Volume 173 Issue 2

Fitness And Health Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice Julie A Halbert, Christopher A Silagy, Paul M Finucane, Robert T Withers and Phil A Hamdorf MJA 2000; 173: 84-87 Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on General practice and primary care Abstract Objective: To determine whether provision of individualised physical activity advice by an exercise specialist in general practice is effective in modifying physical activity and cardiovascular risk factors in older adults. Design: Randomised controlled trial of individualised physical activity advice, reinforced at three and six months (intervention) versus no advice (control). Setting: Two general practices in Adelaide, South Australia, 1996. Participants: 299 adults aged 60 years or more who were healthy, sedentary and living in the community. Main outcome measures: Changes to physical activity (frequency and duration of walking and vigorous exercise), selected cardiovascular risk factors (blood pressure, body weight, serum lipid levels) and quality of life over 12 months. Results: Self-reported physical activity increased over the 12 months in both groups (P < 0.001). The increase was greater for the intervention than the control group for all measures except time spent walking (P < 0.05). More intervention than control participants increased their intention to exercise (P < 0.001). Serum levels of total and low-density lipoprotein cholesterol and triglycerides fell significantly over the 12 months to a similar extent in the two groups. No other significant changes in cardiovascular risk factors were seen. Quality-of-life scores decreased over the 12 months. The decrease was significantly greater among intervention than control women, but not men, for emotional well-being (P = 0.02), physical well-being (P = 0.04) and social functioning (P = 0.04). Discussion: Provision of general practice-based physical activity advice reinforced three-monthly produced a sustained increase in self-reported physical activity. However, there were no associated changes in clinical measures of cardiovascular risk factors and minimal changes in quality-of-life measures. A large body of evidence shows that all-cause mortality and death and disability from cardiovascular disease decrease with regular physical activity1 and physical fitness.2 Leisure-time activity also reduces coronary risk factors,3 and the greatest decrease is achieved by moving individuals from the sedentary, low-fitness category.4,5Among Australians aged over 60 years, 55% of men and 61% of women are not sufficiently active to maintain general health.6 Encouragingly, a Western Australian survey found that 93% of general practitioners (GPs) reported asking about physical activity when a patient presented with a condition that might benefit from exercise, and 50% asked new patients about current physical activity patterns.7 However, GPs comment on a lack of skill in assessing and guiding activity and a lack of guidelines.8 Although many believe referral to a qualified fitness professional is desirable, fewer than 15% make these referrals.9 Previous studies of interventions to increase provision of advice and patients' physical activity in primary care have had mixed results and are of varying methodological quality.10 To reduce the demand on GPs, several groups have examined the effectiveness of advice from practice staff. Results of advice from a health visitor were initially favourable but were not sustained,11 while advice from practice nurses produced no increases in objectively measured12 or self-reported13 exercise levels in the short term. Therefore, we designed a properly powered study to determine the effectiveness of individualised advice from an exercise specialist in a general practice setting on changing physical activity levels and cardiovascular risk factors at 12-month follow-up. Methods The study was a randomised, controlled trial. Ethics approval was granted by the Committee on Clinical Investigation, Flinders Medical Centre, Adelaide. Recruitment and baseline measures Sedentary adults aged 60 years or over who lived in the community were recruited from two general practices in the southern region of Adelaide, South Australia, in 1996, as described previously.14 Briefly, 2878 people who met the above criteria were invited to a screening appointment; 913 attended and completed a questionnaire on demographic characteristics, medical history, medication use and physical activity levels. Exclusion criteria included a cerebrovascular or ischaemic cardiac event in the previous six months, malignancy or other life-threatening disease, inability to comply with the requirements of the study, a condition for which physical activity was contraindicated, use of β-blocker medication, and regular physical activity, leaving 351 people eligible. These 351 were invited to attend a baseline appointment at which they signed a consent form and were randomly allocated to the intervention or control groups using sealed opaque envelopes. They also answered a written questionnaire about current physical activity levels, intention-to-exercise,15 quality of life (assessed by the Short Form 3616) and demographic information. Blood pressure, body weight and height were measured, and a blood sample was taken for lipid studies. Interventions Both groups had a 20-minute session with an exercise specialist (with a master's degree in exercise physiology; J A H). Spouses were invited to attend these and follow-up sessions, which were held at the participants' usual GP surgeries. The intervention group received individualised advice about the benefits of physical activity and a pamphlet containing a plan for physical activity for the next three months. This plan, based on current position statements,17,18 involved aerobic activities at moderate intensity for a minimum of three sessions per week for at least 20 minutes per session, with self-monitoring of heart rate. The exercise plan, potential barriers to exercise and strategies to overcome these were discussed. The focus was on incorporating physical activity into the individual's usual activities and on increasing "self-efficacy" (belief in one's ability to perform the activity) by recommending a preferred, familiar activity and setting modest targets for the first three months. These targets were to be progressively increased, depending on progress, enthusiasm and health. The control group received a pamphlet promoting good nutrition for older adults, which was discussed for 20 minutes. Follow-up At three and six months, all participants were mailed a follow-up questionnaire to be returned in a postage paid envelope (control participants) or at an interview (intervention participants). This interview was arranged by telephone, and intervention participants were encouraged to attend whatever their adherence to the exercise plan. Participants were also asked to complete a seven-day physical activity log as a prompt for discussion, which included physical activity levels and benefits, reasons for success or failure, injuries, heart-rate monitoring and changes to the plan. At 12 months, all participants were invited to a follow-up interview, at which they completed a questionnaire, and clinical characteristics (except height) were remeasured. Energy expenditure was measured for 59 participants (31 intervention and 28 control participants) over four days (two weekends and two weekdays) using a Caltrac portable, vertical accelerometer.19 These 59 were recruited by telephoning randomly selected participants until six volunteers per week were obtained (a total of 88 were telephoned). Statistical analyses Sample size calculations indicated that 212 people were required to detect a 5 mm Hg difference in systolic blood pressure between the intervention and control group using a parallel group design (assuming a power of 0.9 and type I error rate of 0.05). Targeting 300 subjects allowed for a 40% dropout and non-compliance rate. Assumptions for parametric analysis were investigated. Repeated-measures analyses of variance were used to examine data for physical activity and five quality-of-life scores, using time as the within-subject variable, and time, intervention and sex as the between-subject variables. As data for three quality-of-life scales (roles physical and emotional and social functioning) were non-continuous and skewed, they were dichotomised (score of 100 = 0, score < 100 = 1) and then analysed with generalised estimating equations -- an extension of generalised linear models -- to examine time, intervention and sex interactions.20 Twelve-month changes in clinical characteristics, quality-of-life and accelerometer results were analysed with Student's t tests (independent samples). Intention-to-exercise data were analysed with χ2 statistics. All data were analysed on an intention-to-treat basis. In the event of missing responses, data were entered at the previous follow-up, thereby assuming no change. Results Participants Of the 351 people eligible for the study, 299 attended the baseline interview and were randomised (149 to the intervention group and 150 to the control group). Their characteristics have been reported previously.14 There were no statistically significant differences between the intervention and control groups in age (mean age, 67.3 years [SD, 7.9 years] versus 67.8 years [SD, 5.5 years]), sex distribution (48% versus 44% men), current and past medical history and current medication use or clinical parameters at baseline (Box 1). Three- and six-month follow-up questionnaires were returned by 274 (92%) and 269 (90%) participants, respectively, while 264 (88%) attended the 12-month follow-up interview (123 in the intervention and 141 in the control group). Of the 35 who did not attend, two had died, six were on holidays, seven were ill, and 20 were not interested. There were no statistically significant differences in baseline clinical and sociodemographic measures between participants who attended the 12-month follow-up interview and those who did not. Physical activity At all three follow-ups, all self-reported measures of physical activity had increased significantly from baseline levels in both the intervention and control groups (P < 0.05; Box 2). However, the intervention group reported significantly more physical activity than the control group for all measures except time spent walking (P < 0.05). Men reported significantly more minutes of walking per session (P = 0.02) and more frequent vigorous exercise (P = 0.02) than women at all follow-ups. In addition, the difference in frequency of vigorous exercise between the intervention and control groups was significantly greater for men than for women (P < 0.001). Energy expenditure data were available for 59 participants who wore an accelerometer (31 intervention and 28 control participants). The intervention and control groups did not differ significantly in any measured parameter of energy expenditure -- total per day, per day as a percentage of total energy expenditure, during activity per day, or during activity per kg body weight. At all follow-ups, there were significant differences between the intervention and control groups for change in intention to exercise (P < 0.001). At 12-month follow-up, more intervention than control participants increased their intention to exercise (Box 3). Cardiovascular risk factors Over the 12 months, there were no statistically significant changes in body weight, resting heart rate, blood pressure or serum high-density lipoprotein levels in either the control or intervention group (Box 1). However, there were significant decreases in serum levels of total and low-density lipoprotein cholesterol and triglycerides in both groups; the decreases did not differ significantly between the two. In addition, body weight decreased for all men and for control-group women, but increased for intervention-group women (P = 0.01). Quality of life Quality-of-life scores decreased between baseline and 12-month follow-up in both the intervention and control groups. These score decreases were significant in both groups for bodily pain (P = 0.001), general health (P < 0.001), physical functioning (P < 0.001), vitality (P = 0.04) and role physical (odds ratio [OR], 1.80; 95% CI, 1.33-2.43). Women in the intervention group had significantly greater score decreases than women in the control group for the scales role emotional (P = 0.02), role physical (P = 0.04) and social functioning (P = 0.04). In addition, women reported worse scores at 12-month follow-up than men for bodily pain (P = 0.02), mental health (P = 0.03), physical functioning (P = 0.04) and vitality (P = 0.01), and were 1.5 times more likely to report some difficulty with role physical (OR, 1.43; 95% CI, 1.03-1.99) and social functioning (OR 1.53; 95% CI, 1.06-2.21). Discussion This randomised controlled trial showed that provision of physical activity advice by an exercise specialist was effective in increasing the intention to exercise and self-reported physical activity among patients 60 years and over in two general practices. Other studies have also found increased intention to exercise14 and increased physical activity levels12,21 as a consequence of physical activity advice. However, our study differs from most others in that it had a large number of participants and high retention rate (88% at 12 months), and calculated results on an intention-to-treat basis. The high retention rate possibly resulted from participants' strong association with their GPs, who were aware and possibly encouraging of their participation, and the fact that all visits were conducted at the GPs' practices. The success of the intervention may be attributed to the enthusiastic volunteer population, who, while sedentary, were keen to start regular activity. Another possible contributor was the strong emphasis on walking as the preferred activity. The physical activity advice had the characteristics of successful physical activity interventions -- a home-based program, comprising unsupervised, informal exercise (generally walking), of moderate intensity and comparatively low frequency (which is associated with better maintenance), as well as frequent professional contact.22 The major limitation of this study was its reliance on self-report, as patients over 65 years tend to overestimate their physical activity.12 The number of participants and limited resources precluded general use of more objective measures of physical activity or fitness. Objective measurements of energy expenditure by accelerometer in 59 volunteers did not detect a difference between the control and intervention groups, possibly because of the small sample size. Other possible reasons are that people in each group who had established regular physical activity volunteered preferentially for accelerometer measurement, or that the self-reported increase in physical activity in the intervention group was not real. We were also unable to detect any differences between the intervention and control groups in cardiovascular risk factors after 12 months. This is consistent with results of others. For example, patients referred by their GPs to a local leisure centre had increased self-reported physical activity after 37 weeks, but no changes in systolic or diastolic blood pressures or body mass index.23 In our study, the increase in self-reported physical activity in the intervention group was possibly not large enough to increase physical fitness. Previous investigators have shown that cardiovascular risk factors are more strongly related to physical fitness than to physical activity,4,5and that, in individuals with low levels of fitness, increased physical activity without a change in fitness does not modify cardiovascular risk factors.24 Further, although the difference in physical activity between the intervention and control groups reached statistical significance, it was modest in absolute terms. Finally, all participants remained under the usual care of their GPs, who were free to initiate or cease prescribing medications that might modify cardiovascular risk factors. We found declines in quality of life from baseline to 12 months in both groups, with the greatest change in the first three months. We hypothesise that quality of life was more accurately reported at three months than at baseline, when scores were much higher than the Australian norms for the participants' age. It is possible that participants were initially keen to present themselves as healthy in all respects or that they were expressing high hopes for the study. In conclusion, this study showed that, for a specific population of general practice patients, providing physical activity advice three-monthly for six months resulted in increases to both self-reported physical activity and intention to exercise, which were maintained at 12-month follow-up. Further research in primary care is needed to determine whether these changes apply to other groups and whether they confer significant health benefits. Acknowledgements This project was funded by a Public Health Research and Development Project Grant from the National Health and Medical Research Council and Department of Health, Housing, Local Government and Community Services. We wish to thank the GPs and staff from Blackwood and Flinders Clinics, Adelaide, SA, for their assistance and Lynne Giles (Flinders University, Adelaide, SA) for statistical advice. Conflict of interest: None. References Paffenbarger RS, Hyde RT, Wing AL, et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med 1993; 328: 538-545. Blair SN, Kohl HW, Paffenbarger RS, et al. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA 1989; 262: 2395-2401. Folsom AR, Caspersen CJ, Taylor HL, et al. Leisure time physical activity and its relationship to coronary risk factors in a population-based sample. Am J Epidemiol 1985; 121: 570-579. Eaton CB, Lapane KL, Garber CE, et al. Physical activity, physical fitness and coronary heart disease risk factors. Med Sci Sports Exerc 1995; 27: 340-346. Lochen M-L, Rasmussen K. The Tromso study: physical fitness, self-reported physical activity, and their relationship to other coronary risk factors. J Epidemiol Community Health 1992; 26: 103-107. Active Australia. Physical activity levels of Australians. Results of the Active Australia baseline survey 1997. Available at <www.ausport.gov.au/ partic/actozfr.html> Bull FCL, Schipper ECC, Jamrozik K, Blanksby BA. Beliefs and behaviour of general practitioners regarding promotion of physical activity. Aust J Public Health 1995; 19: 300-304. Murphy B, Ruth D. GPs role in CVD Prevention. A report on focus group discussions with general practitioners for the RISK study in general practice. Melbourne: Monash University, 1991. Bull FCL, Schipper ECC, Jamrozik K, Blanksby BA. How can and do Australian doctors promote physical activity? Prev Med 1997; 26: 866-873. Eaton CB, Menard LM. A systematic review of physical activity promotion in primary care settings. Br J Sports Med 1998; 32: 11-16. Harland J, White M, Drinkwater C, et al. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999; 319: 828-832. Sims J, Smith F, Duffy A, Hilton S. The vagaries of self-report of physical activity: a problem revisited and addressed in a study of exercise promotion in the over 65s in general practice. Fam Prac 1999; 16: 152-157. Simmonds GJ, Naylor P-J, Riddoch CJ, Velleman G. Stage-based counselling for exercise in primary care -- a controlled trial. Presented at the Scientific Basis of Health Services Conference. 1995 Oct; London. Halbert JA, Silagy CA, Finucane P, et al. Recruitment of older adults for a randomized, controlled trial of exercise advice in a general practice setting. J Am Geriat Soc 1999; 47: 477-481. Marcus BH, Banspach SW. Using the stages of change model to increase the adoption of physical activity among community participants. Am J Health Promot 1992; 6: 424-429. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 health survey manual and interpretation guide. Boston: New England Medical Center, 1993. National Institutes of Health Consensus Development Panel on Physical Activity and Cardiovascular Health. Physical activity and cardiovascular health. JAMA 1996; 276: 241-246. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Position Stand. Med Sci Sports Exerc 1990; 22: 265-274. Jacobs DR, Ainsworth BE, Hartman TJ, Leon AS. A simultaneous evaluation of 10 commonly used physical activity questionnaires. Med Sci Sports Exerc 1993; 25: 81. Liang K-Y, Zeger S. Longitudinal data analysis using generalized linear models. Biometrika 1986; 73: 13-22. Stevens W, Hillsdon M, Thorogood M, McArdle D. Cost-effectiveness of a primary care based physical activity intervention in 45-74 year old men and women: a randomised controlled trial. Br J Sports Med 1998; 32: 236-241. Hillsdon M, Thorogood M, Anstiss T, Morris J. Randomized controlled trials of physical activity promotion in free living populations: a review. J Epidemiol Community Health 1995; 49: 448-453. Taylor AH, Doust J, Webborn N. Randomised controlled trial to examine the effects of a GP exercise referral programme in Halisham, East Sussex, on modifiable coronary heart disease risk factors. J Epidemiol Community Health 1998; 52: 595-601. McMurray RG, Ainsworth BE, Harrell JS, et al. Is physical activity or aerobic power more influential on reducing cardiovascular disease risk factors? Med Sci Sports Exerc 1998; 30: 1521-1529. (Received 4 Feb, accepted 4 May, 2000) Authors' details Department of Rehabilitation and Aged Care, Flinders University of South Australia, Adelaide, SA. Julie A Halbert, MSc, Research Manager; Paul M Finucane, FRCPI, FRACP, Head. Monash Medical Centre, Melbourne, VIC. Christopher A Silagy, PhD, FRACGP, FAFPHM, Head of Institute of Public Health and Health Services Research. School of Education, Flinders University of South Australia, Adelaide, SA. Robert T Withers, PhD, FASMF, FACSM, Senior Lecturer in Rehabilitation. Hampstead Centre, Royal Adelaide Hospital, Adelaide, SA. Phil A Hamdorf, PhD, Head of Centre for Physical Activity in Ageing. Reprints will not be available from the authors. Correspondence: Ms J A Halbert, Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daw Park, SA 5041. julie.halbertATflinders.edu.au Make a comment 1: Clinical measures at baseline and 12-month follow-up (mean and 95% confidence interval) Control group (n=150) Intervention group (n=149) Baseline 12 months Baseline 12 months Body weight (kg) Height (cm) Resting heart rate (bpm) 74.0 (71.8-76.1) 165.8 (164.4-167.2) 71.3 (69.7-72.9) 73.6 (71.5-75.8) ND 71.6 (70.0-73.2) 75.9 (73.8-78.0) 166.9 (165.5-168.4) 70.9 (69.1-72.6) 76.0 (73.9-78.1) ND 71.1 (69.6-72.6) Blood pressure (mm Hg) Systolic Diastolic 148.1 (145.1-151.0) 85.7 (84.2-87.1) 146.6 (143.4-149.6) 86.3 (84.9-87.7) 148.6 (145.9-151.4) 85.6 (84.1-87.1) 147.4 (144.4-150.5) 86.1 (84.6-87.7) Serum levels (mmol/L) Total cholesterol Triglycerides HDL cholesterol LDL cholesterol 5.88 (5.73-6.03) 1.64 (1.50-1.78) 1.34 (1.27-1.40) 3.81 (3.67-3.95) 5.70 (5.55-5.85)* 1.57 (1.43-1.70)* 1.34 (1.28-1.41) 3.65 (3.52-3.80)* 5.85 (5.68-6.02) 1.70 (1.50-1.89) 1.30 (1.24-1.37) 3.78 (3.65-3.95) 5.63 (5.47-5.80)* 1.57 (1.42-1.73)* 1.29 (1.23-1.35) 3.64 (3.50-3.79)* *Significant decrease from baseline level (P<0.05). HDL=high-density lipoprotein. LDL=low-density lipoprotein. ND=measurement not done. Back to text 2: Self-reported physical activity at baseline and follow-up (median value and 25th-75th percentile) Control group (n=150) Intervention group (n=149) Baseline 3 months 6 months 12 months Walking Frequency (sessions/week) Time (mins/session) 0 (0-2) 0 (0-20) 2 (0-3)* 30 (0-49)* 2 (0-4)* 30 (0-60)* 2 (1-3)* 30 (10-60)* Vigorous exercise Frequency (sessions/week) Time (mins/sessions) 0 (0-0) 0 (0-0) 0 (0-1)* 0 (0-16)* 0 (0-2)* 0 (0-21)* 0 (0-1)* 0 (0-15)* Walking Frequency (sessions/week) Time (mins/session) 0 (0-1) 0 (0-25) 3 (1-4)*† 30 (19-50)* 3 (2-4)*† 30 (20-60)* 3 (1-4)*† 30 (10-60)* Vigorous exercise Frequency (sessions/week) Time (mins/sessions) 0 (0-0) 0 (0-0) 2 (0-3)*† 20 (0-35)*† 2 (0-3)*† 20 (0-40)*† 2 (0-3)*† 20 (0-35)*† *Statistically significant increase from baseline level (P<0.05). †Values significantly higher than for control group (P<0.05). Back to text Back to text

Julie A Halbert · Christopher A Silagy · Paul M Finucane · Robert T Withers · Phil A Hamdorf

Fitness And Health Healthy ageing: what role can physical activity play? Adrian E Bauman and Ben J Smith MJA 2000; 173: 88-90 Moderate activity is clearly beneficial for elderly people and should be actively promoted by general practitioners Epidemiological evidence - Strength, flexibility and prevention of falls in the elderly - Special needs of the frail elderly - Implications for practice - References - Authors' details - - More articles on General practice and primary care In an ageing Australia, important approaches to spiralling healthcare costs are primary and secondary prevention. The second most important area for risk factor reduction, after tobacco use, is physical inactivity, in terms of its contribution to the overall burden of disease for Australia.1 This applies equally to older patients and to the general community. Recent evidence, summarised in the 1996 United States Surgeon General's Report and elsewhere, has identified consistent epidemiological evidence for health benefits of physical activity at least as great as treating hypertension or cholesterol reduction.2,3Nonetheless, physical activity remains a poor relation in population disease prevention. In contrast to exponential increases in the volume of research in exercise science or broader disease prevention, research into physical activity in the elderly has remained quite static over recent decades.4 Our purpose was to review the available evidence for health benefits of physical activity among older adults. A summary of our key points is given in the Box. Epidemiological evidence The benefits of regular moderate physical activity are now acknowledged internationally.2,3 Health benefits for older adults are mostly similar to those for the general community: there is evidence of reduced risk of all-cause mortality and reduced rates of coronary heart disease among moderately active elderly men and women.2Population studies in diverse cohorts (such as 40 000 Iowan postmenopausal women and 472 elderly Dutch men) report similar findings -- a graded dose-response relationship between activity and all-cause mortality and coronary heart disease deaths.5,6 A South Australian study identified a mortality risk 74% greater in elderly people who were completely sedentary, compared with the (mostly moderately) active.7 Further, even those aged over 60 years who change from being sedentary to engaging in at least moderate levels of activity accrue a clear health benefit.8 New findings repeatedly confirm that aerobic or vigorous activities are not essential for these cardiovascular benefits. For those who are sedentary, accumulating half an hour of moderate activity on most days of the week seems sufficient. This finding is replicated across studies which adjust for other risk factors and for clinical comorbidity, and which measure physical activity in diverse ways. This notion is particularly important for older adults, where adherence to physical activity will be much more likely if they perceive they are capable of performing the activity, such as moderate walking.9 There is good evidence that regular moderate activity protects against the development of diabetes in populations quite independent of body weight.2,3,10 Up to half of people with diabetes are completely sedentary,11 presenting a further clinical opportunity for secondary prevention, as physical activity is part of optimal management. Moderate physical activity may also reduce the risk of ischaemic stroke in the elderly,12 and there is clear evidence, pooled across almost 30 studies, that physical activity reduces colon cancer risk, and may have a role in reducing breast cancer incidence in postmenopausal women.2,3 In addition, physical activity is recognised as being associated with improved mental health, and is a clinical approach to mild anxiety and depression.2 Cohort studies in the elderly show that more active people have a reduced risk of developing depression, and are more likely to maintain wellbeing.13 Clinical data suggest that moderate exercise regimens are anxiolytic, but that vigorous activity may have less effect, or even be counterproductive, among older adults. Finally, the quality and duration of sleep may be improved by activity, both for those living in the community14 and for nursing home residents.15 One important idea raised by the epidemiological literature is the notion of "compression of morbidity". Population studies suggest that the "disability-free years" can be increased in people who remain active,16 and that overall healthy lifestyles could postpone disability by up to five years.17 This has ramifications for improved functional status and quality of life. The concept of risks versus benefits of activity is worth exploring. The transient increases in the risk of acute cardiac events and sudden death following bouts of vigorous activity are not found for moderate activity, and overall, even for vigorous activity, the benefits outweigh the risks. This provides further support for encouraging moderate activity in middle-aged and older adults. Strength, flexibility and prevention of falls in the elderly Physical activity is commonly seen as a means of maintaining strength and vigour, and staving off the functional declines of ageing. Muscle strength is closely related to functional capacity, and has consistently been found to improve as a result of progressive resistance training.18 Resistance training techniques include using gymnasium equipment and elastic tubing, home-based exercise and even walking. Strength-building programs have additional benefits, such as improving mobility and balance and aiding in weight maintenance. Physical activity can help improve balance. This in turn helps older people by improving mobility and functional capacity, and reducing the risk of falls and injuries. Regular, gentle exercise classes, involving aerobic, strength, balance and coordination activities, improve balance when undertaken twice weekly over 12 months.19 Even a supervised program of gentle exercise such as tai chi may help to maintain balance.20 Flexibility is another domain of physical performance that is necessary for daily activities such as climbing stairs, rising from a chair or bed, or walking. The evidence is less clear here, but some studies have shown yoga and flexibility training, supervised aerobics classes and walking and upper-body training can benefit flexibility.21 Two key public health issues related to these areas of physical functioning are osteoporosis, and falls and injuries. Some studies indicate that older people who have stayed active have significantly lower losses of bone mineral density than their sedentary counterparts. However, as bone mineralisation is completed by late adolescence, strategies later in life may have less of a role in preventing osteoporosis. The American College of Sports Medicine concluded that functional loading through physical activity exerts a positive influence on bone mass, but that the types of program that may be most effective in producing beneficial results are still uncertain.21 Physical activity is a beneficial component of falls prevention, because of its effects on muscle strengthening and balance, and possibly on bone density. In the meta-analysis of the seven Frailty and Injuries Cooperative Studies Intervention Trials (FICSIT), participation in an exercise program was found to reduce the risk of falling, although some programs were supplemented by education and other interventions.22 The Cochrane review also found that activity had a beneficial role, particularly when supplemented by additional measures such as medications review and home modification among elderly people identified as at risk of falling.23 Many of these studies used supervised rather than at-home exercise interventions. Special needs of the frail elderly Initiating activity programs is more problematic in the frail elderly or in those with multiple comorbidities. This group may require medical screening and assessment before they begin. The frail elderly have typical problems that may make physical activity more difficult. Many may benefit from more moderate or even light activities; many of these can be carried out in residential settings and community centres. Apart from walking programs, other locally based interventions to improve mobility, increase strength and improve balance can be implemented and achieve improvements in this age group.15,21 In addition to strength training, working to reduce polypharmacy, and making residential environments more physical activity friendly are also important. A recent controlled trial has identified positive outcomes of intensive exercise and resistance training among 100 hostel residents with a mean age of 87 years -- even in this frail elderly group physical activity, gait velocity and muscle strength improved.24 Implications for practice There are two quite distinct forms of recommendation for physical activity. One is the opportunistic recommendation for regular walking and moderate activity for all adults to prevent chronic disease; the other focuses on strength, mobility and balance, and has quality-of-life and falls prevention benefits among older age groups, but may require more intensive program attendance. Recommending physical activity to people over 65 is cost effective,25 and a worthwhile part of many patient encounters in general practice. The counselling objectives are to identify achievable, moderate activities, increase confidence among patients that they can perform the activity, and highlight the importance of these activities in delaying disability. It is useful to know about local programs for referring patients to, and to encourage people to exercise with someone else. A New Zealand study identified general practice-based advice as being more effective if focused on written "exercise prescriptions" rather than verbal advice alone.26 However, it is not easy to train doctors to promote physical activity to the elderly,27 and other strategies may support this process. Given the time constraints of practice, allied health professionals may provide specialised counselling in this area. Another New Zealand study ascertained lower rates of falls among women aged over 80 years who were referred to a physiotherapist for an exercise intervention delivered through general practice.28 These improvements were maintained even at two years of follow-up. In a Victorian controlled trial, education of practitioners, extensive GP advice and home follow-up increased physical activity time per week among patients aged at least 65 years.29 Further, in this issue of the Journal, Halbert and colleagues show that having a qualified exercise scientist in the GP's surgery to provide detailed advice and exercise plans provided a sustained increase in self-reported physical activity.30 Thus, adjunctive methods like these may enhance the range of health outcomes, and achieve more than GP advice alone. It appears that many of the benefits of activity are reasonably acute, and it may be recent physical activity which confers many of the chronic disease and musculoskeletal benefits.21,31 Hence the advice "use it or lose it" should be as prevalent as antismoking messages. Given the credibility with which doctors' advice about exercise in older adults is perceived in the general community,32 each consultation presents an important -- and possibly overdue -- opportunity for promoting health to older adults. References Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. AIHW publication PHE 17. Canberra: Australian Institute of Health and Welfare, 1999. US Surgeon General's Report. Physical activity and health. Atlanta, Ga: US Department of Health and Human Services, Centers for Disease Control, 1996. Bauman A, Owen N. Physical activity of adult Australians: epidemiological evidence and potential strategies for health gain. J Sci Med Sport 1999; 2: 30-41. Lidor R, Miller U, Rotstein A. Is research on aging and physical activity really increasing? A bibliometric analysis. J Aging Physical Activity 1999; 7: 182-195. Bijnen FCH, Feskens EJM, Caspersen CJ, et al. Baseline and previous physical activity in relation to mortality in elderly men -- The Zutphen Elderly Study. Am J Epidemiol 1999; 150: 1289-1296. Kushi LH, Fee RM, Folsom AR, et al. Physical activity and mortality in post-menopausal women. JAMA 1997; 277: 1287-1292. Finucane P, Giles LC, Withers RT, et al. Exercise profile and subsequent mortality in an elderly Australian population. Aust N Z J Public Health 1997; 21: 155-158. Blair SN, Kohl HW, Barlow CE, et al. Changes in physical fitness and all cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995; 273: 1093-1098. Kriska A. Physical activity and the prevention of type 2 diabetes mellitus. How much for how long? Sports Med 2000; 29: 147-151. Hu FB, Sigal RJ, Rich-Edwards JW, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women. A prospective study. JAMA 1999; 282: 1433-1439. Hays LM, Clark DO. Correlates of physical activity in a sample of older adults with type 2 diabetes. Diabetes Care 1999; 22: 706-712. Wannamethee SG, Shaper AG. Physical activity and the prevention of stroke. J Cardiovasc Risk 1999; 6: 213-216. Morgan K, Bath PA. Customary physical activity and psychological wellbeing: a longitudinal study. Age Ageing 1998; 27 Suppl 3: S35-S40. King AC, Oman RF, Brassington GS, et al. Moderate intensity exercise and self rated quality of sleep in older adults. A randomised controlled trial. JAMA 1997; 277: 32-37. Alessi CA, Yoon EJ, Schnelle JF, et al. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc 1999; 47: 784-791. Leveille SG, Guralnik JM, Ferrucci L, Langlois JA. Aging successfully until death in old age: opportunities for increasing active life expectancy. Am J Epidemiol 1999; 149: 654-664. Vita PJ, Terry RB, Hubert HB, Fries JF. Aging, health risks, and cumulative disability. N Engl J Med 1998; 338: 1035-1041. Healthy ageing and physical activity. State Health Publication No. (HP) 980195. Sydney: New South Wales Health Department,1999. Lord S, Ward J, Williams P, Strudwick M. The effect of a 12-month exercise trial on balance, strength, and falls in older women: a randomised controlled trial. J Am Geriatr Soc 1995; 43: 1198-1206. Wolfson L, Whipple R, Derby C, et al. Balance and strength training in older adults: intervention gains and Tai Chi maintenance. J Am Geriatr Soc 1996; 44: 498-506. American College of Sports Medicine. Position stand on exercise and physical activity for older adults. Med Sci Sports Exercise 1998; 30: 992-1008. Province M, Hadley E, Hornbrook M, Lipsitz L. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. JAMA 1995; 273: 13411-1347. Gillespie L, Gillespie W, Cumming R, et al. Interventions to reduce the incidence of falling in the elderly. Cochrane Database Systematic Reviews 1998; 3. Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994; 330: 1769-1775. Munro J, Brazier J, Davey R, Nicholl J. Physical activity for the over 65s: could it be a cost effective exercise for the NHS? J Public Health Medicine 1997; 19: 397-402. Swinburn B, Walter LG, Aroll B, et al. The green prescription study: a randomised controlled trial of written exercise advice provided by general practitioners. Am J Public Health 1997; 88: 288-291. Eckstrom E, Hickam DH, Lessler DS, Buchner DM. Changing physician practice of physical activity counselling. J Gen Intern Med 1999; 14: 376-278. Campbell AJ, Robertson CM, Gardner MM, et al. Falls prevention over two years: a randomised controlled trial in women aged over 80 years. Age Ageing 1999; 28: 513-518. Kerse NM, Flicker L, Jolley D, et al. Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme. BMJ 1999; 319: 683-687. Halbert JA, Silagy CA, Finucane PM, et al. Physical activity and cardiovascular risk factors: effects of advice from an exercise specialist in Australian general practice. Med J Aust 2000; 173; 85-87. Sherman SE, D'Agostino RB, Silbershatz H, Kannel WB. Comparison of past versus recent physical activity in the prevention of premature death and coronary artery disease. Am Heart J 1999; 138: 900-907. Booth M, Bauman A, Owen N, Gore C. Physical activity preferences and sources of assistance, and perceived barriers to increase activity among physically inactive Australians. Preventive Med 1997; 26: 131-137. Authors' details School of Community Medicine, University of New South Wales, Sydney, NSW. Adrian E Bauman, FAFPHM, PhD, Professor of Public Health and Epidemiology, School of Community Medicine, University of New South Wales. National Centre for Health Promotion, University of Sydney, NSW. Ben J Smith, MPH, Research Assistant. Reprints will not be available from the authors. Correspondence: Professor A E Bauman, Epidemiology Unit, Locked Bag 7017 Liverpool BC, NSW 1871. Make a comment Evidence for physical activity and exercise promotion in the elderly Evidence for: Level of evidence Comments Decreased incidence of and mortality from cardiovascular disease and diabetes with moderate activity Level III Replicated across many well designed population-based cohort studies Decreased incidence of falls in the elderly who engage in regular physical activity Level I and II Some systematic review data, several individual randomised controlled trials; needs resistance training, as well as training for balance and gait Improved functional status and quality of life in the elderly who engage in regular physical activity Level II and III Some randomised controlled trials for functional status; mostly observational (cohort) studies for quality of life Benefit of counselling and advice for moderate physical activity from general practitioners Level II Several randomised controlled trials but effects are modest; may be better if written advice is given, and if allied health professionals are involved Back to text

Adrian E Bauman · Ben J Smith

Changing Healthcare Complementary therapies: the appeal to general practitioners Heather L Eastwood MJA 2000; 173: 95-98 Abstract - Reasons for GPs' use of CAM - Clinical legitimacy - Ideological motivations - Postmodernisation - Postmodern values - References - Authors' details - - More articles on General practice and primary care Abstract Pragmatism -- among consumers seeking a cure and among general practitioners seeking clinical results and more patients -- is not a complete explanation for the burgeoning of complementary and alternative medicine (CAM) in Western societies. Instead, this growth is substantially a result of pervasive and rapid social change, alternatively termed 'globalisation' and 'postmodernisation'. Globalisation and postmodernisation are creating a new social reality, of which a prominent characteristic is the proliferation of consumer choice. GPs are enmeshed in this social change and subject to the trend to greater choice -- both their patients' and their own. On the one hand, GPs are reacting to social change as "economic pragmatists", responding to consumers' increasing demand for CAM. On the other hand, GPs themselves are acting as agents of social change by acknowledging the limitations of orthodox biomedical treatments and promoting CAM as part of their service delivery. Lack of scientific validation of CAM has not prevented GPs' use of such therapies. The phrase "clinical legitimacy" can be seen as a trump card that overrides "scientific legitimacy". It is the shibboleth of a postmodern movement among GPs towards healing and the "art" of medicine, as opposed to the "science" of medicine per se. Recent articles and editorials in the Journal1-3 have highlighted the increasing demand for complementary and alternative medicine (CAM) by Australians, and its provision by general practitioners (GPs). The findings of Pirotta et al that 1 in 5 Victorian GPs are using CAM in their practice1 support earlier data of the Royal Australian College of General Practitioners that 1 in 6 Australian GPs employed some form of CAM.4 A secondary analysis of Health Insurance Commission data indicates that about 1 in 7 GPs in Australia use acupuncture.5 CAM is a billion-dollar industry in Australia, and a multibillion-dollar industry globally.6-8 Pirotta and others have emphasised the need for further research into the reasons behind GPs' use of CAM. Reasons for GPs' use of CAM My research in this area -- a qualitative study involving GPs and alternative practitioners (see Box) -- produced two main explanations for the increasing use by GPs of CAM.9 The first is that GPs are responding to increasing consumer demand for these therapies because of their clinical success. The second and more contentious finding is that consumers are demanding, and GPs are using, these therapies because of factors beyond clinical success -- factors related to globalisation and the characteristics of the global market. These market characteristics include increased consumer choice,10 increased competition among providers, a resultant power shift from provider to consumer,11 and a return to and commercialisation of nature, history, and tradition.12The GPs I interviewed cited reasons for incorporating CAM into their practices that fall into three broad categories:13 Last resort: The use of or referral to practitioners of CAM to treat patients with chronic conditions unresponsive to orthodox medicine. Integrated approach: A considered choice to regularly incorporate CAM, in addition to orthodox biomedical therapies. Ideological conversion: The adoption of CAM as the main treatment practice. GPs who fall into this category also tend to use diagnostic techniques similar to those of alternative practitioners.13 The prevalence of the last two categories, at least among the GPs I have interviewed formally and conversed with informally, contradicts the conclusion by Bensoussan, in a Journal editorial,3 that simple pragmatism -- among both patients and doctors -- adequately accounts for the dramatic increase in the use of CAM. Clinical legitimacy Bensoussan, rightly and with apt humour, criticises recent articles that narrowly attribute patient demand for CAM to "postmodern" or "new age" values usurping scientific rationalism. He notes that a considerable segment of the medical profession has recognised this consumer demand, and that chronic sufferers and the elderly account for a large portion of the patients who request or accept CAM. He suggests that common sense indicates that medical practitioners, the elderly, and the chronically ill are not likely to embrace the naivety of "new age" thought or the jargonistic obscurity of postmodernism;3 instead, Bensoussan and others suggest that simple pragmatism among both doctors and patients provides a more satisfactory explanation for the dramatic increase in the use of CAM.3,14Other writers have coined the term "clinical legitimacy" (see Glossary) to explain the links among consumer demand, pragmatism, and increased GP provision of CAM. That is to say, CAM is effective, particularly in the treatment of chronic conditions, regardless of the lack of scientific explanation or validation. This clinical success, aside from gratifying both patient and doctor, ensures continuing consumer demand, and thereby increases the financial viability of GPs who incorporate CAM, whether directly or through referrals.14 Data from my research show that GPs acknowledge that, regardless of the deficit of scientific evidence for how or why, CAM does achieve clinical results. Ideological motivations GPs note that, in addition to being pragmatic, their patients want healthcare options, and some are indeed ideological in their increasing demand for "natural" therapies and their concomitant mistrust of pharmaceuticals and invasive surgery, a phenomenon described by one GP interviewed as the "greening of medicine".9GPs who offer CAM are keenly aware of this demand for "natural" therapy, and clearly do respond partly as pragmatists catering to consumer demand. However, my interviews reveal that GPs are not acting entirely as economic rationalists responding to market forces. GPs who resort to CAM, like their patients, are often ideological in their motivations. Many are genuinely disillusioned with their biomedical training and with the reality of general practice. They are genuinely seeking a more rewarding approach to primary healthcare, for themselves as well as their patients. For example, some GPs recommend CAM even to patients who prefer or expect synthetic drugs -- a practice described by one doctor interviewed as "good medicine", particularly in light of antibiotic overprescribing.13 Therefore, while my findings validate the roles of both therapeutic and market pragmatism in the increasing use of CAM by Australian GPs, these same findings suggest that this increase involves factors beyond simple pragmatism. The interview data support the sociological hypothesis that a broad cultural shift is occurring in late capitalist societies such as Australia, the United States, the United Kingdom and Western Europe, and GPs, like consumers, are not immune to this sweeping social change.15-17 Arguably, GPs who use CAM are not just influenced by this social change, they contribute to it. Postmodernisation Social scientists use the term postmodernisation -- which incorporates globalisation processes -- to designate fundamental changes occurring within Western societies, of which the inclusion of CAM into mainstream healthcare is a part. Bensoussan notes that factors in the globalisation processes include: increasing public access to information; increasing sensitivity towards traditional cultural practices; and increasing openness to traditional medicines, for example traditional Chinese medicine.3Another aspect of globalisation is concern about the ecological crisis, which has contributed to a "return to nature" within Western societies. Postmodernisation theorists point to this trend -- the return to nature -- as a key determinant in the historical shift from modernity to postmodernity. The return to "natural" medicines is a part of this trend and of globalisation processes generally.18 In Western societies, the effects of globalisation, along with the postmodernist movement, are creating a new social reality (ie, postmodernity), one that has created a greater awareness and, for some, greater appreciation of other cultures, which historically have used traditional medicines.12 Postmodernism has attacked the philosophical foundations that underpin the modernist worldview, including the belief that science, particularly medical science, holds the key to a utopian world "free of disease and inequality".19 All the GPs and alternative practitioners I interviewed advocated more scientific research into CAMs. However, the effects of globalisation processes and postmodernism are contributing to a new, relativistic, postmodernist worldview whereby both doctors and consumers see biomedicine as only one road to health and wellbeing -- not necessarily a dead-end road, but also not a freeway.9 Postmodern values Bensoussan rightly critiques facile resorts to postmodernism to portray increased consumer demand for CAM as a rejection of medical science in favour of individualist, "new age" values.3 Yet he and others fail to recognise adequately that the process of postmodernisation contributes to the rise of new values, values that are no longer an "alternative ideology" but are increasingly mainstream values. Moreover, CAM is being commercialised and aggressively marketed, an outcome predicted by globalisation and postmodernisation theory,12,18,20 and a far cry from a starry-eyed conversion to "new age" values.3 Benoussan notes that one does not have to adopt postmodern values to use CAM, but rather that we live in an age in which people shop around for healthcare services.3 No doubt this is true, but increased consumer choice -- the ability to shop around -- is itself a postmodern value. A fundamental premise of postmodernisation theory is that globalisation and the commercialisation of traditional culture, including healthcare, increases diversity in the market place and thereby increases consumer options.10,12,20 Market forces aside, a surprising number of the GPs interviewed were openly critical of their biomedical training and their perceived role in general practice as "technocrats" rather than "healers". As a result, GPs are seeking new avenues of specialisation and professional development. To reiterate, GPs who offer CAM are, like their patients, not only pragmatic but also ideological in their incorporation of CAM. Many of these GPs acknowledge the limitations of biomedical and synthetic pharmaceutical treatments. The lack of scientific evidence for CAM does not appear to have constrained these developments. In fact, my research revealed that GPs often legitimise their use of CAM -- in addition to citing clinical legitimacy -- by citing the history and tradition underlying these treatments.9 This return to tradition, history, and roots is a prominent aspect of postmodernisation.12,18 It is of considerable interest that the Australian Therapeutic Goods Administration has specified two major categories of evidence for complementary therapies: (1) scientific evidence, and (2) evidence based on traditional use of a substance or product.21 Despite the obvious weakness of much "postmodernist" literature on CAM, to dismiss postmodern theory outright is limiting and misleading. The following may serve to illustrate the effect of globalisation and postmodernisation upon Western health systems. Remarkably, these comments come from a GP who attended the Alternative Medicines Summit (organised by the Commonwealth Department of Health and Family Services) held in Canberra on 16 October 1996. This summit, the first of its kind, was attended by medical as well as alternative practitioners. In reporting events, the representative for the medical practitioners wrote: I felt the tone of the day's proceedings was one of "us versus them". Inasmuch as "natural and complementary practitioners" were seen as a distinct alternative to orthodox practitioners, particularly in cases of serious illnesses. Indeed, one speaker during the day indicated that as it was an Alternative Medicines Summit, orthodox doctors present should really be in only an observer capacity. There was no integration going on, rather the attitude was one of them seeking status as practitioners of the "new medicine", and control of their therapies.22 Note the dramatic contrast to the relationship between orthodox and alternative medical practice in modernity. Orthodox doctors are now concerned about being excluded from the "new medicine" practised by alternative practitioners rather than vice versa. The same doctor went on to conclude: There is a paradigm shift, occurring in health from within, that reflects a societal evolution, unstoppable by anyone. How to integrate all these practitioners, or even if it is desirable to, is a question that still perplexes me. There seems to be no one universal model, thus it becomes an exercise in lobbying for market share, and seeking, for example, inclusion in Medicare.22 With all due respect to common sense, simple pragmatism and clinical legitimacy, this type of sea change requires globally informed, forward-looking sophistication in the area of policy. For example, Duckett has noted that Australian health financing arrangements have not kept pace with a population that is embracing natural therapies. He opines that, as a society, "we may be over-investing in services for which there is a Medicare rebate and under-investing in other more effective or cost-effective services".23 Within the climate of evidence-based medicine, this observation invites the controversial question Based on evidence, who achieves the more cure-effective and cost-effective results: GPs who use exclusively orthodox treatments, GPs who incorporate CAM, or traditionally trained practitioners who use only CAM?. As things stand, any answer invites the truly urgent question Who regulates what, and how?. References Pirotta MV, Cohen MM, Kotsirilos V, Farish SJ. Complementary therapies: have they become accepted in general practice? Med J Aust 2000; 172: 105-109. Lewith G. Complementary and alternative medicine: an educational, attitudinal and research challenge [editorial]. Med J Aust 2000; 172: 102-103. Bensoussan A. Complementary medicine -- where lies its appeal? Med J Aust 1999; 170: 247-248. Services Division RACGP. Directory of RACGP Members and their Special Interests. Surry Hills: New Litho Pty Ltd. 1996. Easthope G, Beilby J, Gill G, Tranter B. Acupuncture in Australian general practice: practitioner characteristics. Med J Aust 1999; 169: 197-200. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Eisenburg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998; 280: 1569-1575. Complementary medicine is booming worldwide [news]. BMJ 1996; 313: 131-133. Eastwood H. Why are Australian general practitioners using alternative medicine? Postmodernisation, consumerism, and the shift towards holistic health. J Sociol 2000; in press. Featherstone M. Consumer Culture and Postmodernism. London: Sage, 1991. Commonwealth Department of Health and Aged Care. Reforming the Australian Health Care System. The Role of Government. Occasional papers: New Series No. 1. Canberra: Publications Production Unit, 1999. Robertson R. Globalization: Social Theory and Culture. New York: Sage Publications, 1992. Eastwood H. General Medical Practice, Alternative Medicine and the Globalisation of Health [unpublished doctoral thesis]. Brisbane: University of Queensland, 1997. Willis E. Complementary healers. In: Illness and Social Relations. Sydney: Allen and Unwin, 1994; 54-74. Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994; 309: 107-311. Pietroni P. Beyond the boundaries: relationship between general practice and complementary medicine. BMJ 1992; 305: 564-565. Goldszmidt M, Levitt C, Duarte-Franco F, Kacorowski J. Complementary health care services: a survey of general practitioners' views. CMAJ 1995; 153: 29-35. Crook S, Pakulski J, Waters M. Postmodernisation: Changes in Advanced Society. London: Sage Publications, 1992. Chan JJ, Chan JE. Medicine for the millennium: the challenge of postmodernism. Med J Aust 2000; 172: 332-334. Waters M. Globalization. New York: Routledge, 1996. Complementary Medicines Evaluation Committee's guide to levels and kinds of evidence to support claims. Canberra; Commonwealth Department of Health and Aged Care, 2000. Available at <http://www.health.gov.au/tga/docs/pdf/ tgaccevi.pdf>. Integrative Medicine Association. IMA Newsletter, Issue 6, December. 1996. Duckett S. Policy challenges for the Australian Health Care system. Aust Health Review 1999; 22: 130-147. Authors' details Department of Social and Preventive Medicine, University of Queensland, Brisbane, QLD. Heather L Eastwood, PhD, BA(Hons), Lecturer. Reprints will not be available from the author. Correspondence: Dr H L Eastwood, Department of Social and Preventive Medicine, Herston Medical School, University of Queensland, QLD 4072. h.eastwoodATspmed.uq.edu.au Make a comment Summary of the study of why general practitioners (GPs) use complementary and alternative medicine (CAM)9,13 Participants: GPs (n=27); alternative practitioners without a medical degree (n=17); GPs and alternative practitioners who represent key educational and political organisations (n=16). All practitioners were located in Brisbane, QLD. Methods: Qualitative, telephone and face-to-face in-depth interviews, observation, and primary document analysis. Findings: Increased resort by GPs to CAM is not entirely pragmatic. It is partly due to factors beyond consumer demand, clinical effectiveness and financial reward. GPs attribute consumer demand for CAM to increased consumer wariness of synthetic drugs and invasive surgery, greater consumer choice, and a more educated public. GPs' own reasons for their provision of CAM include competition in the healthcare market; personal dissatisfaction with general practice; personal satisfaction gained through the clinical effectiveness of CAM; resistance to becoming "technocrats" rather than "healers"; recognition of the limitations of orthodox biomedical treatments; and concern, genuinely shared with patients, about over-reliance on synthetic drugs and invasive surgery. Back to text Glossary Clinical legitimacy: Validation conferred by the clinical effectiveness of a given treatment with or without scientific evidence as to why or how it works. Globalisation: The "shrinking planet" phenomenon, caused by dramatic advances in transportation and communications and by increasing ecological and economic interdependence, encouraging the concept that the whole world is but a single, albeit very large and complex, community. Globalisation processes: The many and varied inputs to social change in Western societies (ie, postmodernisation), which include (1) a "return to nature" arising from ecological concerns; (2) a return to tradition, history and "roots"; and (3) greater awareness and appreciation of other cultures. Postmodernisation: A sociological term denoting the broad social change occurring in Western societies. The term refers to those processes that are changing modern Western society and its values, organisation, and institutions (modernity) to a new social reality (postmodernity). Postmodernism: A confusing term, referring to the ideological movement that attacks the philosophical foundations of modernity and the modernist worldview based on the assumption that science, technology and reason will create the optimal society. Postmodernism can also refer to the creation, via contemporary social change (ie, postmodernisation), of a new mainstream culture and concomitant "postmodern" values, such as consumer choice (eg, shopping around for health services), independence from scientific and technological products (eg, rejection of, or concern about, genetically modified foods and synthetic drugs), and increased public access to information (eg, the Internet). Back to text

Heather L Eastwood

Clinical Practice An approach to managing depression in general practice Ian B Hickie MJA 2000; 173: 106-110 Long term management of patients with depression: an essential skill for all general practitioners Abstract - Early detection - Diagnostic pragmatism - Risk assessment - Engaging and empowering - Choosing an antidepressant - Beyond drug therapy - Conclusion - Authors' details - - More articles on Allied health Abstract Detection of depression in primary care can be enhanced by use of self-report assessment forms. With the new classes of antidepressants, there is the opportunity to choose specific drug classes for different types of depressive disorders. Depression is frequently a relapsing illness. Treatment goals should include long term reduction of vulnerability factors. An active therapeutic partnership can be facilitated by providing accurate detailed information early in the course of the illness. Behavioural therapies, which focus on modification of the sleep-wake cycle, activity planning and reduction of substance abuse, are essential. Structured problem solving is the most accessible form of cognitive intervention that general practitioners can readily provide. More complex cognitive therapies are usually provided by mental health professionals or general practitioners with extensive training. Although major depression is common in primary care, general practitioners (GPs) may still find it difficult to detect and treat depression unless they have a high index of suspicion and additional mental health training.1-3 A range of patient, doctor and practice organisation factors contribute to this difficulty.1-4 Patient factors include comorbid medical disorders, presentation of somatic rather than psychological symptoms, poor understanding of mental health and fear of stigma. Examples of practitioner factors are inadequate training and reluctance to provide psychological treatments, whereas practice organisation factors include too little time, too little remuneration, too little mental health specialist support, lack of use of screening tools, and lack of access to independent educational materials. However, improvement in the quality of mental health care provided by GPs is now firmly on the national agenda.4High quality mental health care consists not only of informed prescribing, but also of early detection, provision of sound information, use of effective non-pharmacological techniques and reduction in factors which will lead to long term vulnerability to recurrent depression. A range of initiatives are under way nationally to improve mental health practice in primary care. In this article, elements derived from SPHERE: A National Depression Project are described to highlight one coordinated approach to the educational, training and practice support infrastructure needed to make such initiatives sustainable.5 Early detection in primary care GPs are ideally placed to detect depression early in its course. While patients frequently present with other urgent medical problems or unexplained physical symptoms,2,6 primary care contacts are ideal for mental health screening. Although much mental health training focuses on improving interview and assessment skills, simple screening instruments are time-efficient and engage patients actively in the therapeutic process. As with other screening procedures, such tests are not diagnostic. Instead, they highlight those patients who require specific assessment by the practitioner. Patients usually welcome the opportunity to reveal their difficulties in this way. Good examples of such instruments include the 12-item General Health Questionnaire (GHQ),7 the Prime-MD,8 and the 34-item Somatic and Psychological HEalth REport (SPHERE).5 SPHERE can be used to produce an output that compares the severity of the patient's physical and mental symptoms with a national practice sample. Currently, the SPHERE Project promotes a simple screening device (Box 1), which emphasises that depression is a syndrome with major effects on thoughts, feelings, behaviours and bodily function. Diagnostic pragmatism Formal psychiatric classification systems have become extremely complex and lack validity in primary care.3 However, for GPs to make use of the available evidence on treatment efficacy, certain grades of depression need to be recognised. British and European psychiatry has emphasised the importance of identifying "endogenous" or "melancholic" disorders, as they respond preferentially to antidepressant drugs. The depressed phase of bipolar disorder (manic depressive illness) also fits this category. Recent Australian research has re-emphasised this concept,9 highlighting the need to recognise observed (not patient-reported) psychomotor slowing, or agitation, as hallmarks of the disorder. Melancholia is relatively rare in primary care (as distinct from specialist and hospital-based practice). In primary care, non-melancholic depressive disorders (either primary, concurrent with anxiety or secondary to medical illness) are common and disabling.1,2,10,11 Key risk factors include premorbid anxiety, family history of anxiety, depression and substance abuse, medical ill-health, dysfunctional intimate relationships, and social adversity. Increasing sophistication of genetic,12 biochemical and psychosocial research has led to a new conceptualisation of these disorders, with greater emphasis on the interaction between long term (genetic and past experiential) vulnerabilities and current life stressors. That is, depression rarely occurs "out of the blue", and patients who have had major episodes are at high risk of relapse.13 Further, in this model, patients with non-melancholic disorders have their own individual biology (genetically determined arousability or nervousness) that may be treated pharmacologically or non-pharmacologically. Diagnostically, it is important to recognise not only the overt depressive disorder but also whether it is accompanied by a specific anxiety disorder (eg, panic attacks or agoraphobia) that requires additional attention. The recognition of premorbid anxiety, substance abuse and/or significant personality dysfunction completes this diagnostic phase. Risk assessment One of the most important tasks in primary care is the assessment of risk of various forms of self-harm. Prevention of suicide should not be seen as the primary goal; nevertheless, research has highlighted the high risks of self-harm in both younger and older men, with the latter frequently contacting family doctors before making serious suicide attempts.14 Other risk factors, such as social isolation, substance abuse and access to lethal means, need to be noted and appropriate risk-reduction strategies implemented (eg, involvement of family, frequent appointments, emergency contact procedures, reduction of alcohol, removal of lethal means). GPs can underrate the degree of both short- and longer-term risk,15 and may need to engage others (eg, family, other primary care practitioners, or mental health specialists) more actively in collaborative long term risk reduction. A necessary emphasis is the assessment of a range of risk-taking strategies (eg, deliberately driving fast or recklessly) and forms of self-harm other than overt suicide attempts (eg, prolonged substance abuse, neglect of other medical problems). Engaging and empowering the patient The community has little specific knowledge about depression, and patients hold generally negative views about antidepressant drug therapy.16 The key to overcoming these negative stereotypes is the provision of independent and sophisticated information. Most patients wish to make active choices about treatment and, increasingly, to receive alternative opinions, but few practitioners have the materials they need to facilitate such discussions. Furthermore, some are reluctant to provide detailed information that may apparently contradict their therapeutic choices. Provision of accurate information early in the course of illness facilitates active engagement and helps create the framework for long term treatment adherence.17 While these concepts are now routine for disorders such as diabetes and asthma, they are yet to become routine even among mental health specialists who treat severe and/or relapsing depression. Choosing an antidepressant The new classes of antidepressants differ substantially in their benefits and side-effects. Rather than prescribing the same antidepressant (or the same class) to every patient with depression, there is the chance to choose specific classes for different types of depressive disorders. Pharmacological therapy should be accompanied by appropriate means for recording benefits and side-effects and placing drug therapy within an overall treatment framework. One also needs a "road-map" for initiating rational prescribing (Box 2). Currently, there is a general paucity of comparative evidence to influence choices of antidepressant compounds (both within and across classes). Internationally, this has meant a reliance on panels of experts rather than systematic reviews of published studies. In the course of designing the SPHERE Project, we relied strongly on the clinical opinion of experts and a survey of practitioners.18,19 Subsequent studies20,21 and professional group recommendations22 are largely consistent with these views. Consequently, we still recommend some specific starting points for antidepressant therapy. These include: Selective serotonin reuptake inhibitors (SSRIs) are particularly helpful for those with moderately depressed mood, premorbid anxiety and/or panic disorder, agoraphobia and/or obsessive-compulsive disorder.23,24 They are also "first-line" agents for depression in the context of other medical illnesses, adolescents, and older patients.19,22 Generally, these drugs are very similar and good reasons for choosing one over another are limited. When selecting an SSRI, factors to consider are drug interactions (cytochrome P-450 enzyme systems), severity of withdrawal syndromes, and tendency to cause initial agitation. Patients with principal complaints of fatigue and/or sleep disturbance, without severe mood disturbance, may require different strategies. Fatigue without obvious mood disturbance responds poorly to SSRIs,25 and SSRIs may be associated with worsening sleep patterns in the first few weeks of therapy.26 Some of these patients may benefit from the use of other antidepressant classes. Preliminary evidence suggests the usefulness of moclobemide in patients with fatigue,27 and nefazodone in patients with fatigue and sleep disturbance.28 Patients who do not respond to a course of SSRIs may instead respond to serotonin and noradrenaline reuptake inhibitors (SNRIs).20 Whether to use SNRIs as first-line agents in primary care is debatable, but psychiatrists do not generally recommend them in this setting19 because of their side-effects and more complex dosing schedule. They are strongly favoured for use in specialist practice where patients have generally failed one or more courses of the first-line agents or have more severe illnesses. Patients with melancholia, psychotic depression, treatment-resistant depression and/or other very severe mood disorders may do less well with SSRIs and may benefit from commencing therapy with SNRIs20 or tricyclic antidepressants (TCAs).29 Some particular patient groups (eg, those with chronic pain) still respond preferentially to TCAs.19 Beyond drug therapy A great deal of educational effort has been invested (largely by the pharmaceutical industry) in increasing doctor recognition of major depression and provision of safer pharmacological therapy. Unfortunate consequences of this drive may be the perception that these agents are more efficacious than the older agents or that non-pharmacological strategies are no longer relevant.30 Although initial drug therapy can assist patients to get "out of the hole", ongoing maintenance therapy (Box 3) is also critical. Maintenance therapy needs to be thought of in terms of How long should this patient stay on the drug? and What other non-pharmacological strategies are necessary for this patient?. One of the clear (and somewhat unexpected) benefits of the SSRIs is their capacity to reduce ongoing "trait" anxiety in those who have been life-long worriers.23 That is, they appear to modify a personality style that is otherwise at high risk of recurrence of depression. In general, patients should continue effective drug therapy for at least 6 to 12 months after they recover from a major depressive episode. If patients have had several previous depressive episodes, and have responded to drug therapy, then they should consider longer periods (2 to 5 years) of prophylactic antidepressant therapy.22 The effective non-pharmacological therapies are generally lumped together as "cognitive-behavioural" approaches. This describes a range of potential interventions that commence with essential behavioural elements (eg, education, treatment adherence monitoring, sleep-wake cycle and activity planning, modification of substance use; see Box 4)31 and then move to more cognitive approaches (eg, structured problem solving, formal cognitive therapy). While debate continues as to the extent of benefit from these approaches,32 it is generally accepted that they form the basis of most non-pharmacological interventions.22,33 There is an ongoing issue of practitioner competency, as such treatments are not necessarily effective if provided by clinicians with limited training.34 For all patients, keeping a daily diary is an essential part of the behavioural approach. A very good analogy for patients with depression is that of diabetes. Whatever drug therapy may be required, major lifestyle modifications are also needed. The more effective the non-drug therapy, then the greater the chance that the patients will be able to withdraw drug therapy. Many doctors provide lifestyle advice, but fail to encapsulate it within other critical features of the behavioural approach, such as explaining the rationale, self-monitoring, reviewing the effects of modified behaviour, and identifying obstacles to implementation. Behavioural management of anxiety (eg, general stress, panic attacks, avoidant behaviour, social anxiety) needs to be considered in those with high premorbid anxiety or ongoing anxiety phenomena. This may include general stress management (including physical exercise), slow-breathing techniques, progressive muscle relaxation, and staged confrontation of feared situations (exposure therapy). In general, patients with significant anxiety disorders do best when they receive cognitive as well as behavioural approaches. Structured problem solving Many untrained professionals confuse effective psychological interventions (eg, structured problem solving, interpersonal therapy, cognitive therapy) with non-specific support and advice. Although the latter may help reduce the risk of self-harm, they do little to resolve major depression. The most accessible form of psychological intervention for primary care practitioners is structured problem solving.35 This creates a framework for the patient to re-engage with practical approaches to perceived problems and learn new cognitive skills (Box 5). The key factor is not whether the patient's preferred solution is ultimately successful (which tends to be the doctor's main preoccupation), but whether the patient learns a more general approach to coping with ongoing life stressors. By focusing initially on a style of behavioural analysis that describes specific rather than general problems, and then ranks them in terms of likely difficulty, the patient is forced to move from a position of general hopelessness (eg, "There's nothing I can do", "Everything fails in the end") to more specific problems (eg, "I don't have a job"). Identifying specific problems allows the generation of option lists (eg, "Ask family", "Register with Centrelink", "Change industries"). Once a reasonable option list has been generated, the patient then evaluates the potential interventions. That is, the patient is being forced to engage in the style of rational thinking that people without depression take for granted. By contrast, patients with depression tend to think in global terms, generate few solutions, fail to evaluate their actions, and avoid implementation of realistic options. This approach is well suited to general practice as it can be learnt quickly, requires little ongoing supervision, and can be broken down into manageable time frames (eg, three to six sessions of 15 to 30 minutes each). As with other cognitive approaches, it engages the patient as an active partner and formally prohibits practitioners from simply offering their own behavioural analyses and/or preferred solutions. It may also prove to be a useful means for recruiting additional input from other key people (eg, spouse or parent), as they may be encouraged to generate additional options or assist with implementation. As many depressed patients find themselves in dysfunctional intimate relationships,36 this change of focus may also assist to re-engage those who have found interactions with the depressed person non-rewarding or aversive. Cognitive and interpersonal therapies These more formal psychological therapies are suited to patients with repeated episodes of depression, chronic depression, or clear evidence of repeating patterns of self-defeating thoughts, avoidant behaviours, or dysfunctional intimate relationships.33,37 These treatments can be difficult to provide in primary care, as they require considerable therapist training, ongoing supervision and monitoring of clinical skills, and modification of the practice environment (typically 12 to 16 sessions of 45 minutes' duration). However, GPs have indicated a willingness to learn key aspects of these skills and implement them in their practice.38 Widespread provision of these treatments will require more radical training and financing. These may be in the form of more "shared" and better-structured care with secondary mental health specialists systems,39 or through the development of a large group of GPs with these specialised skills. Conclusion Most GPs can now provide reasonable antidepressant therapy for patients they identify as having depression. Improved quality of practice depends on greater identification (particularly in those with concurrent medical illness), better quality of initial psychoeducation and behavioural management, and initiation of psychological strategies designed to improve treatment adherence and reduce long term vulnerability. Acknowledgements: The assistance of Tracey Davenport and Joanne Gander with the preparation of this manuscript was greatly appreciated. Disclosure statement: SPHERE: A National Depression Project was supported in 1998 and 1999 by Bristol-Myers Squibb Pharmaceuticals, manufacturers of Serzone (nefazodone). Evaluation of the SPHERE Project is currently supported by the New South Wales Health and Mental Health Branch of the Commonwealth Department of Health and Aged Care. Australian Divisions of General Practice provide financial support for SPHERE training programs in local districts. A trial of Aurorix (moclobemide) in patients with chronic fatigue was supported by Roche Pharmaceuticals. Pfizer, manufacturers of Zoloft (sertraline), plan to support a SPHERE education module (Depression in the Medically Ill) in 2000. Representatives of the SPHERE Project have provided educational sessions for employees of Wyeth Pharmaceuticals, manufacturers of Efexor (venlafaxine). References Thompson C, Kinmonth AL, Stevens L, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000; 355: 185-191. Simon GE, Von Korff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999; 341: 1329-1335. Hickie I. Primary care psychiatry is not specialist psychiatry in general practice. Med J Aust 1999; 170: 171-173. Primary care psychiatry -- the last frontier. A report of the Joint Consultative Committee. Canberra: Royal Australian College of General Practitioners and Royal Australian and New Zealand College of Psychiatrists, 1997. Hickie I, Hadzi-Pavlovic D, Scott E, et al. SPHERE: A National Depression Project. Australas Psychiatry 1998; 6: 248-250. Simon G, Ormel J, Von Korff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995; 152: 352-357. Goldberg D, Williams P. A user's guide to the General Health Questionnaire. Windsor, Berkshire: NFER-NELSON Publishing Company, 1988. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994; 272: 1749-1756. Parker G, Hadzi-Pavlovic D, editors. Melancholia: a disorder of movement and mood. New York: Cambridge University Press, 1996. Ustun TB, Sartorius N, editors. Mental illness in general health care: an international study. Chichester: John Wiley and Sons, 1995. Katon W, Von Korff M, Lin E, et al. Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry 1997; 19: 169-178. Kendler KS, Neale MC, Kessler RC, et al. Major depression and generalised anxiety disorder: same genes, (partly) different environments? Arch Gen Psychiatry 1992; 49: 716-722. Frank E, Kupfer DJ, Perel JM, et al. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47: 1093-1099. Stoppe G, Sandholzer H, Huppertz C, et al. Family physicians and the risk of suicide in the depressed elderly. J Affect Disord 1999; 54: 193-198. Milton J, Ferguson B, Mills T. Risk assessment and suicide prevention in primary care. Crisis 1999; 20: 171-177. Jorm AF, Korten AE, Jacomb PA, et al. "Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166: 182-186. Kemp R, Kirov G, Everitt B, et al. Randomised controlled trial of compliance therapy: 18-month follow-up. Br J Psychiatry 1998; 172: 413-419. Hickie IB, Scott ES, Davenport TA. Enhancing the evidence base for clinical psychiatry: are practice surveys a useful tool? Med J Aust 1999; 171: 315-318. Hickie IB, Scott ES, Davenport TA. Are antidepressants all the same? Surveying the opinions of Australian psychiatrists. Aust N Z J Psychiatry 1999; 33: 642-649. Poirier M-F, Boyer P. Venlafaxine and paroxetine in treatment-resistant depression: double-blind, randomised comparison. Br J Psychiatry 1999; 175: 12-16. Boyd IW. Venlafaxine withdrawal reactions. Med J Aust 1998; 169: 91-92. American Psychiatric Association. Practice guideline for the treatment of patients with major depression. 2nd ed. Washington, DC: APA, 2000. Boerner RJ, Moller HJ. The importance of new antidepressants in the treatment of anxiety/depressive disorders. Pharmacopsychiatry 1999; 32: 119-126. Bakker A, van Dyck R, Spinhoven P, van Balkom AJ. Paroxetine, clomipramine, and cognitive therapy in the treatment of panic disorder. J Clin Psychiatry 1999; 60: 831-838. Vercoulen JHHM, Swanink CMA, Zitman FG, et al. Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome. Lancet 1996; 347: 858-861. Sharpley AL, Williamson DJ, Attenburrow MEJ, et al. The effect of paroxetine and nefazodone on sleep: a placebo controlled trial. Psychopharmacology 1996; 126: 50-54. Hickie I, Wilson A, Bennett B, et al. A double-blind placebo control trial of moclobemide in patients with chronic fatigue syndrome. J Clin Psychiatry 2000; in press. Hickie I. Nefazodone for patients with chronic fatigue syndrome. Aust N Z J Psychiatry 1999; 33: 278-280. Boyce P, Judd F. The place for the tricyclic antidepressants in the treatment of depression. Aust N Z J Psychiatry 1999; 33: 323-327. Boyce P, Hickie I. A brave new world in managing depression -- or is it? Aust Fam Physician 1994; 23: 627-632. Hickie I, Davenport T. A behavioral approach based on reconstructing the sleep-wake cycle. Cognitive Behav Pract 2000; in press. King R. Evidence-based practice: where is the evidence? The case of cognitive behaviour therapy and depression. Aust Psychol 1998; 33: 83-88. Scott J. Treatment of chronic depression. N Engl J Med 2000; 342: 1518-1520. Roth A, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: Guilford Press, 1996. D'Zurilla TJ. Problem-solving therapy: a social competence approach to clinical intervention. 2nd ed. New York: Springer Publishing Company, 1999. Hickie I, Parker G, Wilhelm K, Tennant C. Perceived interpersonal risk factors of non-endogenous depression. Psychol Med 1991; 21: 399-412. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000; 342: 1462-1470. Morgan H, Sumich H, Hickie I, et al. A cognitive-behavioural therapy training program for general practitioners to manage depression. Australas Psychiatry 1999; 7: 141-145. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996; 53: 924-932. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Ian B Hickie, MD, FRANZCP, Professor of Community Psychiatry. Reprints: Professor I B Hickie, Academic Department of Psychiatry, 7 Chapel Street, Kogarah, NSW 2217. i.hickieATunsw.edu.au Make a comment 1: SPHERE checklist for depressive disorders. (From Hickie I, Scott E, Morgan H, et al. A brief guide to depression management. Melbourne: Educational Health Solutions, 2000. Used with permission.) Back to text 2: A "road map" for initiating antidepressant therapy. The times between treatment changes are a guide only. Actual washout periods will depend on the dose and duration of treatment and the current severity of depression. *For fluoxetine allow 14 days' washout. SSRI = selective serotonin reuptake inhibitor. 5HT2 antagonist=serotonin 2 receptor antagonist. RIMMA = reversible inhibitor of monoamine oxidase. SNRI = serotonin and noradrenaline reputake inhibitor. TCA = tricyclic antidepressant. ECT = tricyclic antidepressant. ECT = electroconvulsive therapy. (From Hickie I, Scott E, Morgan H, et al. Treating depression and anxiety in general practice: a training manual. Sydney: Educational Health Solutions, 1998. Used with permission.) Back to text 3: The course of depressive disorders. (From Hickie I, Scott E, Morgan H, et al. A brief guide to depression management. Melbourne: Educational Health Solutions, 2000. Used with permission.)Back to text Click in box for larger imageBack to text 5: A practical guide to structured problem solving. (From Hickie I, Scott E, Morgan h, et al. A brief guide to depression management. Melbourne: Educational Health Solutions, 2000. Used with permission.)Back to text

Ian B Hickie