Emotional disorders in primary care.

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Basic family therapy skills: III. Brief and strategic schools of family therapy.

688 family therapy supervisors (C. R. Figley and T. Nelson; 1989, 1990) previously nominated and rated generic and theory-specific beginning family therapy skills. 53 Ss returned questionnaires related to brief family therapy, and 91 Ss returned questionnaires related to strategic family therapy. 14 brief family therapy skills and 29 strategic family therapy skills are presented in table form, with means, standard deviations, and frequencies listed. Items are rank ordered according to mean scores. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Debatable issues in the problem of somatoform and related disorders

The questions of including into ICD-10 and DSM-III-R of extranosological category--somatoform disorders is discussed. Some positive moments were considered, but inexpediency of the limitation of somatoform disorders to psychological disturbances only, doubtfulness of both including psychosomatic diseases in this category and age limitations in beginning and duration of the disease were stressed. The concept of somatopsychic diseases was proposed with three main variations: 1) with relatively independent rise of somatic and psychic disorders, 2) with prevailing etiopathogenic role of psychic factor (psychosomatic disorders, somatized psychic disturbances, somatoform neurotic and psychosomatic disturbances), 3) with prevailing etiopathogenic role of somatic factors (somatogenic psychic disorders). The actual distribution of somatopsychic disturbances are presented on the syndromal, nosologic and personal levels using data of prophylactic medical examination of one big enterprise's employees.     

Stepped care treatment for eating disorders.

A stepped care approach would link different patient needs to therapeutic modalities that range from simple advice to intensive inpatient care. Brief methods, including self-help and psychoeducation, may be effective for a subset of patients with bulimia nervosa and binge eating disorder. Identifying this subset remains a challenge. It is unclear how patients who fail to respond to evidence-based, first-line treatments should be treated. Given the absence of data on effective treatment of anorexia nervosa (AN), discussion of a stepped care approach is speculative. Because AN typically demands expert and sustained treatment, the lower levels of stepped care models are inapplicable for these patients. A stepped care approach poses methodological challenges for clinical research and raises important clinical issues, such as when to switch from 1 level of treatment to another. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Group therapy and the somatoform patient: An integration.

Recent reports and literature reviews suggest that psychotherapeutic interventions with somatoform patients have efficacy. From their clinical experience with somatoform patients, the authors identify helplessness as the central psychotherapeutic issue for these patients. They propose that effective group therapy interventions have their impact through the addressing and working through of this affect. They discuss paradigmatic stages in the group therapeutic process of addressing helplessness in somatoform patients. Technical issues regarding membership selection and leadership style with this intervention are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prostatitis: diagnosis and treatment in primary care

Prostatitis refers to the inflammation and/or infection of the prostate gland, which occurs in several forms or syndromes and presents with varied etiologies, clinical features, and sequelae. The four common forms of prostatitis are acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Differential diagnosis of prostatitis is based on history, physical exam findings, and, frequently, analysis of expressed prostatic secretions. Complaints may vary, but pain or discomfort in the rectal or perineal area is usually present. Clinicians in primary care settings should be knowledgeable about the types of prostatitis, etiology, and pathogenesis; the methods of diagnosis; and treatment/education issues.     

Diagnosing pediatric epilepsy: an update for the primary care clinician

Epilepsy is a chronic disorder that first appears in childhood. Seizure types and presentation vary from dramatic and obvious to subtle and discrete. Accurate identification of the seizure type is imperative to ensure proper disease management. The International league Against Epilepsy has developed two classification systems--the classification of Epileptic Seizures and the classification of Epilepsies and Epileptic Syndromes--to assist in the provision of an International language of epilepsy, to improve the diagnosis and management of seizures, and to establish prognostic criteria. Knowledge of the classification systems of seizures, seizure types, and management of seizures is essential in the delivery of health promotion, disease prevention, and anticipatory guidance for the child with epilepsy. The primary care practitioner is often the first person consulted when medical questions or problems arise, and therefore is in a key position to detect seizures, monitor treatment, and educate the family. A comprehensive knowledge of pediatric epilepsy will allow the practitioner to provide the additional resources needed to coordinate the care of this special population.     

Prevalence of comorbid anxiety disorders in primary care outpatients

OBJECTIVE: To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions. DESIGN: Observational study. SETTING: Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes. PATIENTS: Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression. MEASURES: Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed). METHODS: Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers. RESULTS: Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%). CONCLUSION: Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.     

Management of somatisers in primary care: are family doctors motivated?

OBJECTIVE: The aim of this paper is to assess the attitudes of Spanish general practitioners towards somatisers and the degree of involvement that family doctors are ready to adopt in the care of these patients. METHOD: A postal questionnaire on attitudes was sent to a representative sample (n = 135) of general practitioners from two health districts of the region of Aragon. Seventy (51.8%) of them returned usable questionnaires. RESULTS: Most of the general practitioners were interested in the treatment of somatisers and considered that they should be treated at primary care level. However, when specific treatment tasks were proposed, they only accepted to act as a filter to specialised care and to care for patients with chronic functional syndromes. Additionally, they refuse to detect presenting somatisers, to prescribe psychotropic drugs or offer any psychological approach, and to avoid reinforcing abnormal illness behaviour in these patients and their families. These findings can be explained because the main emotions somatisers produce in doctors are frustration and anger. CONCLUSIONS: Family doctors need a lot more help, education and support in the management of somatisers, and psychiatrists need to provide it. Any management program for the treatment of somatisers in primary care should include methods to modify general practitioners' attitudes towards these patients.     

The treatment of common mental disorders by a community team based in primary care: a cost-effectiveness study

Thirty patients suffering from new episodes of depression or anxiety disorders seen by a hospital-based psychiatric service were matched for severity of illness with 30 patients seen by a community mental health team based upon primary care. These patients were drawn from a total of 108 such patients seen in the community and 57 seen by the hospital service. Clinical and social outcomes were similar in both groups, and neither was clearly superior in terms of quality of clinical information recorded. However, patients treated in the community were seen more quickly, had more continuity of care and were more satisfied with the service. Health services costs were less for those patients treated in the community, because patients were less likely to be admitted. With one atypical patient excluded, treatment by the community team is more cost effective. The greater number of patients seen by the primary-care-based service means that there is no overall cost saving to the NHS.     

The buccal bifurcation cyst: in non-surgical treatment an option?

The mandibular buccal bifurcation cyst (BBC) was first described by Stoneman and Worth in 1983. It is a lesion with a specific location, classically the buccal surface of the mandibular first molar and less frequently the mandibular second molar. There have been numerous reports in the literature describing the BBC and its treatment. Treatment advocated thus far includes extraction of the involved first molar, marsupialization and enucleation of the cyst. In their most recent article, Pompura, Sándor and Stoneman reported on the successful treatment of 44 cysts with enucleation without tooth extraction. This article will describe the diagnostic features of the BBC and present three cases with a total of five cysts, which were treated non-surgically and ultimately resolved. The authors, therefore, propose that a more conservative non-surgical approach to these lesions may be considered.     

Breath test diagnosis of Helicobacter pylori in peptic ulcer disease: a noninvasive primary care option

The role of chemotherapy in malignant neuroendocrine tumours is difficult to assess because of their rarity and variation in biological behaviour. We present a retrospective review of chemotherapy given to 18 patients with metastatic and one with locally advanced neuroendocrine tumours. There were eight poorly differentiated neuroendocrine tumours, six thyroid medullary carcinomas, two phaeochromocytomas, two pancreatic islet cell tumours and one undifferentiated neuroblastoma. Four patients were given 3-weekly dacarbazine, vincristine and cyclophosphamide (DOC) chemotherapy. In eight patients, this regimen was modified by substituting the dacarbazine and cisplatin and etoposide (OPEC). A further six patients were treated with dacarbazine reintroduced into the 3-weekly regimen (DOPEC). The remaining patient received cisplatin and etoposide. There were two complete responses (both with OPEC) and eight partial responses (two with DOC, three with OPEC and three with DOPEC). Five patients had stable disease and four progressed. Four received further chemotherapy on relapse, producing one complete and one partial response. The median response duration to initial chemotherapy was 10 months (range 3-34). The median survival was 12 months (range 1-42). The main toxicity was haematological, with grade 3-4 neutropenia in 12 patients; eight suffered episodes of sepsis. One death was treatment related. Other toxicity was mild although three patients discontinued vincristine with grade 2 neurotoxicity. The response rate and side effects of these three regimens appear comparable. We conclude that, although these patient numbers are small, combination chemotherapy produces an encouraging response rate (53%; 95% CI 30-75) in malignant neuroendocrine tumours, with acceptable toxicity.     

Promoting tobacco cessation in the military: an example for primary care providers

The tobacco cessation program from one isolated duty station is presented. The cessation program used active duty Marines who wished to cease tobacco use. After completion of four classes, abstinence rates of 47% were obtained based on weekly follow-up self-reports for periods ranging from 7 to 32 weeks. Most relapses were noted in the first 2 weeks after quitting. The command expense was estimated at $165 per participant. Military health care professionals should actively participate in tobacco cessation regardless of access to specialized preventive medicine services. The cost benefit and optimal utilization of nicotine replacement therapy and newer tobacco cessation aids in active duty populations should be studied further.     

Chronic pain: primary care treatment of the older patient

The prevalence of chronic diseases associated with pain increases with age, and pain prevalence appears to increase with the level of functional dependence. Chronic pain in older patients is associated with sleep disorders, impaired physical and social function, and increased healthcare utilization. Symptoms of pain, anxiety, and depression are often associated and may intensify each other. Because a complete resolution of chronic pain is unlikely, it is important to establish early in therapy the level of pain that the patient would find acceptable. The goal of therapy is to treat chronic pain while minimizing side effects and optimizing the patient's functional status.