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Getting the message across
At the first meeting of the Wessex Clinical Network for mental health, we discussed the purpose and function of the group. Clearly meetings are not an end in themselves and goal setting is a fundamental principle when it comes to implementation of ideas or plans.
However to some extent this is not as easy as it may seem. We are all in agreement on basic principles namely the eradication of stigma, the need for education and the need to interest every health professional in mental health issues. The challenge remains how to get there. If we think too big, then we can easily find ourselves grinding to a halt, yet if we lose sight of these, then the whole reason for setting up the network is lost.
There lies a compromise, a path meandering between global or national strategy and regional or local function.
We would aim to get a Primhe resource pack to every practice within our region but with the awareness that assistance would be required to implement it, preferably by way of a facilitator who could visit each practice. The former seems achievable, but the latter is still much more idealistic.
We were mindful of the continued battle to ‘get the message across’. The very fact that you are reading this probably means that we are ‘preaching to the converted’. Knowing that most if not all consultations contain a ‘mental’ element to them and furthermore the well documented fact that many primary care consultations are overtly over mental health issues, why is there not more interest shown? We are also well aware of time constraints and the competing interests in other equally valid areas of health. Incentives are the obvious answer, but let us hope that our medical heritage will become more of a reality as we progress into the future. Medicine started as treating whole people. Once again we need to remember this easily forgotten premise. Secondary care and primary care are being carved up into even more specialisms, but people, our patients remain one thoroughly integrated person every time they dare to privilege us with their dis-eases.
Dr Cathy Wield
Research DigestMay 2005
What are the views of patients and health professionals providing primary care for people with serious mental illness? Last month in the British Medical Journal, Helen Lester (chairperson of PriMHE) and colleagues explores this important question.1 They found that most health professionals felt that care of patients with serious mental illness was too specialised for primary care. This was in contrast to the patient perspective that primary care is the cornerstone of their health care, and they expressed a preference to consult their GP rather than be referred. They concluded that primary care is very important to people with serious mental health problems and that services need to adapt so that health professionals in primary care are able to play a greater role in the care of patients with serious mental illnesses.
A paper by van Os and colleagues has demonstrated that good GP communication skills augment the effectiveness of guideline-based depression treatment.2 In an observational study they found that neither depression-specific interventions nor good GP communication skills were sufficient for optimal improvement, and only in combination were found to be effective.
Golden and colleagues have reviewed the evidence for the use of light therapy for treating mood disorders.3 Unfortunately, they concluded that most studies to date have not been based on rigorous designs. However, their meta-analysis of randomised controlled trial data suggested that bright light treatment and dawn simulation were effective for seasonal affective disorder, and bright light is effective for non-seasonal depression, with effect sizes similar to those of antidepressants.
Anderson and colleagues have reviewed the evidence for the efficacy of self-help books for depression. 4 A systematic search found 11 randomised controlled trials though none fulfilled CONSORT guidelines. They concluded that there is little direct evidence of the effectiveness of self-help materials and only weak evidence for the effectiveness of bibliotherapy based on CBT.
How best to detect and monitor depression in primary care? Lowe and colleagues evaluated the Patient Health Questionnire-2 (PHQ-2), a two-item questionnaire , as a measure for diagnosing and monitoring depression.5 They found the PHQ-2 had a sensitivity of 87%, and a specificity of 78% for major depressive disorder when used in medical outpatients, and a specificity of 86% for any depressive disorder using the Structured Clinical Interview for DSM-IV as the gold standard. The two questions, by the way, are:
Over the last 2 weeks have you had little interest or pleasure in doing things?
Over the last 2 weeks have you been feeling down, depressed, or hopeless?
Reference List
1. Lester HE, Tritter JQ, Sorohan H. Patients' and health professionals' views on primary care for people with serious mental illness: focus group study. BMJ 2005;330:1122-7.
2. van Os TW, van den Brink RH, Tiemens BG, Jenner JA, Van Der MK, Ormel J. Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment. Journal of Affective Disorders.84(1):43-51, 2005.
3. Golden RN, Gaynes BN, Ekstrom RD, Hamer RM, Jacobsen FM, Suppes T et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am.J.Psychiatry 2005;162:656-62.
4. Anderson L, LEWIS G, Araya R, Elgie R, Harrison G, Proudfoot J et al. Self-help books for depression: how can practitioners and patients make the right choice? British Journal of General Practice.55(514):387-92, 2005.
5. Lowe B, Kroenke K, Grafe K. Detecting and monitoring depression with a two-item questionnaire (PHQ-2). Journal of Psychosomatic Medicine 2005;58:163-71.
Paul Walters
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