WHAT’S IN A NAME?
In his provocative leading article, Professor Chris Dowrick says that, for primary care practitioners ‘... there is good reason to be sceptical about current diagnostic categories of depression. They are based on shaky foundations, and created within cultural boundaries that will be subject to substantial shifts in the coming decades’. Coinciding with the publication of the 5th edition of the American Psychiatric Association’s DSM-V manual, this issue of the BJGP includes research on aspects of depression. In their systematic review, Shaw and colleagues sound a warning bell about the strength of evidence for the use of structured tools in the assessment and management of depression, and express concerns that sticking to QOF indicators may have unintended adverse consequences. They report that ‘GPs considered the routine use of depression severity structured tools as incentivised by the QOF had a number of unintended consequences, specifically compromising the doctor–patient relationship, threatening holistic practice and intuition, and interfering with the consultation process’. However, it should be added that ‘In contrast, patients were more positive, seeing the tools as efficient and structured supplements to medical judgement, and as evidence that GPs were taking their patients’ problems seriously through full assessment of their depression’.
The intriguing study from Warmenhoven and colleagues, reporting from Nijmegen, the Netherlands, found much lower than expected levels of depressive disorder in the last year of life in patients with cardiovascular disease, cancer, and COPD. There are many possible interpretations of this counterintuitive finding, including a number related to the methods used in the diagnosis and classification of depression. The researchers commented that ‘Changes in perspective on depressive disorder, for example the concern for medicalisation and overtreatment, may influence the assessment of depressive disorder by physicians’.
We also look at other mental health topics, including medically unexplained symptoms in parents and children; an interesting and not altogether unexpected association, along with Clinical Intelligence articles on approaches to perinatal obsessive– compulsive disorder and to low mood and depression in adolescents, for which Jane Roberts reports that ‘new developments include the successful use of mobile phone delivery of a depression intervention derived from CBT, using automated text, video, and cartoon images. Computerised self-help interventions are also being trialled, both to address the gap in accessing psychological therapies and to capitalise on teenagers as “digital natives”. Existing guidelines do not support the use of antidepressants in under 18-year-olds in primary care’.
Scientific fraud and research misconduct have, mercifully, not emerged as major problems in primary care publications in recent years, although the high profile cases of Diederik Stapel, the Dutch psychologist and, more recently, Joachim Boldt, the German anaesthetist, both prodigious frauds, have once again raised questions about the peer-review system. Some critics say that the system is broken; I don’t think it is true, but it does clearly still have some difficulties in dealing with bad apples, who crop up more frequently than we would like to think, despite the best efforts of reviewers and editors. At the BJGP we are developing plans to improve our peer-review system. Our instructions to peer reviewers have been redrafted, with a link to the newly-published guidelines on peer review from COPE, the Committee on Publication Ethics. We will shortly be publishing more detailed guidance on undertaking peer review for the Journal, with examples of good and less good reviews, and will offer feedback to reviewers on request to assist in raising standards of peer review.
Careful readers of the Journal will notice another change this month. The Review has become Out of Hours. We decided to make this change largely because of potential confusion in the Thomson Reuters Journal Citation Report system between review articles published as original research and the non-academic articles in The Review, that could potentially have an effect on the BJGP’s citation indices. You will see from our newly-drafted instructions to authors that the content of Out of Hours will be much the same as The Review, and we look forward to continuing to receive your contributions.
- © British Journal of General Practice 2013