This week in the BMJ
Volume 325, Number 7370, Issue of 26 Oct 2002How can we improve the management of depression?
How can we improve the management of depression?
Ongoing efforts to improve depression management yield ongoing benefits
for patients. Rost and colleagues (p 934) find that, in addition to
increasing remission rates, ongoing intervention improved both
emotional and physical functioning in depressed patients in primary
care practices across the United States. These results should encourage
health planners to make a small but continuing investment in the
treatment of depression. Meanwhile, Scott and colleagues
(p 951) show that a simple practice based approach improved the
detection and management of depression in a team familiar with the
philosophy of chronic disease management. However, this approach failed
to affect depression management in a less well resourced practice,
suggesting that developing an effective system in a wide variety of
practice settings remains a challenge.
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Computerised decision support may be ineffective
A computerised decision support system delivering guidelines for the
management of stable angina and asthma in primary care made no apparent
difference to a range of measures of the process or outcome of care.
This was almost certainly because of low levels of use. Eccles and
colleagues (p 941) conducted a cluster randomised controlled trial of
a computerised decision support system in 60 general practices with a
total of 4600 patients in north east England. Considerable challenges
still exist to computerising guidelines in a way that supports the
management of complex disease.
Home based COPD care of limited value
Home based care for patients with chronic obstructive pulmonary disease
after discharge from hospital improves patients' knowledge and some
aspects of quality of life, but fails to engage general practitioners
adequately or to prevent patients' readmissions to hospital. Hermiz
and colleagues (p 938) suggest that additional interventions or
interventions earlier in the disease process may be required to reduce
hospitalisations.
(Credit: SCOTT CAMAZINE/SPL)
Managing HIV infection as a chronic disease
As people with HIV infection in developing countries gain access to
antiretroviral drugs and treatments for opportunistic infections, they
should be able to live longer lives. Kitahata and colleagues (p 954)
argue that the chronic care model used in richer countries could
greatly improve the quality of these lives. They warn, however, that
the model cannot be simply superimposed on existing acute, episodic
care: services in the world's poorest regions should be redesigned
from scratch.
Most disease management programmes are effective
Most disease management programmes are associated with improvements in
care. Weingarten and colleagues (p 925) reviewed 118 programmes and
found that those directed at providers and patients were associated
with significant improvements in provider adherence to guidelines.
However, since few studies have directly compared interventions,
further research is needed to determine the relative effectiveness and
costs of the different strategies.
Needs of people dying of heart failure not being met
The needs of people with advanced cardiac failure are not being met.
Murray and colleagues (p 929) show that these patients had a poorer
understanding of their condition and prognosis and were less involved
in decision making than patients with lung cancer. Cardiac patients
also received less health, social, and palliative care. The authors
argue that all patients with advanced serious illness should be
afforded the same level of care as experienced by patients with cancer.
Eating fish cuts risk of dementia
Elderly people who eat fish or seafood at least once a week are at
lower risk of developing dementia, including Alzheimer's disease,
report Barberger-Gateau and colleagues (p 932). This "protective"
effect was partly explained by higher education of regular consumers.
The authors suggest that, as well as providing vascular protection, the
fatty acids contained in fish oils could reduce inflammation in the
brain and may have a specific role in brain development and
regeneration of nerve cells.
The burden of disease
Knowing what people die of is only partly useful: it's just as
important to know what makes people miserable, sick, and needy. Throughout this issue are fillers on the world's leading causes of
disability and premature death (pp 928, 933, 937, 947, and 964). The
information comes from the Harvard School of Public Health's ongoing
project on the global burden of disease (summarised at
www.hsph.harvard.edu/organizations/bdu/summary.html),
supported by WHO and the World Bank. Using age and sex adjusted data
from around the world, the project continues to shed light on the big challenges to public health.
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