Young adults with depression: A registry-based longitudinal study of work-life marginalisation. The Norwegian GP-DEP study

Aims: To explore the association between a depression diagnosis in young adulthood and risk of marginalisation at age 29 years, among those who had completed upper secondary school and those who had not completed at age 21. Methods: In a longitudinal cohort study based on nationwide registers we followed 111,558 people from age 22–29 years. Outcomes were risk of marginalisation and educational achievement at age 29. Exposure was a diagnosed depression at ages 22–26 years. Comorbid mental and somatic health conditions, gender and country of origin were covariates. Relative risks were estimated with Poisson regression models, stratified by educational level at age 21. Results: For people who had not completed upper secondary school at age 21 years, a depression diagnosis at age 22–26 increased the risk of low income (relative risk = 1.33; 95% confidence interval = 1.25–1.40), prolonged unemployment benefit (1.46; 1.38–1.55) and social security benefit (1.56; 1.41–1.74) at age 29 compared with those with no depression. Among those who had completed upper secondary school at age 21 years, depression increased the risk of low income (1.71; 1.60–1.83), prolonged unemployment benefit (2.17; 2.03–2.31), social security benefit (3.62; 2.91–4.51) and disability pension (4.43; 3.26–6.01) compared with those with no depression. Mental comorbidity had a significant impact on risk of marginalisation in both groups. Conclusions: Depression in one’s mid-20s significantly increases the risk of marginalisation at age 29 years, and comorbid mental health conditions reinforce this association. Functional ability should be given priority in depression care in early adulthood to counteract marginalisation.publishedVersio

Practice characteristics influencing variation in provision of depression care in general practice in Norway; a registry-based cohort study (The Norwegian GP-DEP study)

Background There is growing evidence of variation in treatment for patients with depression, not only across patient characteristics, but also with respect to the organizational and structural framework of general practitioners’ (GPs') practice. However, the reasons for these variations are sparsely examined. This study aimed to investigate associations of practice characteristics with provision of depression care in general practices in Norway. Methods A nationwide cohort study of residents aged ≥ 18 years with a new depression episode in general practice during 2009–2015, based on linked registry data. Exposures were characteristics of GP practice: geographical location, practice list size, and duration of GP-patient relationship. Outcomes were talking therapy, antidepressant medication and sick listing provided by GP during 12 months from date of diagnosis. Associations between exposure and outcome were estimated using generalized linear models, adjusted for patients’ age, gender, education and immigrant status, and characteristics of GP practice. Results The study population comprised 285 113 patients, mean age 43.5 years, 61.6% women. They were registered with 5 574 GPs. Of the patients, 52.5% received talking therapy, 34.1% antidepressant drugs and 54.1% were sick listed, while 17.3% received none of the above treatments. Patients in rural practices were less likely to receive talking therapy (adjusted relative risk (adj RR) = 0.68; 95% confidence interval (CI) = 0.64–0.73) and more likely to receive antidepressants (adj RR = 1.09; 95% CI = 1.04–1.14) compared to those in urban practices. Patients on short practice lists were more likely to receive medication (adj RR = 1.08; 95% CI = 1.05–1.12) than those on long practice lists. Patients with short GP-patient relationship were more likely to receive talking therapy (adj RR = 1.20; 95% CI = 1.17–1.23) and medication (adj RR = 1.08; 95% CI = 1.04–1.12), and less likely to be sick-listed (RR = 0.88; 95% CI = 0.87–0.89), than patients with long GP-patient relationship. Conclusions Provision of GP depression care varied with practice characteristics. Talking therapy was less commonly provided in rural practices and among those with long-lasting GP-patient relationship. These differences may indicate some variation, and therefore, its reasons and clinical consequences need further investigation.publishedVersio

Variation in general practitioners’ depression care following certification of sickness absence: a registry-based cohort study

Background Depression is more prevalent among women and people with low socio-economic status. Uncertainties exist about how general practitioner (GP) depression care varies with patients’ social position. Objective To investigate associations between patients’ gender and educational status combined and GP depression care following certification of sickness absence. Methods Nationwide registry-based cohort study, Norway, 2012–14. Reimbursement claims data from all consultations in general practice for depression were linked with information on socio-demographic data, social security benefits and depression medication. The study population comprised all individuals aged 25–66 years with taxable income, sick-listed with a new depression diagnosis in general practice in 2013 (n = 8857). We defined six intersectional groups by combining educational level and gender. The outcome was type of GP depression care during sick leave: follow-up consultation(s), talking therapy, medication and referral to secondary care. Associations between intersectional groups and outcome were estimated using generalized linear models. Results Among long-term absentees (17 days or more), highly educated women were less likely to receive medication compared to all other patient groups [relative risk (RR) ranging from 1.17 (95% confidence interval 1.03–1.33) to 1.49 (1.29–1.72)] and more likely to receive talking therapy than women with medium [RR = 0.90 (0.84–0.98)] or low [RR = 0.91 (0.85–0.98)] education. Conclusions Our findings suggest that GPs provide equitable depression care regarding consultations and referrals for all intersectional groups but differential drug treatment and talking therapy for highly educated women. GPs need to be aware of these variations to provide personalized care and to prevent reproducing inequity.publishedVersio

Patient experiences with depression care in general practice: a qualitative questionnaire study

Objective To investigate patient experiences and preferences regarding depression care in general practice. Design and setting A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis. Subjects 250 persons completed the web-based survey, 86% were women. Results The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful. Conclusions Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment. KEY POINTS Depression is common, and GPs are often patients’ first point of contact when they seek help.  • Patients who feel depressed appreciate help from their GP.  • Patients prefer an empathetic GP who listens attentively and acknowledges their problems.  • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.Pasienterfaringer med depresjonsomsorg i allmennpraksis: en kvalitativ spørreskjemastudiePatient experiences with depression care in general practice: a qualitative questionnaire studypublishedVersio

Comparison of depression care provided in general practice in Norway and the Netherlands: registry-based cohort study (The Norwegian GP-DEP study)

Background Depression is highly prevalent in general practice, and organisation of primary health care probably affects the provision of depression care. General practitioners (GPs) in Norway and the Netherlands fulfil comparable roles. However, primary care teams with a mental health nurse (MHN) supplementing the GP have been established in the Netherlands, but not yet in Norway. In order to explore how the organisation of primary mental care affects care delivery, we aimed to examine the provision of GP depression care across the two countries. Methods Registry-based cohort study comprising new depression episodes in patients aged ≥ 18 years, 2011–2015. The Norwegian sample was drawn from the entire population (national health registries); 297,409 episodes. A representative Dutch sample (Nivel Primary Care Database) was included; 27,362 episodes. Outcomes were follow-up consultation(s) with GP, with GP and/or MHN, and antidepressant prescriptions during 12 months from the start of the depression episode. Differences between countries were estimated using negative binomial and Cox regression models, adjusted for patient gender, age and comorbidity. Results Patients in the Netherlands compared to Norway were less likely to receive GP follow-up consultations, IRR (incidence rate ratio) = 0.73 (95% confidence interval (CI) 0.71–0.74). Differences were greatest among patients aged 18–39 years (adj IRR = 0.64, 0.63–0.66) and 40–59 years (adj IRR = 0.71, 0.69–0.73). When comparing follow-up consultations in GP practices, including MHN consultations in the Netherlands, no cross-national differences were found (IRR = 1.00, 0.98–1.01). But in age-stratified analyses, Dutch patients 60 years and older were more likely to be followed up than their Norwegian counterparts (adj IRR = 1.21, 1.16–1.26). Patients in the Netherlands compared to Norway were more likely to receive antidepressant drugs, adj HR (hazard ratio) = 1.32 (1.30–1.34). Conclusions The observed differences indicate that the organisation of primary mental health care affects the provision of follow-up consultations in Norway and the Netherlands. Clinical studies are needed to explore the impact of team-based care and GP-based care on the quality of depression care and patient outcomes.publishedVersio

Overcoming Clinician and Parent Ambivalence: General Practitioners' Support of Children of Parents With Physical or Mental Illness and/or Substance Abuse

Children who are next of kin to parents with physical or mental illness and/or substance abuse need access to mental health support and several cost-effective interventions are available. Because most parents in the target group often consult general practitioners (GPs), GPs may have a crucial role in identifying burdened children and ensuring their follow-up. However, this important topic has received little attention in clinical discussions and research. In response to the knowledge gap, we conducted the research project Burdened Children as Next of Kin and the General Practitioner. Four sub-studies have been completed and published: a sub-study with qualitative analysis of focus group interviews with GPs (paper 1), a qualitative analysis of focus group interviews with adolescents as next of kin (paper 2), and a qualitative analysis of individual interviews with parents with illness and/or substance abuse (paper 3). The results from these sub-studies were incorporated in a survey sent to members of a nationwide GP organization (paper 4). The aim of the present sub-study was to gain further knowledge about conditions for the encounters between GPs and parents with impairments to be supportive for the children as next of kin. The material of the present sub-study derived from the project's four previous sub-studies and comprised a secondary analysis of the four prior sub-studies. We conducted an overarching thematic analysis of these sub-studies' results sections. We searched for statements from the GPs, the adolescents, and the parents on their experiences and evaluations of the needs of the children and their families, and the possible ways of accommodating these needs in general practice. The analysis shows that both GPs and parents were ambivalent about addressing the topic of the patients' children during consultations. This was the case although the GPs were in a good position to identify these vulnerable children, and the parents were worried about their children's situations. Possible strategies for GPs to overcome this ambivalence can be to (1) strengthen their competence in the topic, (2) gradually build trusting relationships with parents, and (3) gradually gain contextual knowledge about the families' situations. GPs can do this by performing ordinary GP tasks and acknowledging the parents' efforts to give their children good daily lives

Self-rated health among Mayan women participating in a randomised intervention trial reducing indoor air pollution in Guatemala

<p>Abstract</p> <p>Background</p> <p>Indoor air pollution (IAP) from solid fuels is a serious health problem in low-income countries that can be alleviated using improved stoves. Although women are the principal users, few studies have investigated the self-assessed impact of the stoves on their health and lives.</p> <p>Methods</p> <p>This study was conducted in rural highland Guatemala, involving 89 intervention and 80 control Mayan Indian young women (mean 27.8 years, SD 7.2). Outcomes were assessed after approximately 18 months use of the new stove. Our objectives were to compare self-rated health and change in health among women participating in a randomised control trial comparing a chimney stove with an open fire, to describe impacts on women's daily lives and their perceptions of how reduced kitchen smoke affects their own and their children's health.</p> <p>Results</p> <p>On intention-to-treat analysis, 52.8% of intervention women reported improvement in health, compared to 23.8% of control women (p < 0.001). Among 84 intervention women who reported reduced kitchen smoke as an important change, 88% linked this to improvement in their own health, particularly for non-respiratory symptoms (for example eye discomfort, headache); 57% linked reduced smoke to improvement in their children's health, particularly sore eyes.</p> <p>Conclusion</p> <p>Women's perception of their health was improved, but although smoke reduction was valued, this was linked mainly with alleviation of non-respiratory symptoms like eye discomfort and headache. More focus on such symptoms may help in promoting demand for improved stoves and cleaner fuels, but education about more severe consequences of IAP exposure is also required.</p

Ill and substance-abusing parents: how can the general practitioner help their children? A qualitative study

Background: Severe illness among parents may interfere with their parenting. Children having ill or substanceabusing parents are at risk of own health problems and psychosocial difficulties. The health care system should identify families in need of help and provide the help needed. For ill parents, it can be difficult to seek help and advices for their parenting. The aim of this study was to identify important factors for the general practitioner (GP) to bear in mind during encounters with ill and substance-abusing parents, to enable the GP to provide appropriate support for the children. Method: A qualitative approach was chosen and the data material was semi-structured individual interviews with 12 parents with mental illness, substance abuse or severe somatic illness. The participants were recruited through GPs in Norway, and the interviews were performed in 2014. We used systematic text condensation for analysis. Results: It was important for the participants that the GP was oriented about their family and children’s situation. They wanted to be regarded as competent parents in ordinary families; however, they were aware that their illness affected their parenting. They expressed a need for advice about how to inform the children of their illness and talk to them about their challenges, and, if necessary, utilize helpers who could inform the children and talk to them directly. There were often many agencies involved, and it was important that the helpers cooperated and shared information. In addition, the parents were in need of information about support services. Conclusion: Ill parents in this study conveyed a double message to their helpers. They wanted to be considered as responsible and well-intended parents who wished the best for their children. At the same time they needed support in parenting. The GP should take the time to listen to the parents’ first spontaneous description about an ordinary daily life (while realising that it may not necessarily be an accurate report), then explore their worries and needs of support

To give the invisible child priority: Children as next of kin in general practice. A qualitative study among general practitioners

Objective. To explore general practitioners’ (GPs’) experiences in helping children as next of kin of drug-addicted, mentally ill, or severely somatic ill adults. These children are at risk of long-term mental and somatic health problems. Design. Qualitative focus-group study. Setting. Focus-group interviews were conducted in western Norway with a total of 27 GPs. Participants were encouraged to share stories from clinical encounters with parents who had one of the above-mentioned problems and to discuss the GP's role in relation to helping the patients’ children. Results. The GPs brought up many examples of how they could aid children as next of kin, including identifying children at risk, counselling the parents, and taking part in collaboration with other healthcare professionals and social workers. They also experienced some barriers in fulfilling their potential. There were time constraints, the GPs had their main focus on the patient present in a consultation, and the child was often outside the attention of the doctors, or the GPs could be afraid of hurting or losing their vulnerable patients, thus avoiding bringing up the patients’ children as a subject for discussion. Conclusions. Norwegian GPs are in a good position to help children as next of kin and doctors make a great effort to support many of them. Still, support of these children by GPs often seems to depend not on careful consideration of what is best for the patient and the child in the long run, but more on short-term convenience reasons

Fastleger i møte med barn som pårørende

Etter en endring i helsepersonelloven i 2010 er fastleger pålagt å sørge for informasjon og oppfølging av barna til pasienter med psykiatrisk sykdom, rusmisbruk og alvorlig somatisk sykdom – på foreldrenes samtykke. Målet for denne studien var å undersøke fastlegers erfaringer med og mulighetene til å hjelpe barn som pårørende og deres familier, dvs. at vi ønsket å få mer kunnskap om hvordan barnas rett til informasjon og oppfølging kan ivaretas innen rammene for fastlegetjenesten. Et nettbasert spørreskjema ble i april 2015 sendt til medlemmene av Norsk forening for allmennmedisin (NFA), og vi mottok 499 gyldige svar. De fleste så det som sitt ansvar å følge opp de aktuelle barna når de sto på deres fastlegeliste, mot bare halvparten dersom barna sto på annen leges liste. Kompetanseheving hos fastlegene og bedre samarbeid med andre instanser synes nødvendig for å sikre at barn som pårørende i risiko får den nødvendige oppfølgingen de har rett på initiert av foreldrenes fastlege