problems that have a psychological background induce the highest perceived burden on the GP.

Background: The general practitioner is usually the first health care contact for mental problems. The position of a general practitioner may vary between health care systems, depending on the referral system (gatekeepers versus directly accessible specialists), presence of fixed lists and the payment system. This may influence patients’ expectations and requests for help and GPs’ performance. In this paper the effects of working in different health care systems on demand and supply for psychological help were examined. Methods: Data were collected in six European countries with different health care system characteristics (Belgium, Germany, the Netherlands, Spain, Switzerland and the UK). For 15 consecutive contacts with 190 GPs in the six countries, each patient completed questionnaires concerning reason for visit and expectations (before) and evaluation (after consultation). General practitioners completed registration forms on each consultation, indicating familiarity with the patient and diagnosis. General practitioners completed a general questionnaire about their personal and professional characteristics as well. Results: Practices in different countries differed considerably in the proportion of psychological reasons for the visit by the patient and psychological diagnoses by the GP. Agreement between patients’ self-rated problems and GPs’ diagnoses also varied. Patients in different countries evaluated their GPs’ psychological performance differently as well, but evaluation was not correlated with agreement between request for help and diagosis. In gatekeeping countries, patients had more psycho-social requests, GPs made more psychological diagnoses and agreement between both was relatively high. Evaluation, however, was more positive in non-gatekeeping countries. Individual characteristics of doctors and patients explained only a relatively small part of variance. Conclusions: Health care system characteristics do affect GPs’ performance in psycho-social care.

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor–patient communication and the GPs’ performance of these aspects, both being from the patients’ perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor–patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients’ perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs’ assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs’ psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

Computerized diary measurement of pain, disability and psychological adaptation was performed four times a day for 4 weeks in 80 patients with various duration of unexplained pain. Reported are (1) the temporal characteristics and stability of pain report during the 4-week measurement period, (2) the association between pain duration and pain report, disability and general psychopathology, and (3) the accordance between diary assessment versus questionnaire assessment of pain, disability and psychological adaptation. No evidence of instrument reactivity was found: pain report was stable across the 4-week period. However, pain report appeared to be highly variable both between and within days. About half the patients showed a clear increasing trend in pain during the day. Several differences were found between subgroups of patients varying in pain duration. Patients with less than 6 months of pain reported significantly less pain intensity, disability and fatigue than patients whose pain persisted for more than 6 months. Pain coping and responses to pain behaviors by the spouse also differed for the subgroups: longer pain duration was associated with increased catastrophizing and solicitous responses from the spouse. Comparison of scores obtained with diary versus questionnaire assessment indicated moderate correlations for most variables. Retrospective (questionnaire) assessment of pain intensity yielded significantly higher pain scores than diary assessment.

In this review epidemiological studies concerning chronic benign pain among adults are discussed. To this end, studies focusing on chronic pain, reporting prevalences at a population or primary health care level, including subjects aged between 18 and 75 years have been collected and analyzed. Focus of analysis was on research methods, definitions of chronic benign pain used, and reported prevalences. Prevalences varied between 2% and 40% of the population. Nor method used (telephone survey, postal survey, nor definition of chronicity (>1 month; >3 months; >6 months) clearly explained the differences in prevalence in the various studies. Implications for future research are discussed.