Computerised patient-specific guidelines for management of common mental disorders in primary care: a randomised controlled trial

Background: A large proportion of people with depression and anxiety go unrecognised by their general practitioner (GP). Case-finding does not appear to be effective on its own. Aim: To compare the effectiveness of case-finding followed by computer-generated patient-specific guidelines with usual care for the management of common mental disorders in primary care. Design of study: Individual patient randomised controlled trial. Setting: Five general practices in Bristol and Cardiff. Method: 762 individuals aged ≥16 years scoring ≥12 on the Clinical Interview Schedule Revised were randomised. The experimental intervention required participants to complete a computerised psychosocial assessment that generated a report for the GP including patient-specific treatment recommend-ations. The control patients were treated as usual with access to locally agreed guidelines. Results: Participants' 12-item General Health Questionnaire (GHQ) score dropped irrespective of treatment allocation. The experimental group had a significantly lower GHQ score at 6 weeks, but not at 6 months. Recovery at 6 months was 3% greater among those receiving the experimental intervention (95% confidence interval [CI] = −4 to 10). Treatment was not significantly associated with quality of life or patient satisfaction. Conclusion: Only small benefits are likely from using case-finding followed by patient-specific guidelines to improve clinical management of common mental disorders in primary care. However, depression and anxiety are important public health problems so the utility of such systems should be further investigated

Mental health and quality of residential environment

Background: There is increasing interest in the proposition that residential environment can affect mental health. Aims: To study the degree to which common mental disorder clusters according to postcode units and households. To investigate whether contextual measures of residential environment quality and geographical accessibility are associated with symptoms of common mental disorder. Method: A total of 1058 individuals aged 16–75 years (response rate 66%) participated in a cross-sectional survey. The 12-item General Health Questionnaire measured symptoms of common mental disorder. Results: Only 2% (95% CI 0–6) of the unexplained variation in symptoms existed at postcode unit level, whereas 37% (95% CI 27–49) existed at household-level, but the postcode unit variation was reduced to zero after adjustments. There was little evidence to suggest that residential quality or accessibility were associated with symptoms. Conclusions: There was substantial unexplained variation at the household level but we could find no evidence of postcode unit variation and no association with residential environmental quality or geographical accessibility. It is likely that the psychosocial environment is more important than the physical environment in relation to common mental disorder

An observation tool to assist with the assessment of urban residnetial environments

The effect of the built environment on the quality of life of its residents is of growing interest. To investigate this properly, a method for measuring the physical condition of residential areas is required and this paper describes the development of such a tool. The Residential Environment Assessment Tool (REAT) is designed as a survey instrument, to be completed by an independent observer, to produce a contextual measure of a neighbourhood, reflecting both physical aspects and also the extent to which residents have established territoriality over the area. The tool is based on 28 items which are aggregated to give a total score, ranging between 0 and 68, and subdivided into 5 different domains to reflect different aspects of the environment. Inter-observer comparisons show that the tool is reliable, with kappa coefficients for most of the item scores exceeding 0.9. To investigate its validity the results were compared with responses to a detailed survey of individual residents and significant positive associations were found between most relevant items. The tool is being used for studies involving common mental disorders in the community and should be valuable for local authorities in targeting interventions to improve the physical condition of their area