Primary care studies

In a matched case-control, primary-care study of over 150 000 patients who received at least one prescription for an antidepressant between 1993 and 1999, in which dosu-lepin was used as the reference standard, there was no relative increased risk of non-fatal self-harm for fluoxetine (OR = 1.16 95% Cl = 0.90,1.50), while the risk for paroxetine approached significance (OR = 29 95% Cl = 0.97, 1.70) (24). The authors suggested that the latter finding might have been due to uncontrolled confounding by severity of depression or apparent suicide risk. In the small number of cases of fatal suicide there was no... 

MTX is potentially toxic. Therefore, the nurse observes closely for development of adverse reactions, such as thrombocytopenia (see Nursing Alert in Gold Compounds section) and leukopenia (see discussion of adverse reactions associated with hydroxychloroquine). Hematology, liver, and renal function studies are monitored every 1 to 3 months with MTX therapy. The primary care provider is notified of abnormal hematology, liver function, or kidney function finding. The nurse immediately brings all adverse reactions or suspected adverse reactions to the attention of the primary health care provider. 

Using a primary-care model of treatment, O Malley et al. (2003) initially treated alcohol-dependent patients with open-label naltrexone for 10 weeks, in combination with either CBT or primary care management (PCM), a less intensive, supportive approach. They found no effect of psychosocial treatment on response to treatment, although CBT was associated with a lower risk of drinking. Treatment responders from this study were then randomly assigned to one of two placebo-controlled 24-week continuation studies in... 

O Connor PG, Carroll KM, Shi JM, et al Three methods of opioid detoxification in a primary care setting a randomized trial. Ann Intern Med 127 526-530, 1997 Oppenheimer E, Tobutt C, Taylor C, et al Death and survival in a cohort of heroin addicts from London clinics a 22-year follow-up study Addiction 89 1299—1308, 1994... 

Data on antidepressant dmgs are available from a number of sources randomized, controlled clinical trials (RCTs) in both hospital and primary-care populations decision analytic models population-based naturalistic observational studies of usual... 

Naturalistic studies reveal that in primary care, the suboptimal use of antidepressants appears to be an almost universal practice worldwide. Patients treated with TCAs are... 

Another approach uses a synthesis of RCTs and naturalistic studies, while addressing the limitations of both (Simon et al, 1995b Hotopf et al, 1996). In such studies the treatment setting is routine primary-care clinical practice selection criteria are limited to those affecting safety and treatment is normal , i.e. provided under conditions where differences in clinical practice and patient behaviour can emerge freely. However, participants are randomized to initial treatment, and accurate diagnosis and baseline assessments are recorded. This approach is... 

The only study conducted in the UK (Forder et al, 1996) employed a retrospective, quasi-experimental design in which patients from an open-label study of sertraline were compared with age- and gender-matched patients prescribed TCAs in a primary care setting. The study found that sertraline was more effective than TCAs (87% versus 74%,... 

Differences exist in primary care between the patterns of prescribing fluoxetine, paroxetine or sertraline, which may influence cost outcomes. Sertraline-treated patients are more likely to have their dose increased (Sclar et al, 1995 Donoghue, 1998), and to drop out of treatment prematurely (Donoghue, 1998). The apparent need to titrate doses upwards with sertraline may require more involvement by the clinician and may delay response to treatment, with resultant increases in direct health costs (Sclar et al, 1995). However, these economic findings are retrospective, may suffer from selection bias, and being derived from HMO patients may not be generalizable to other populations confirmation in further studies is required. 

Donoghue JM (1998). Selective serotonin re-uptake inhibitor use in primary care a five year naturalistic study. Clin Drug Invest 16, 453-62. 

Shah and Jenkins (2000) in a review of mental health economic studies from around the world identified 40 cost-of-illness studies, of which five covered all disorders, one neuroses, two panic disorders and one anxiety. All were from developed countries. There were numerous cost-effectiveness studies but none involving the anxiety disorders specifically. One study in the UK examined the cost-benefit analysis of a controlled trial of nurse therapy for neurosis in primary care (Ginsberg et al, 1984). 

Evaluation of the economics of mental illness in primary care is an ongoing initiative of the UK Department of Health (Lloyd and Jenkins, 1995). A similar American study in Washington State included sub-threshold anxiety or depression, but these imposed relatively little economic load compared with disorder-level anxiety or depression (Simon et al, 1995). Mental health treatment accounted for only a small part of overall utilization, approximately 5%. Nevertheless, most patients with anxiety or depressive disorders showed considerable improvement. This was accompanied by only modest reductions in cost. 

An Australian study compared medical utilization and costs in patients with panic disorder, those with social anxiety disorder, and a control group (Rees et al, 1998). Almost half of the panic disorder patients had seen a primary-care physician more than seven times over a 6-month period, compared with 7% of the social phobic patients and none of the control group. The mean costs were A 150, A 60 and A 20 respectively. The patients with panic disorder were treated with antidepressants (39%), benzodiazepines (15%), relaxants (12%), beta-blockers (7%) and other medication (7%). Twenty per cent received no medication. Patients with panic... 

Depression, a treatable condition that affects nearly five million seniors, also goes undetected by some healthcare providers. Some healthcare professionals view depression as just part of getting old. Untreated, this illness can have serious, even fatal consequences. According to the National Institute of Mental Health, older Ameri-(40) cans account for a disproportionate share of suicide deaths, making up 18% of suicide deaths in 2000. Healthcare providers could play a vital role in preventing this outcome—several studies have shown that up to 75 % of seniors who die by suicide visited a primary care physician within a month of their death. 

CAM has become a big business as Americans dip into their wallets to pay for alternative treatments. A 1997 American Medical Association study estimated that the public spent 21.2 billion for alternative medicine therapies in that year, more than half of which were out-of-(20) pocket expenditures, meaning they were not covered by health insurance. Indeed, Americans made more out-of-pocket expenditures for alternative services than they did for out-of-pocket payments for hospital stays in 1997. In addition, the number of total visits to alternative medicine providers (about 629 million) exceeded the tally of visits (25) to primary care physicians (386 million) in that year. 

McShane R, Keene J, Gedling K et al. (1997) Do neuroleptic drugs hasten cognitive decline in dementia Prospective study with necropsy follow up. BMJ 314(7076) 266-270 Mortimer AM, Shepherd CJ, Rymer M et al. (2005) Primary care use of antipsychotic drugs an audit and intervention study. Ann Gen Psychiatry 4 18 DOI 10.1186/1744-859X-4-18 Mulsant BH, Pollock BG, Kirshner M et al. (2003) Serum anticholinergic activity in a community-based sample of older adults relationship with cognitive performance. Arch Gen Psychiatry 60(2) 198-203... 

Catassi, C., Kryszak, D., Louis-Jacques, O., Duerksen, D. R., Hill, I., Crowe, S. E., Brown, A. R., Procaccini, N. J., Wonderly, B. A., Hartley, P., Moreci, J., Bennett, N., et al. (2007b). Detection of Celiac disease in primary care A multicenter case-finding study in North America. Am.. Gastroenterol. 102,1454—1460. 

Bayly, J. R., Hollands, R. D., Riordan-Jones, S. E., Yemm, S. J., Brough-WilUams, I., Thatcher, M., Woodman, N. M., and Dixon, T. (2006). Prescribed vitamin D and calcium preparations in patients treated with bone remodelling agents in primary care A report of a pilot study. Curr. Med. Res. Opin. 22,131-137. 

Primary care physicians were recruited in four physician networks by mail with telephone follow-up, and were told only that the study would involve seeing two standardized patients several months apart, that each patient would present with a combination of common symptoms, and that the purpose of the study was to assess social influences on practice and the competing demands of primary care. The physician visits were surreptitiously audiotaped. Eighteen standardized patients completed a total of 149 encounters presenting with major depressive disorder, and another 149 with adjustment disorder, with each split approximately evenly among the three patient request types. 

---