entire issue. - The Royal New Zealand College of General ...

OF PRIMARY HEALTH CARE 

‘It is possible that 

the knowledge of 

uncertainty might set 

patients free to choose, 

but it won’t set them 

free from fear.’ 

See Ethics page 71 

VOLUME 1 • NUMBER 1 • MaRch 2009 

Guest Editorial 

A primary care–led medical 

education system? 

See page 5 

Back to Back 

GPs should prescribe more 

benzodiazepines for the elderly 

See page 57 

Original Scientific Paper 

Depression in Maori 

See page 26 


Managing cardiovascular risk in mental 

health patients 

See page 11 


NZ Samoans’ understanding and use 

of antibiotics 

See page 30 

Improving Performance 

A patient-centred pathway for lifestyle 

and mental health problems 

See page 50

OF PRIMARY HEALTH CARE 

2 Editorials 

From the Editor 

2 Simple, fresh, tasty and local 

Felicity Goodyear-Smith 

Guest Editorials 

5 A primary care–led medical education system? 

Peter Crampton 

6 Using psychoactive medication to intervene in children’s 

behaviour: An evidence-based practice? 

Barry Parsonson 

11 Original scientific Papers 

Quantitative Research 

11 Cardiovascular risk assessment and management in mental 

health clients: Perceptions of mental health and general 

practitioners in New Zealand 

Amanda Wheeler, Jeff Harrison, Zara Homes 

20 Prevalence of acne and its impact on the quality of life in 

school-aged adolescents in Malaysia 

Arshad Hanisah, Khairani Omar, Shamsul Azhar Shah 

26 The prevalence of depression among Maori patients in 

Auckland general practice 

Bruce Arroll, Felicity Goodyear-Smith, Ngaire Kerse et al. 

Mixed Method Research 

30 Understanding and use of antibiotics amongst Samoan 

people in New Zealand 

Pauline Norris, Marianna Churchward, Fuafiva Fa’alau et al. 

Systematic Reviews 

36 Summary of an evidence-based guideline on soft tissue 

shoulder injuries and related disorders—Part 1: Assessment 

Gillian Robb, Bruce Arroll, Duncan Reid et al. 

42 Summary of an evidence-based guideline on soft tissue 

shoulder injuries and related disorders—Part 2: Management 

Gillian Robb, Bruce Arroll, Duncan Reid et al. 

50 Improving Performance 

A patient-centred referral pathway for mild to moderate 

lifestyle and mental health problems: Does this model work 

in practice? 

Jill Calveley, Angela Verhoeven, David Hopcroft 

57 Back to Back 

GPs should prescribe more benzodiazepines for the elderly 

Yes Bruce Arroll; No Ngaire Kerse 

61 Continuing Professional Development 

61 POEMS: Patient Oriented Evidence that Matters 

62 String of PEaRLS 

COnTEnTs 

VOLUME 1 • NUMBER 1 • MaRch 2009 

issn 1172-6164 (Print) 

issn 1172-6156 (Online) 

62 cochrane corner: Benzodiazepines may hasten improvement 

in major depression for up to six weeks 

Bruce Arroll 

63 Pounamu: Bridging two worlds in the interview process 

—the psychiatric assessment and Maori in primary care 

Pamela Ara Bennett 

65 charms & harms: St John’s wort (Hypericum perforatum) 

Joanne Barnes 

66 Resource Summary: Destination: Recovery 

Te Unga Ki Uta:Te Oranga; Future responses to mental 

distress and loss of well-being—discussion paper from the 

Mental Health Advocacy Coalition 

Helen Rodenburg 

67 Practical Pointers: Effective communication strategies to 

enhance patient self-care 

Fiona Moir, Renske van den Brink, Richard Fox et al. 

71 Ethics 

Uncertainty, fear and whistling happy tunes 

Katherine Wallis 

74 Essays 

74 Sub-threshold mental health syndromes: Finding an 

alternative to the medication of unhappiness 

Fiona Mathieson, Sunny Collings, Anthony Dowell 

77 Mind over matter—implications for general practice 

Andrew Corin 

80 Letters to the Editor 

82 Book Reviews 

82 The Baby Business: What’s happened to maternity care in New 

Zealand—Lynda Exton 

Reviewers: William Fergusson and Joan Carll 

83 The New Zealand Pregnancy Book: A guide to pregnancy, birth 

and a baby’s first three months 

3rd ed.—Sue Pullon and Cheryl Benn 

Reviewers: Jon Wilcox and Helen Ride 

84 Ideological Debates in Family Medicine 

—Stephen Buetow and Tim Kenealy 

Reviewer: Marjan Kljakovic 

85 Integrating mental health into primary care: 

A global perspective 

86 Gems of nZ Primary Health Care Research 

88 About the Journal of Primary Health Care 

VOLUME 1 • nUMBER 1 • MARCH 2009 J OURnAL OF PRiMARY HEALTH CARE 1

EDITORIALs 

FROM THE EDiTOR 

Felicity Goodyear- 

Smith MBChB MGP 

FRnZCGP, Editor 

CORREsPOnDEnCE TO: 

Felicity Goodyear-smith 

Department of General 

Practice and Primary 

Health Care, Faculty 

of Medical and Health 

sciences, The University 

of Auckland, PB 92109, 

Auckland, new Zealand 

f.goodyear-smith@ 

auckland.ac.nz 

simple, fresh, tasty and local 

campbell Murdoch rightfully mourns the 

passing of the NZFP. Although he suspects 

foul play, hers was not an untimely 

death. 1 While we may grieve her loss, we can 

also welcome the Journal of Primary Health Care 

(JPHC), whose time has come. Like Campbell, I 

remember nostalgically when, as a GP, I was ‘a 

clinician, physician, [minor] surgeon, obstetrician 

and paediatrician’. My work day routinely 

included family planning, palliative care, ‘VD’ 

(now called sexual health), numerous cervical 

smears and dealing with patients with addictions. 

There were also opportunities when my resuscitation 

skills were required, and I was frequently up 

all night attending patients in their homes when 

I was on-call. Except possibly for a few rural colleagues, 

those days have passed. 

The content of general practice has fragmented, 

with roles played not only by other doctors, 

but also by colleagues from other disciplines, 

including nursing and pharmacy. The Primary 

Health Care Strategy was introduced in 2001. 2 

Its mission was to shift from traditional general 

practice to ‘a new direction for primary health 

care with a greater emphasis on population health 

and the role of the community, health promotion 

and preventive care, the need to involve a range 

of professionals’. This is the model under which 

now we work. What still requires greater clarity 

is the role of these different professionals, how 

they work together and how care is integrated. 

Campbell is right—we still need our own doctor. 

GPs are pivotal to health care. We know our patients 

and their families. The relationship is the 

key. We need communication and integration— 

to be informed if our patients are on the pill, 

pregnant, taking complementary and alternative 

medicines, receiving methadone maintenance 

therapy, in the hospice for respite care. 

The final issue of NZFP included editorials from 

its distinguished line-up of previous editors 

with advice and support to me as the incoming 

editor of the new journal. Rae West can be 

reassured that the JPHC remains the academic 

publication of the RNZCGP, ‘by and for doctors’, 

3 although with considerable contribution 

from colleagues from numerous other disciplines, 

and of significant relevance and interest 

to their practices. 

JPHC aims both to move research into practice 

and practice into research. Latest evidence is 

provided in a distilled form for rapid and easy 

assimilation by busy practitioners. These will 

be pithy and succinct, hopefully avoiding one 

of the challenges articulated by Ian St George, 

of ‘information smothering’. 4 As well as the 

POEMs (‘Patient Oriented Evidence that Matters’) 

lauded by Rae, 3 you will find the Cochrane 

Corner, a String of PEARLS (‘Practical Evidence 

About Real Life Situations’), Gems (short précis) 

of NZ Primary Health Care Research, Charms and 

Harms (evidence on the effectiveness and safety 

of herbal and other complementary remedies), 

Pounamu (precious Maori research, essays and 

items for practitioners) and brief synopses of 

guidelines and bulletins. 

This first issue focuses on mental health. Many 

of the contributions are by GPs. Bruce Arroll and 

Ngaire Kerse go Back to Back on giving benzodiazepines 

to the elderly. 5 Katherine Wallis, our 

guest ethicist, writes elegantly about the possible 

effects of the knowledge of uncertainty. 6 Fiona 

Moir, Richard Fox, Renske van den Brink and 

Susan Hawken discuss communication strategies 

to enhance patient self-care. 7 Helen Rodenberg 

presents a discussion paper on responses to mental 

distress and loss of well-being; Andrew Corin 

ponders on mind over matter. 8 

This issue also contains valuable contributions 

from a diverse range of other disciplines, including 

pharmacy, public health, physiotherapy, 

psychology, psychiatry, nursing and midwifery. 

2 VOLUME 1 • nUMBER 1 • MARCH 2009 J OURnAL OF PRiMARY HEALTH CARE

Our Pounamu (Maori primary health care 

treasure) this month is provided by psychiatrist 

Pamela Bennett, who discusses how to bridge 

the Maori and Pakeha worlds when assessing and 

managing Maori with psychiatric illness. 9 

Read the challenge issued by our editorial board 

member Peter Crampton, public health physician 

and Dean of the Wellington School of Medicine, 

on a primary care–led medical education system, 10 

and the thought-provoking article by another 

board member, psychologist Barry Parsonson, on 

whether giving psychoactive drugs to control children’s 

behaviour is evidence-based. 11 Psychologist 

Fiona Mathieson and psychiatrist Sunny Collings, 

joined by Tony Dowell (GP and editorial board 

member), consider ultra-brief interventions as 

alternatives to drugs in treating unhappiness. 12 

PHO initiative she championed to provide an 

intervention pathway for patients with mild and 

moderate mental health and lifestyle problems. 15 

Sadly, Jill died suddenly and unexpectedly in 

December. Her paper was under revision and we 

have published her final version as she left it. 

Amanda Wheeler et al. explore the challenge of 

assessing and managing cardiovascular risk in 

patients with mental health problems and the difficulties 

of the primary/secondary care interface. 16 

A study finds that facial acne has a significant 

emotional and social impact on Malaysian high 

school students, and is likely to be generalisable 

to our NZ adolescents. 17 

A study on Samoan perception of the purpose of 

antibiotics reveals just how important communi- 

The content of general practice has fragmented, with roles played 

not only by other doctors, but also by colleagues from other 

disciplines, including nursing and pharmacy… What still requires 

greater clarity is the role of these different professionals, how they 

work together and how care is integrated. 

Moving practice into research requires collaboration. 

Guest editor of the final NZFP, Susan 

Dovey, expressed concerns ‘about leaving research 

to university-based researchers’. 13 Just as today’s 

GPs do not practise in isolation, so too they 

cannot be expected to conduct research on their 

own. Preparing research proposals and ethics 

applications and following proscribed protocols 

for specific methodologies takes both time and 

expertise. JPHC will regularly publish studies 

conducted by GPs and other primary health care 

practitioners under the mentorship and support 

of their university colleagues. 

The original studies in this issue are diverse, but 

all address practical issues for practitioners on 

the ground. Bruce Arroll and colleagues present 

results from a large study on the prevalence of 

depression in Maori. 14 Jill Calveley describes the 

cation with our patients is, and that it cannot be 

assumed that patients share a Western scientific 

understanding of what antibiotics are or do. 18 

Finally, on a very practical level, the systematic 

reviews of shoulder injury assessment 19 and 

management 20 provide summary tips on diagnosis 

and treatment. 

Campbell Murdoch points out that NZ leads 

the world in general practice and primary health 

care publications per head of population, 1 which 

are now accessible to you in our Gems section. A 

surprising number of NZ books of interest and 

relevance to family medicine are also published, 

which are critiqued by local reviewers. 

JPHC provides a forum for discussion and debate. 

As well as Back to Back, essays, the guest Ethics 

column and editorials, we welcome letters to the 

EDITORIALs 



EDITORIALs 


editor. The electronic version of JPHC is available 

free; we aim to publish ‘in press’ papers online 

prior to release of the hard copy, and electronic 

discussion will come as soon as the IT capacity is 

available. 

The mission for JPHC reflects that of NZFP—publish 

original relevant research, provide educational 

updates, stimulate critical thinking and debate and 

reflect on changes in modern general practice. 21 

The mission for JPhc reflects that of 

NZFP—publish original relevant research, 

provide educational updates, stimulate 

critical thinking and debate and reflect on 

changes in modern general practice 

To follow through on Ian St George’s culinary 

metaphor, 4 JPHC offers a smörgåsbord of wholesome 

dishes. Continuing professional education is 

served as simple, fresh and local morsels. Essays 

and editorials offer more meaty fare—tasty but 

easily digestible. Original scientific papers have 

pride of place at every table, presented in a palatable 

fashion. Readers either may merely pick at the 

abstract and summary box, or devour the studies 

in their entirety. 

You may choose to graze from time to time or to 

sit down for the full meal. Either way, I wish you 

bon appétit. 

References 

1. Murdoch C. What’s in a name? nZ Fam Physician 

2008;35(6):12–15. 

2. Ministry of Health. The Primary Health Care strategy. Wellington; 

2001 Feb. 

3. West R. Regarding my editorship. nZ Fam Physician 

2008;35(6):7–8. 

4. st George i. A bright future for the journal. nZ Fam Physician 

2008;35(6):5–6. 

5. Arroll B, Kerse n. Back to Back: GPs should prescribe more 

benzodiazepines for the elderly. J Primary Health Care 

2009;1(1):57–60. 

6. Wallis K. Uncertainty, fear and whistling happy tunes. J 

Primary Health Care 2009;1(1):71–73. 

7. Moir F, van den Brink R, Fox R, Hawken s. Effective communication 

strategies to enhance patient self-care. J Primary Health 

Care 2009;1(1):67–70. 

8. Corin A. Mind over matter—implications for general practice. 

J Primary Health Care 2009;1(1):77–79. 

9. Bennett P. Bridging two worlds in the interview process—the 

psychiatric assessment and Maori in primary care. J Primary 

Health Care 2009;1(1):63–65. 

10. Crampton P. A primary care-led medical education system? J 


11. Parsonson B. Using psychoactive medication to intervene in 

children’s behaviour: An evidence-based practice? J Primary 

Health Care 2009;1(1):6–10. 

12. Mathieson F, Collings s, Dowell A. sub-threshold mental 

health syndromes: Finding an alternative to the medication of 

unhappiness. J Primary Health Care 2009;1(1):74–77. 

13. Dovey s. Transitions. nZ Fam Physician 2008;35(6). 

14. Arroll B, Goodyear-smith F, Kerse n, Hwang M, Crengle s, 

Gunn J, et al. The prevalence of depression among Maori 

patients in Auckland general practice. J Primary Health Care 

2009;1(1):26–29. 

15. Calveley J, Verhoeven A, Hopcroft D. A patient-centred referral 

pathway for mild to moderate lifestyle and mental health 

problems: does this model work in practice? J Primary Health 

Care 2009;1(1):50–56. 

16. Wheeler A, Harrison J, Homes Z. Cardiovascular risk assessment 

and management in mental health clients: perceptions 

of mental health and general practitioners in new Zealand. J 


17. Hanisah A, Khairani Os, A. Prevalence of acne and its impact 

on the quality of life in school-aged adolescents in Malaysia. J 


18. norris P, Churchward M, Fa’alau F, Va’ai C. Understanding and 

use of antibiotics amongst samoan people in new Zealand J 


19. Robb G, Arroll B, Reid D, Goodyear-smith F. summary of an 

evidence-based guideline on soft tissue shoulder injuries and 

related disorders—Part 1: Assessment. J Primary Health Care. 

2009;1(1):36–41. 

20. Robb G, Arroll B, Reid D, Goodyear-smith F. summary of an 

evidence-based guideline on soft tissue shoulder injuries and 

related disorders—Part 2: Management. J Primary Health 

Care 2009;1(1):42–49. 

21. Townsend T. Editing the nZFP. nZ Fam Physician. 

2008;35(6):16–18. 


A primary care–led medical 

education system? 

The primary health care sector is an underutilised 

resource for medical education. 

The combined forces of ageing demographics, 

advances in community-based medical 

treatments for chronic diseases, a commitment 

to reducing health inequalities, and cost pressures 

increasingly conspire to push health care 

into primary care settings. Medical education 

must mirror this trend—if for no other reason 

than the practical imperative that medical 

education needs to occur where the bulk of 

treatment occurs. The numbers are compelling: 

four out of five children and adults visit their 

GP at least once in a 12-month period, and with 

a mean number of visits being 3.2 this accounts 

for millions of individual contacts. 1 About one 

quarter of children and adults use a public 

hospital service in a 12-month period (counting 

emergency department use, outpatient, day case 

and inpatient episodes). 1 Our medical graduates 

must be prepared to meet the treatment patterns 

reflected in these numbers. 

The shift of medical education into community 

settings is happening in many countries, and is 

readily evident in New Zealand with the setting 

up of rural programmes at both our medical 

schools, the increasing use of general practice in 

undergraduate medical education, and government 

funding support for increased numbers of 

vocational training places for general practice. 

But the barriers to increasing primary care–based 

medical education are numerous. Not least is the 

lack of a long-established tradition of widespread, 

routine, undergraduate medical education in 

primary care, resulting in weak or absent basic 

physical infrastructure for teaching, the absence 

of a well-established pattern of GP registrars 

teaching undergraduate medical students as occurs 

in hospitals, and poor career structure for primary 

care–based teachers. Added to this is the relatively 

low level of government support for specialist GP 

vocational training compared with other specialist 

training programmes, notwithstanding the strong 

policy emphasis this decade on New Zealand’s 

‘primary care–led health system’. Then there is 

the sticky problem of ownership; we need to find 

mechanisms for government to invest in basic infrastructure 

for primary care–based education in 

a way that secures and protects public investment 

and simultaneously meets the needs of trainers. 

A head of steam is rapidly building to see these 

problems addressed, fuelled by recognition not 

only of the above issues, but also that the current 

training system is not especially orientated towards 

equipping graduates for a career in primary 

care. This point is well made in a recent report of 

the Workforce Taskforce: 2 

The traditional model of training doctors and 

nurses focuses on preparing them to work in hospital 

environments. This model does not meet the 

demands of an aging population, the rise in chronic 

disease and co-morbidities, and the emphasis on 

treatment in the community. 

Primary health care requires a workforce with skills 

and competencies to implement primary and population 

health services in the community. Practitioners 

need to be flexible, contextually responsive, innovative 

and engaged in a process of life-long learning. 

A new and exciting development is the recent 

establishment of a project by the Universities 

of Auckland and Otago and the RNZCGP. 

They have jointly funded the establishment of 

a National General Practice Clinical Placement 

Coordination position. The first-year objectives of 

this project are to: 

• coordinate student and registrar placements 

in general practice settings; 

EDITORIALs 

GUEsT EDiTORiAL 


MBChB, PhD, FAFPHM, 

MRnZCGP, Dean and 

Head of Campus, 

University of Otago 

Wellington 



school of Medicine 

and Health science, 

University of Otago, 

Wellington, PO Box 7343, 

Wellington, new Zealand 

peter.crampton@ 

otago.ac.nz 


EDITORIALs 


Barry S Parsonson 

MA(Hons), 

PGDipClinPsych, PhD, 

FnZPss, 

Registered Psychologist, 

special Education Group, 

Ministry of Education, 

new Zealand 


Barry Parsonson 

PO Box 829, napier, 

new Zealand 

drp@appliedpsych.co.nz 

• establish a common database of 

teaching practices; 

• develop and implement a joint communications 

plan to promote GP teaching; 

• initiate liaison with DHBs to link with 

second-year house surgeon placements; and 

• provide project management support 

for combined University and 

College policy development. 

This project is a coordinated attempt to plan and 

build basic infrastructure for primary care-based 

medical education in the hope of meeting the 

medical needs of New Zealand’s population in 20 

and 30 years’ time. It will require the support of 

the Ministry of Health and the Tertiary Education 

Commission to promote and fund some of 

the vital elements such as quality standards for 

teaching practices and student consulting rooms. 

I am hopeful that the Journal will keep abreast of 

medical education issues and play an important 

role in disseminating research papers related to 

primary care–based teaching and learning. While 

this editorial has focused on medical education, 

needless to say similar attention must be paid 

to the future of primary care–based nursing 

education. In the meantime, the challenge for the 

sector is to translate the vision of a primary care– 

led health system into a primary care–led medical 

education system. There is much work to be done. 

Using psychoactive medication to 

intervene in children’s behaviour: 

An evidence-based practice? 

Introduction 

This paper arose out of concern that many child 

clients with behaviour issues also are clients of 

paediatric and child and adolescent health services 

which prescribe medication as a means of behaviour 

management. In addition, concerns arose over 

the increasing moves to ‘pathologise’ children’s 

behaviour. For example, in an editorial preceding 

a series of research articles on ‘preschool 

pathology’, Angold and Egger 1 state ‘We can now 

confidently assert that we have the wherewithal 

to assess the psychiatric status of children down 

to age two [years]’. While admitting perfection 

was not yet attained, they added that, as a 

consequence, there was no reason to exclude such 

young children from studies of specific psychiatric 

disorders. They describe studies of parental, 

teacher and self assessments of preschoolers 

which predict subsequent behavioural and emotional 

disorders at school age without questioning 

References 

1. Ministry of Health. A Portrait of Health, Key Results of the 

2006/07 new Zealand Health survey. Wellington: Ministry of 

Health; 2008. 

2. Workforce Taskforce. Working Together for Better Primary 

Health Care, Overcoming barriers to workforce change and innovation, 

Report to the Minister of Health from the Workforce 

Taskforce. Wellington Workforce Taskforce; 2008. 

the validity or reliability of such instruments. 

Even more troubling is their opinion that if these 

emergent disorders are not treated by age two to 

three years, it may be too late to produce effective 

change via primary prevention interventions. 

Sterba, Egger, and Angold 2 claim that the rates of 

DSM-IV disorders 3 in preschoolers are similar to 

those for children and adolescents and that DSM- 

IV diagnoses are relevant for children in the 

two- to five-year-old range, even though the DSM 

manual itself does not make such provision. 

Angold and Egger do not comment on what they 

consider to be ‘primary prevention’ for preschoolers, 

nor do they consider the possibility that 

predictions made in toddlerhood that then are 

confirmed in childhood may well be a result 

of constant environmental factors (e.g. parenting, 

parental depression or poverty), rather than 

products of a child’s ‘psychopathology’. 1 One 


further obvious consequence of the focus on 

early childhood psychopathology is the introduction 

of psychotropic medications as interventions. 

Recent publicity concerning the prescription of 

antidepressants to two-year-olds in New Zealand 

is one exemplar. The reported 40-fold increases in 

bipolar diagnosis and medication of children and 

adolescents in the USA between 1994 and 2003 

represents another. 4 Both reports raise concerns. 

Parents and teachers of children with problem 

behaviours appear to demand medication as a 

‘quick fix’. Parents and school personnel praising 

the effects of medication who were quoted in 

some reports were found to focus primarily on 

reductions in these behaviours. Only a few of the 

parents cited were troubled by associated weight 

gains and dyskinesia. Those promoting early diagnosis 

and medication are expressing no concerns 

about any long-term neuro-developmental risks or 

potential learning deficits resulting from medication 

during early childhood or administration on 

a long-term basis, which suggests that these are 

not yet important considerations in their view. 

This is not to say that concerns about the pathologisation 

of childhood are not being expressed 

from within psychiatry, as recent articles 5 and 

books 6 attest. The question remains as to whether 

these critics are being heard over the evident blare 

of publicity from protagonists of early identification 

and treatment, including the reported 

pressures from the pharmaceutical industry for 

psychiatrists, paediatricians and parents to identify 

and treat ‘disorders’ in early childhood with 

medications that rarely have been researched in 

terms of their impacts on children’s development. 

One problem for those working with children in 

the school environment is a lack of knowledge 

by teachers, Resource Teachers Learning and 

Behaviour (RTLB) and educational psychologists 

about medications prescribed for children. There 

is evidence that, despite 25% of children referred 

to them being medicated, many psychologists 

working in schools in the USA lacked adequate 

knowledge of psycho-pharmaceutical agents. 7 

Parents and teachers often report expectations 

that the medication will effect positive changes 

in behaviour, but often seem completely uninformed 

about the efficacy, suitability or potentially 

harmful side effects of the adult psycho- 

pharmaceutical agents typically prescribed for 

these children. There is also evidence of a lack 

of consultation between those providing psychosocial 

interventions within schools and those prescribing 

medication to the same children, despite 

widespread advice that pharmaceutical interventions 

should be accompanied by psychosocial 

ones. 8-10 In many instances any evidence-based rationale 

for prescribing some of these medications, 

especially to children and adolescents (e.g. 11, 12 ), 

is reliant on small sample studies, often comprising 

diverse groups and only a few of which use 

double-blind case controlled designs. In an age 

in which evidence-based practice and informed 

consent are deemed to be requirements of good 

practice, the data need to be examined. 

Attention Deficit Hyperactivity 

Disorder (ADHD) 

The most widely used and, probably, the best 

researched medication for child behaviour 

management is Ritalin (methylphenidate) which 

is widely prescribed for ADHD. 8 Some children 

do appear to respond well to Ritalin, although 

not all diagnosed with ADHD do so and caution 

is advised in assessing and regularly reviewing 

medication. 8,12 There are clearly some common 

CNS and physical side effects which are likely 

to impact on school performance, including 

headache, drowsiness, dizziness and dyskinesia. 12 

There are concerns about the long-term effects of 

Ritalin on children, including stunted growth, 

hypertension and increased risk of stroke, as 

well as questions about the actual benefits of its 

long-term use in managing hyperactivity. Some 

of the major issues of conflict around ADHD, 

apart from concerns about the use of medication, 

are those of whether or not it is a ‘disorder’, how 

valid the DSM-IV 3 criteria are, 13,14 and to what 

extent the ‘disorder’ model of ADHD is driven 

by the pharmaceutical industry itself. 14,15 

In their major review of the literature, Fonagy et 

al. 9 conclude that stimulant medication is most 

effective. For the 25% of children diagnosed as 

ADHD and not responding well to stimulants 

they suggest that antidepressants may represent 

an option, although there are cautions relating to 

their use with children. While acknowledging 

benefits of combining medication with psychoso- 

EDITORIALs 



EDITORIALs 


cial interventions, their review suggests that few 

of the latter, on their own, have as much impact as 

medication on core symptoms, such as inattention 

and hyperkinesis. There is evidence that behaviour 

modification is of some assistance with reducing 

off-task and disruptive behaviours and then can 

lead to reductions in medication. CBT enhanced effective 

coping and choice making and multi-modal 

interventions were still being evaluated at the time 

(i.e. 2000). Systemic and psychodynamic interventions 

lacked empirical data for or against their use. 

Concerns about the high degree of co-morbity 

between ADHD and conduct and mood disorders 

and specific learning deficits, and the reliability 

and validity of ADHD diagnosis 14 may be supported 

by the large variations between studies in 

terms of the efficacy of various medications and 

psychosocial interventions. Questions also have 

been raised about the validity of the neuro-imaging 

studies used to support claims that ADHD 

has a neurological basis. 16 It seems the jury is still 

out on just what ADHD is and whether or not it 

is a ‘disorder’. 

Anxiety 

Wolpert et al. concluded that the front line interventions 

for anxiety disorders in children were the 

behavioural therapies, including Cognitive Behaviour 

Therapy (CBT). 10 They suggested that only if 

these failed to produce effects should the addition 

of anti-depressant medication be considered as an 

option. It was noted that medication alone was less 

effective than medication in combination with 

behavioural interventions. A meta-analysis of 

CBT interventions with children and adolescents 

diagnosed with anxiety disorders concluded that 

both individual and group CBT interventions were 

more effective than placebo; that brief interventions 

were as effective as longer ones; and that 

CBT showed that beneficial treatment effects were 

maintained in long-term follow-up. 

Autism spectrum Disorders (AsD) 

Medications ranging from atypical antipsychotics 

and SSRIs are often prescribed for ASD symptoms 

such as ‘Obsessive Compulsive Disorder 

(OCD)’, ‘depression’, ‘aggression’ and ‘withdrawal’ 

in children and adolescents diagnosed 

with ASD. A review of almost 1700 medication 

studies by Broadstock et al., which included 

adolescents but not children, found only five that 

met criteria for randomised placebo-controlled 

investigations. 11 The medications included risperidone 

(2), naltrexone (1), fluvoxamine (1), and 

clomipramine and haloperidol (1). Most trials 

were comprised of small numbers of participants, 

included older children and adults and were 

short-term (e.g. six weeks), which raised questions 

about the generality of the findings, especially 

in respect of long-term drug administration. The 

authors concluded that while some of the medications 

showed some benefit for some participants, 

no conclusions could be reached about relative 

efficacy other than that haloperidol might have 

some advantage over clomipramine and that naltrexone 

was found to be ineffective. Further, no 

differentiation between efficacy for pre-pubertal 

vs post-pubertal individuals was possible and 

no useful information relating to treatment of 

co-morbid disorders was able to be identified. 

Fonagy et al. concluded from their extensive 

review that, while some medications produced 

some symptom reduction, there was little justification 

for medication of children with ASD 

except where there was co-morbid ADHD, when 

stimulant medication might offer some benefit. 9 

They recommended behavioural intervention as 

the first order intervention, with medication being 

trialled if the former proved ineffective. 

Questions need to be asked about the validity 

of applying separate DSM-IV diagnostic labels 

to behaviours typical of ASD and treating them 

specifically. For example, when narrow, specific 

interests are relabelled as OCD and then medicated 

as such it may be inappropriate, given that the 

mechanisms and functions of such behaviours in 

autism are possibly very different from those in 

OCD. In addition, while there are relatively few 

adequate studies of the efficacy of medications, 

there are many hundreds which demonstrate 

the efficacy of psychosocial interventions for a 

wide range of ASD behaviours, such as Applied 

Behaviour Analysis (cf. Maurice et al. 17 ). 

In summary, Fonagy et al. 9 concluded that there 

were no adequate studies of children with Asperger’s 

Syndrome and that for ASD in general, 

behavioural programmes should be tried first, 


with ADHD being managed by medication and 

that ‘there is no evidence to support the routine 

use of other medications’. 

Attachment disorders 

Diagnosis of children as having these seems to be 

fashionable at present. Reviews of assessment of 

attachment ‘disorders’ 18 and of attachment theory, 

research and treatment 19 point to concerns over 

assessment, diagnosis and treatment strategies. For 

example O’Connor and Byrne noted that clinicians 

rarely use attachment measures in the process 

of diagnosis and often have limited knowledge 

of attachment theory or training in its application. 

Equally, they note, attachment measures are not 

designed to be diagnostic of attachment disorder, 

which has no established assessment protocol. 

Slater comments that so-called ‘attachment disorder’, 

as set out in diagnostic manuals is more about 

child maltreatment than attachment. She states 

that the research underpinning diagnosis owes 

little, if anything, to attachment theory as promulgated 

by Bowlby and Ainsworth and is more 

grounded in research concerned with the social 

behaviour of maltreated children. Similarly, Slater 

notes, interventions focus on introducing a consistent 

and available caregiver or improving the 

relationship with the current caregiver without 

directly addressing the child’s own attachment 

issues or models. She concludes that the current 

definitions of reactive attachment disorder are 

not helpful in meeting children’s needs because 

they owe so little to developmental research in 

attachment and that, regardless, it seems inappropriate 

to pathologise children for having had such 

a disruptive start to life. One has to wonder if the 

‘pathology’ in attachment disorders does not relate 

more to the inadequacies of the children’s caregivers 

than to the children who are so labelled! 

The American Academy of Child and Adolescent 

Psychiatry (AACAP) has recently published a 

practice parameter relating to assessment and 

treatment of children and adolescents with Reactive 

Attachment Disorder that raises concerns 

about the potential harm to young children’s 

developing brains from psychopharmacological 

medication, the need to try medication-free 

interventions first and the risks that any interventions 

pose if they have not been derived from 

appropriate studies. 20 This is one ray of light 

in a field in which many medical practitioners, 

including paediatricians and child psychiatrists, 

seem comfortable with prescribing psychoactive 

medications for young children without trying, 

or necessarily being aware of, any other modes of 

intervention, such as behavioural therapies. 

Mood disorders 

Medication of childhood ‘mood disorders’ (depression 

and bipolar disorders) has, as noted earlier, 

become increasingly popular in recent times. 

Healy and Le Noury 5 are highly critical of the 

emergence of paediatric bipolar disorder as a condition. 

They argue that the ‘disorder’ is primarily 

a creation of the pharmaceutical industry and are 

critical of the apparent lack of academic scepticism 

accompanying the promotion of the ‘disorder’ and 

the capture of psychiatrists by that industry. They 

are concerned at the consequences for children of 

exposure to ‘cocktails of potent drugs without any 

evidence of benefit’. 5 The drugs listed in the article 

include Depakote, olanzapine, risperidone, and 

quetiapine and it is reported that some children 

receive more than one of these medications. 

Prevalence of depression in children aged between 

nine and 16 years is reported as estimated to 

be about 9.5%. In the UK, the NICE guidelines 

relating to childhood depression advise that the 

treatment of choice for the first three months 

should be psychological (CBT, Family Therapy or 

Interpersonal Therapy). 10 Only if this intervention 

does not produce symptomatic improvement 

by six weeks is anti-depressant medication recommended 

for adolescents only, and then only in 

conjunction with either CBT or Family Therapy. 

Medication is not recommended for younger children. 

In other words, the first line of treatment 

is psychological and the second, for adolescents 

only, is the addition of medication, preferably 

fluoxitine. 10 Perera et al. found that in their South 

London CAMHS setting, 28% of 25 children and 

adolescents being treated for depression were medicated 

without any psychological therapy and 72% 

were receiving both, with most being prescribed 

fluoxitine, despite known enhanced risk of suicide 

in adolescents taking this medication. They provided 

no data on whether psychological interventions 

were tried alone at first, on the severity of 

EDITORIALs 



EDITORIALs 


depression or age range of the participants, except 

that seven (28%) were under age 15 years. 

Conclusions 

This overview makes no pretence of being 

comprehensive, but even a brief review of the 

literature raises questions about the direction that 

psychiatric diagnosis and treatment of children 

is taking, along with concerns about the increasing 

tendency to pathologise and medicate what 

are represented as ‘disorders’ of childhood. It 

appears that little cognizance has been taken of 

the changes in society that could lead to what are 

essentially adaptive and functional human behaviours 

in evolutionary terms being increasingly 

deemed pathological as we change living styles. 

In earlier times children were given the freedom 

or opportunity to help adults in a range of activities 

and/or to play and roam outdoors. Nowadays, 

they are more likely to be required to stay within 

the bounds of small sections or to be indoors 

where play involves a video game console or computer 

games. They also are typically transported 

to and from school each weekday, where they 

spend still more time in an environment in which 

they often are expected to sit relatively still, 

to concentrate, and generally to be fairly quiet. 

Expectations of children that they will moderate 

their behaviour and not disturb adults in such 

environments may fuel demands for medication 

to achieve the tolerable states of child behaviour 

which parents and teachers appear to be failing to 

obtain without it. 

The irony of providing children with prescription 

medications to manage their behaviours and 

moods while simultaneously warning them of 

the dangers of so-called recreational drugs seems 

to be lost on our society. Societal changes over 

time are, in part, the focus of the anthropological 

study of ADHD by Neufeld and Foy 15 which is 

instructive and suggests similar cautions should 

apply to other so-called disorders of childhood 

that now are increasingly being identified earlier 

and treated with psychotrophic medications. We 

ignore the contextual circumstances and functional 

purposes of ‘problem’ behaviour at our 

peril. We medicate children without yet being 

aware of the possible long-term risks and costs, 

both for them and us, even if life is more peace- 

ful when they are medicated. The concerns and 

cautions expressed by the AACAP 20 in respect of 

treatment of Attachment Disorder should more 

generally be voiced as applicable to the whole 

spectrum of childhood ‘disorders’ of behaviour, 

given that the underlying developmental risks are 

the same. 

References 

1. Angold A, Egger HL. Preschool psychopathology: lessons for 

the lifespan. J Child Psychol Psychiatry Oct 2007;48(10):961– 

966. 

2. sterba s, Egger HL, Angold A. Diagnostic specificity and nonspecificity 

in the dimensions of preschool psychopathology. J 

Child Psychol Psychiatry Oct 2007;48(10):1005–1013. 

3. American Psychiatric Association, ed. Diagnostic and statistical 

Manual iV. 4th ed. Washington DC; 2004. 

4. Cary B. Bipolar illness soars as a diagnosis for the young. new 

York Times. september 4, 2007. 

5. Healy D, Le noury J. Pediatric bipolar disorder: An object of 

study in the creation of an illness (Cited in sharav, V. H., 2007). 

int J Risk safety Med 2007;19:209–221. 

6. Timimi s, ed. Pathological child psychiatry and the medicalization 

of childhood. Hove, UK: Brunner-Routledge; 2002. 

7. Carlson Js, Demaray MK, Hunter-Oehmk s. A survey of school 

psychologists’ knowledge and training in child psychopharmacology. 

Psych sch 2006;43(5):623–633. 

8. Abrams L, Flood J, Phelps L. Psychopharmacology in schools. 

Psych sch 2006;43(4):493–501. 

9. Fonagy P, Target M, Cottrell D, Phillips J, Kurtz Z. A review of 

the outcomes of all treatments of psychiatric disorder in childhood: 

MCH 17-33. Final Report to the national Health service 

Executive. London: national Health service; July 2000. 

10. Wolpert M, Fuggle P, Cottrell D, Fonagy P, eds. Drawing on 

Evidence: Advice for mental health professionals working with 

children and adolescents. 2nd ed. London: CAMHs Publications; 

2006. 

11. Broadstock M, Doughty C, Eggleston M. systematic review 

of the effectiveness of pharmacological treatments for adolescents 

and adults with autism spectrum disorder. Autism Jul 

2007;11(4):335–348. 

12. Curel P, Kumar n, Robinson B, editors. new Ethicals. 8th ed. 

Auckland: Adis international Ltd; 2004. 

13. Barkley RA. international Consensus statement on ADHD. J 

Am Acad Child Adolesc Psychiatry Dec 2002;41(12):1389. 

14. Timimi s, Moncrieff J, Jureidini J, et al. A critique of the 

international consensus statement on ADHD. Clin Child Fam 

Psychol Rev Mar 2004;7(1):59–63. 

15. neufield P, Foy M. Historical reflections on the ascendancy 

of ADHD in north America c. 1980 – c. 2005. Br J Ed studies 

2006;54(4):449–470. 

16. Leo J, Cohen D. Broken brains or flawed studies? A critical 

review of ADHD neuroimaging research. J Mind Behav Win 

2003;24(1):29–56. 

17. Maurice C, Green G, Foxx RM, eds. Making a difference: Behavioral 

interventions for Autism. Austin; 2001. TX: PRO-ED. 

18. O’Connor TG, Byrne J. Attachment measures for research and 

practice. Child Adolesc Mental Health nov 2007;12(4):187–192. 

19. slater R. Attachment: Theoretical development and critique. 

Educ Psychol Pract sep 2007;23(3):205–219. 

20. Boris nW, Zeanah CH, Work Group on Quality i. Practice 

parameter for the assessment and treatment of children and 

adolescents with reactive attachment disorder of infancy and 

early childhood. J Am Acad Child Adolesc Psychiatry nov 

2005;44(11):1206–1219. 


Cardiovascular risk assessment and 

management in mental health clients: 

Perceptions of mental health and general 

practitioners in New Zealand 

Amanda Wheeler PGDipPsychPharm, BPharm, BSc, MRPharmS, RegPharmNZ; 1,2 Jeff Harrison PhD, 

DipClinPharm, GradCertClinEd, BSc (Hons), MRPharmS, RegPharmNZ, BCPS; 1,2 Zara Homes BPharm 2 

ABSTRACT 

INTRODUCTION: People with mental illness have higher rates of morbidity and mortality, largely due 

to increased rates of cardiovascular disease (CVD). Metabolic syndrome is well recognised but rarely 

expressed as a need to assess and manage cardiovascular risk factors; furthermore there is confusion 

about whose role this is. This study explores health practitioners’ knowledge, attitudes, barriers/solutions 

towards cardiovascular risk assessment and management in mental health patients. 

METHOD: A survey of mental health practitioners (MHPs n=421) and general practitioners (GPs n=232) 

was undertaken in a health service in Auckland. 

RESULTS: Three-quarters of respondents agreed mental illness predisposes to CVD. Fifty-five percent 

of MH doctors agreed they could effectively assess CVD risk compared to 67% of GPs. Only 21% of MH 

doctors agreed they could effectively manage CVD risk compared to 57% of GPs. Seventy-nine percent 

of MHPs believed that assessing CVD risk was a joint responsibility between GP and MHP, compared 

to 33% of GPs; 62% of GPs believed it was their sole responsibility. Forty-six percent of MHPs believed 

managing CVD risk was a joint responsibility compared with 29% of GPs; 58% of GPs saw this as their 

role. Only 13% of MHPs and fewer than 4% of GPs agreed that MH services were effectively assessing 

and managing CVD risk. MHPs identified lack of knowledge and skills (58%) and poor communication between 

primary–secondary care (53%) as the main barriers. GPs identified barriers of poor communication 

(64%) and patient compliance with health care management (71%). The top two solutions proposed by 

MHPs were provision of GP subsidies (47%) and training (43%). GPs also identified provision of a subsidy 

(66%) and collaborative management between GPs and MH (44%) as solutions. 

CONCLUSION: There is widespread recognition of increased risk of CVD in MH patients. MHPs do not 

believe they have the knowledge and skills to manage this risk. GPs believe this is their responsibility. 

Both groups recognise communication with, and access to, primary care for MH patients as key barriers. 

KEyWORDS: Mental health, cardiovascular risk, risk reduction 

Introduction 

People with serious mental illness have increased 

rates of a variety of comorbid physical illness. 1-3 

The NZ Mental Health Survey found that people 

with mental disorder had higher prevalence rates 

of chronic physical conditions, including chronic 

ORIGINAL SCIENTIFIC PAPERS 

pain, cardiovascular disease, hypertension and 

respiratory illness; 68% with a mental disorder 

had at least one chronic physical condition compared 

with 53% without mental disorder. 3 

Serious mental illness is associated with excess 

mortality. 4-6 This excess mortality cannot 

qUANTITATIVE RESEARCH 

1 Waitemata District Health 

Board, Auckland 

2 School of Pharmacy, Faculty 


Sciences, The University of 

Auckland, Auckland 

J PRIMARY HEALTH CARE 

2009;1(1):11–19. 

CORRESPONDENCE TO 

Amanda Wheeler 

Director, Clinical 

Research & Resource 

Centre, Waitemata 

District Health Board, 

Auckland, New Zealand 

amanda.wheeler@ 

waitematadhb.govt.nz 

VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE 11



be explained by self-harm or other injury. 7 A 

meta-analysis demonstrated a 1.5–fold increase in 

age-adjusted mortality for people with schizophrenia; 

8 similar increases have been found in 

cohorts with bipolar and major depression. 4 Cardiovascular 

disease (CVD) is one of the dominant 

factors in this excess mortality 9-12 and there is 

evidence of an excess of obesity, hypertension, 

metabolic syndrome and type II diabetes that 

underpins this greater cardiovascular morbidity 

and mortality. 13-18 

Compounding this increased prevalence of CVD 

risk factors are the medications for mental illness, 

particularly second-generation antipsychotics and 

mood stabilisers. These agents are associated with 

the development of insulin resistance, abdominal 

obesity, the metabolic syndrome and overt diabetes. 

19-26 Such metabolic changes translate directly 

into an atherogenic risk factor profile. 10,27 

The NZ Health Strategy has highlighted significant 

health inequalities and the need to improve 

the health status of people with mental illness as 

one of its 13 goals for improvement. 28 A document 

that recognises the importance of effectively 

assessing and managing risk factors for metabolic 

syndrome in people with mental illness has been 

developed and disseminated by a national mental 

health (MH) metabolic working group. However, 

there is incomplete linkage of this to CVD risk 

and inconsistent implementation of the recommendations 

of this initiative throughout the 

country. 29 There also appears to be confusion over 

role boundaries, with health professionals being 

unsure of whose responsibility it is to assess and 

manage the physical health of patients with a serious 

mental illness. This is particularly a problem 

for people whose only access to the health system 

is through their psychiatrist or MH provider. 

This study aimed firstly to determine health practitioners’ 

attitudes and knowledge about the assessment 

and management of cardiovascular risk 

in patients with a mental illness and, secondly, 

to identify the barriers and possible solutions to 

addressing this issue. There is a particular focus 

on whom health professionals believe should be 

responsible for monitoring and managing the 

physical health of secondary care MH patients. 

Methods 

Questionnaire development 

A semi-structured interview was conducted with 

eight key informants to explore knowledge, experience, 

current practice and attitudes in assessing 

and managing cardiovascular risk in people with 

a serious mental illness. The key informants 

included MH practitioners, GPs and a consumer 

advisor. Based on the preliminary findings, a 

questionnaire was developed addressing the important 

areas of the study. A draft questionnaire 

was piloted with another eight MH and primary 

care practitioners, who provided feedback on the 

questionnaire’s content and format; changes were 

made accordingly. 

Two final questionnaires were developed. One, 

for MH practitioners, consisting of 35 questions 

and the other, for GPs, omitted three questions 

and some questions were amended slightly to 

ensure audience relevancy. Each questionnaire 

took five to 10 minutes to complete. The first 

section collected demographic data (years of 

experience, age, ethnicity) as well as information 

profiling the patients the participant provided 

care for. The second section consisted of attitudinal 

questions. Participants were asked if they 

were concerned about psychotropic medications 

increasing cardiovascular risk and to indicate (using 

a 6-point Likert scale) whether they agreed or 

disagreed with statements ranging from strongly 

agree to strongly disagree, or how often they 

referred patients to particular interventions, ranging 

from always to never. There was also a series 

of questions assessing the practitioner’s level of 

knowledge of cardiovascular risk assessment. 

The final part of the survey asked participants to 

identify (from a list generated from key informant 

interviews and pilot) the three most important 

barriers and solutions to assessment and 

management of cardiovascular risk in people with 

a serious mental illness. Further comments could 

be made at the end of the survey. (A copy of the 

questionnaire can be requested from corresponding 

author). 

Ethics approval was obtained from the University 

of Auckland Human Participants Ethics Committee 

(2006/L/020). 

12 VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE

Participants 

The anonymous questionnaire was distributed to 

MH practitioners and GPs providing care within 

the Waitemata District Health Board catchment 

area. This service is the largest in NZ and provides 

both primary and secondary health care to north 

and west Auckland [2006 population of 481 611 

making up 12% of total population 30 ] and includes 

forensic, acute and community MH services. The 

questionnaire was distributed by email to 421 MH 

practitioners (83 senior medical officers [psychiatrists 

and medical officers], 93 psychiatric trainees, 

seven house officers, six MH pharmacists and 

231 MH nursing staff). An email reminder was 

sent two weeks later; the researchers also attended 

medical education and team meetings to encourage 

participation. Participants were asked to return 

anonymous questionnaires in the internal mail. 

Questionnaires were also disseminated to 232 

GPs across six Primary Health Organisations 

Table 1. Participant demographics 

Professional role 

Response rate 

Years experience 

0–5 

SMO 

n (%) 

22/83 

(27) 

Nil 

5–10 2/22 

(9.1) 

10–15 4/22 

(18.2) 

15+ 16/22 

(72.7) 

Ethnicity 

NZ 

European 

12/22 

(54.5) 

Other** 10/22 

(45.5) 

MH 

nurse 

n (%) 

52/231 

(22.5) 

5/52 

(9.6) 

7/52 

(13.5) 

10/52 

(19.2) 

30/52 

(57.7) 

32/52 

(61.5) 

20/52 

(38.5) 

MH 

pharmacist 

n (%) 

6/6 

(100) 

1/6 

(16.7) 

2/6 

(33.3) 

3/6 

(50) 

House 

officer 

n (%) 

3/7 

(43) 

2/3 

(66.7) 

Nil 

1/3 

(33.3) 

Nil Nil 

5/6 

(83.3) 

1/6 

(16.7) 

1/3 

(33.3) 

2/3 

(66.6) 

Psychiatric 

trainee 

n (%) 

VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE 13 

23/93 

(25) 

6/23 

(26.1) 

9/23 

(39.1) 

3/23 

(13.0) 

5/23 

(21.7) 

9/23 

(39.1) 

14/23 

(60.9) 

GP 

n (%) 

90/232 

(38.8) 

5/90 

(5.5) 

7/90 

(7.8) 

16/90 

(17.8) 

62/90 

(68.9) 

72/90 

(80.0) 

18/90 

(20.0) 

Total* 

n (%) 

203/611 

(33.2) 

19/198 

(9.6) 

27/198 

(13.6) 

37/198 

(18.7) 

115/198 

(58.1) 

132/198 

(66.7) 

66/198 

(33.3) 

* Seven MH participants did not disclose their professional role and five participants did not disclose their ethnicity or 

answer the clinical experience question. 

** Other ethnicities included Other European, Maori, Pacific, Asian, African, Middle Eastern, North American, and not 

specified. These were grouped to protect participants’ identity within small health professional groups. 

SMO = Senior Medical Officer (psychiatrists and medical officers) 

WHAT GAP THIS FILLS 



What we already know: People with serious mental health disorders 

have an excess of morbidity and mortality due to physical health problems, 

including cardiovascular disease. Mental health medicines increase the risk 

of metabolic syndrome contributing to the excess cardiovascular disease 

seen in this group. 

What this study adds: There is a gap between knowledge and action in 

cardiovascular disease (CVD) risk assessment and management for mental 

health patients. Primary health care providers are best placed to manage 

CVD risk, but shared care between primary care and specialist mental health 

services, and mechanisms to improve access to primary care for this vulnerable 

group, are needed. 

(PHOs) located in the health service catchment 

area. This was done using methods chosen at the 

discretion of the PHO and included emailing the 

questionnaire to a central contact who distributed 

the questionnaire to GPs; posting the question-



Table 2. Practitioners’ views about psychotropic treatments increasing cardiovascular risk 

Schizophrenia 

Table 3. Proportion of respondents identifying cardiovascular risk management targets 

correctly 

MH practitioner 

n (%) 

General practitioner 

n (%) 

BP (< 140/85mmHg) 2 /111(1.8) 7/89 (7.9) 

FPG (< 6mmol/L) 25/108 (23.1) 29/89 (32.6) 

Total Cholesterol 

(

or strongly agreed that they could accurately and 

effectively manage CVD risk compared to 54.4% 

of GPs. 

Knowledge 

Most participants were unable to correctly answer 

the target blood pressure, fasting plasma glucose, 

total cholesterol and low-density lipoprotein levels 

for a non-diabetic patient required to achieve 

a reduction in the five-year cardiovascular risk 

(Table 3). 

Responsibility for cardiovascular risk 

assessment and management 

Respondents’ views on whose role it was to assess 

and manage cardiovascular risk were explored 

next, along with questions about their own 

current practice in such activities. Most MH practitioners 

(79.1%) believed that assessing cardiovascular 

risk was a joint responsibility between the 

GP and the MH practitioner, whereas only 31.8% 

of GPs agreed. In contrast, GPs were far more 

likely to believe it was their sole responsibility 

compared with MH practitioners (62.5% vs 17.3%). 

Just less than half of MH practitioners (46.4%) 

believed that managing a patient’s cardiovascular 

risk was the joint responsibility of the GP and 

MH practitioner compared with 28.4% of GPs. 

Again, GPs were more likely to see this as their 

role (56.8% vs 33.6%). 

Finally, only 12.8% of MH practitioners and 6.9% 

of GPs agreed or strongly agreed that MH services 

effectively assess and manage cardiovascular 

risk in patients with serious mental illness. 

Respondents considered dietary advice the most 

required service; most respondents agreed or 

strongly agreed their patients required referral 

for dietary advice (93.6% MH practitioners; 82.2% 

GPs). However, fewer than half of both practitioner 

groups (39.5% MH practitioners; 31.5% 

GPs) stated that they referred patients for dietary 

advice either always or most of the time. 

Most participants agreed or strongly agreed 

that their patients required referral to exercise 

programmes (83.7% and 78.9% respectively), about 


a third of practitioners stating they referred 

patients to these services either always or most of 

the time (36.9% compared with 36.4%). Exercise 

referrals included the Green Prescription, 

to gyms in the local community or to secondary 

care facilities. Just over 80% of participants 

believed that their patients required referral to 

smoking cessation programmes, such as Quitline, 

or for nicotine replacement therapy. GPs were 

more likely to refer patients to appropriate smoking 

cessation services (44.3% vs 27.8%; chi 2 =3.07, 

df=1, p=0.08). 


Figure 1. Barriers to cardiovascular risk assessment and management in mental health 

patients 

Figure 2. Solutions for cardiovascular risk assessment and management for mental health 

patients 




Barriers and solutions to cardiovascular 

risk assessment and management 

Respondents were asked to indicate the three 

most important barriers and solutions to effectively 

assessing and managing CVD for patients 

with a serious mental illness (Figures 1 and 2). 

For MH practitioners the top two barriers were 

secondary care providers’ knowledge and skills 

(57.6%) and lack of communication between MH 

provider and GP (52.9%). Lack of time in secondary 

care to complete assessment and follow-up 

(41.2%) and patients’ financial status to accessing 

primary care and medications (41.2%) were jointly 

the third most frequently rated barrier. 

The top three solutions to overcome barriers 

were (in decreasing importance) subsidising GP 

visits (47.4%), training or continued education 

on cardiovascular screening for MH practitioners 

(43.2%), establishing cardiovascular screening 

guidelines and interventions, and improving 

communication between primary and secondary 

care (both 37.9%). 

This question was presented slightly differently 

to GPs and three options were omitted. GPs rated 

the most important barrier as patient factors; that 

is, compliance with medication and follow-up 

appointments (71.6%). Consistent with MH practitioners, 

lack of communication between MH 

provider and GP and a patient’s financial ability 

to access primary care and medications were both 

rated as second most important barrier (59.5%). 

GPs agreed with MH practitioners that subsidising 

primary care visits would be the most effective 

solution to overcoming these barriers (62.3%). 

The next two important solutions for GPs were 

collaborative management between MH and GP 

(45.5%), and provision of proactive programmes/ 

interventions for cardiovascular risk assessment/ 

management (42.1%). 

Other comments 

Participants were given the opportunity to write 

comments at the end of the survey. Most MH 

practitioners focussed on the fact that they believed 

that they should be involved in the assessment 

of cardiovascular risk and helping patients 

to access primary health care, but that it was not 

their responsibility to manage this risk. Some 

respondents expressed concern about time and 

resource constraints that might restrict their ability 

to comprehensively manage these risk factors. 

There was some personal anxiety and concern 

expressed at the poor level of knowledge of MH 

practitioners in this area of health care. 

Most of the comments from GPs focussed on 

funding, both in terms of a patient’s inability to 

pay for services and in terms of the limitations 

placed on the resources available to GPs. GPs also 

commented, but to a lesser extent, that the expertise 

and therefore the responsibility for managing 

cardiovascular risk lay with GPs. Some respondents 

from this group felt that the restrictions on 

time in primary care for consultations (average 10 

minutes) prevented discussions about anything 

more than acute issues with patients. Lack of 

communication between providers and paucity of 

MH practitioners well-trained in the cardiovascular 

risk area was also of concern. 

Discussion 

This was the first NZ study to explore MH 

practitioners’ and GPs’ views on assessment and 

management of cardiovascular risk in people 

with serious mental illness. Most practitioners 

were aware of MH patients’ increased cardiovascular 

risk. Interestingly, practitioners appeared 

to associate the increased risk with the MH 

treatments they were most used to prescribing in 

everyday practice; treatments for schizophrenia 

and bipolar disorder for MH practitioners and 

treatments for depression in GPs. MH practitioners 

rated second-generation antipsychotics as the 

medications they were most concerned about 

for increasing cardiovascular risk. However, it 

was surprising that other medications, such as 

lithium and sodium valproate were not associated 

with increased risk by MH practitioners; there 

is a well-described relationship between these 

medications and appetite increase, weight gain, 

and metabolic syndrome. 31,32 

Whilst approximately half of MH doctors had 

confidence in their ability to assess patients’ 

CVD risk, only one-fifth had faith in their own 

ability to effectively manage cardiovascular risk. 


In comparison, equal numbers of GPs reported 

confidence in cardiovascular assessment and 

management. Given the recent high profile of 

CVD risk assessment and management both 

nationally and amongst PHOs in the Auckland 

area, it is perhaps surprising that fewer than 

two-thirds of GPs agreed that they could do this 

effectively. Furthermore, respondents reported 

confidence with assessment and management was 

somewhat at odds with the finding that their 

knowledge of current guideline screening targets 

was poor; fewer than one-tenth of MH practitioners 

and GPs could correctly identify the 

NZGG target blood pressure and total cholesterol 

level for a non-diabetic patient with a five-year 

CVD risk >15%. 

The survey found respondents had little faith in 

the current ability of MH services to accurately 

and effectively assess and manage cardiovascular 

risk—overall only 10% of practitioners agreed 

that this was being done effectively at present. 

MH practitioners suggested that they relied on 

the primary care sector (via joint mechanisms) 

for physical health screening and solely on the 

primary care sector for management. Most GPs 

believed that both screening and management 

were their sole responsibility. Written comments 

provided further evidence of this belief, 

with some MH practitioners stating it was their 

responsibility to identify risks, but that they 

referred patients to the GP for risk management, 

and some GPs commented that they had the 

knowledge and expertise in this area. 

Whilst most practitioners believed that MH 

patients needed to be able to access assistance 

and programmes for dietary advice, exercise and 

smoking cessation, only about a third of practitioners 

surveyed actually completed referrals for 

patients as part of their clinical role. This may 

indicate a lack of knowledge about the services 

available and how to access them or may reflect 

the uncertainty about the boundaries of care 

between MH and primary care services. 

Despite suggestions that MH practitioners feel 

partly responsible for assessing cardiovascular 

risk, they were aware of their lack of knowledge 

and skill in this area and believe that they would 

benefit from both further training and guidance. 


They identified that provision of guidelines for 

assessment and management interventions would 

be useful to improve this lack of knowledge. The 

New Zealand Mental Health Metabolic Working 

Group issued guidance on monitoring for the 

metabolic syndrome in patients with mental illness 

in 2006. 33 However, this guidance does not 

make specific links to assessment and management 

of cardiovascular risk, nor do the NZGG 

guidelines 34 identify people with serious mental 

illness as a risk group to be targeted for risk assessment. 

Whilst there is evidence describing the 

effect of MH treatments on some indices of CVD 

risk, there is little data describing their effect 

on global CVD risk. Because the existing risk 

prediction models are based on population data, 

they may underestimate risk in this relatively 

young patient group; further work needs to be 

undertaken in this area. 

Financial factors were identified as an important 

barrier to physical health screening and management 

by both practitioner groups. Traditionally, 

screening has been managed by the primary care 

sector, where a co-payment has been required to 

visit a GP and co-payment is often required for 

prescriptions. The subsidy of regular and longer 

duration primary care visits and long-term treatments 

for this at-risk group potentially removes 

one of the barriers to accessing primary health 

care and treatment. Respondents also identified 

the need for better communication between the 

two services as vital in order to improve physical 

health outcomes. This is particularly important 

if the patient has been prescribed psychotropic 

medications that are essential in the treatment 

of mental illness but which may further increase 

the patient’s cardiovascular risk. Collaborative 

management may be needed to assist patients attend 

follow-up appointments in primary care and 

adhere to additional medication. 

Also of note is the particular significance of some 

of the issues, highlighted in this research, to 

cohorts of mental health clients from Maori and 

Pacific backgrounds. Maori and Pacific ethnicities 

appear to be at increased risk of CVD; Maori are 

known to have a higher incidence of cardiovascular 

events (both fatal and non-fatal) and have 

them earlier than non-Maori. 34 CVD contributes 

significantly to earlier mortality and significant 





morbidity in Pacific people compared to European. 

34 Diabetes and obesity also affect Maori 

and Pacific peoples disproportionately compared 

to Europeans; this is reflected in an increased 

morbidity and mortality due to diabetes. 35 

This inequitable burden of disease is exacerbated 

further where CVD, diabetes and serious mental 

illness intersect. Maori were found to have a 

higher prevalence of mental illness, both serious 

and in general, compared to the NZ general 

population. 36 For serious mental illness requiring 

inpatient treatment, admissions for Maori have 

been found to be higher than non-Maori. 37,38 

The relationship between socioeconomic position, 

CVD, diabetes and mental illness is strong 

and, in NZ, over half the Maori population and 

an even greater proportion of Pacific people live 

in the most deprived areas. 34 However, the NZ 

Mental Health Survey found that Maori and 

Pacific people with mental illness were less likely 

to access health services of any type, regardless 

of sociodemographic factors such as age and 

household income. 39 This could partially be due 

the fact that, although secondary services are free 

at the point of care, primary care services where 

physical health is traditionally managed are only 

partially subsidised and the two systems function 

independently of each other. All of these factors 

may collectively put Maori and Pacific people 

at further risk of cardiovascular mortality. The 

issues raised by both MH practitioners and GPs 

with regard to access and subsidy for primary 

care services may be of particular significance to 

Maori and Pacific people, and those in the lowest 

socioeconomic groups. 

We are not aware of any published studies exploring 

the views of both MH practitioners and 

GPs, nor any focussing on cardiovascular risk. 

However, our findings, in terms of the concerns 

of MH practitioners, are reflected by two papers 

examining US psychiatrists’ awareness of and 

concerns about the impact of therapies for bipolar 

disorder 40 and schizophrenia 41 on metabolic 

syndrome. These surveys highlighted that US 

psychiatrists recognise metabolic syndrome as 

a significant health risk and screen for metabolic 

effects, primarily weight gain and glucose 

intolerance. Psychiatrists treating bipolar disorder 

indicated that they also measure lipids and, to a 

lesser degree, blood pressure and waist circumference. 

40 Suppes et al. reported that three-quarters 

of respondents reported having diagnosed metabolic 

syndrome, but only 28% correctly identified 

the five variables used to diagnose metabolic syndrome; 

this has parallels with our own findings 

about CVD risk factor targets. Finally, Suppes 

et al. reported that 92% of respondents referred 

patients to primary care for management of 

metabolic risk factors; this reflects the views of 

our respondents that this is the most appropriate 

setting for management of CVD risk. 

The main limitation of this study is the poor 

response rate, particularly from nursing staff. 

Whilst the response rate is disappointing, the 

possible implication is that non-responders were 

less knowledgeable or, perhaps, less concerned 

about the risks of CVD in MH patients. The 

assumption that lack of knowledge about the 

area resulted in a poorer response is somewhat 

supported by comments made at the end of the 

survey and to the facilitators who presented the 

survey to potential participants at journal club 

and CME meetings. If this assumption is correct, 

then the scale of inaction and unmet need may be 

greater even than highlighted in this study. 

In conclusion, this survey found that there is 

widespread recognition of the increased risk of 

CVD in patients with a serious mental illness. 

MH practitioners do not currently have the 

knowledge and skills to assume responsibility for 

assessing or managing this risk. GPs believe that 

this is primarily their responsibility. Both groups 

recognise the barriers presented by communication 

with, and access to, primary care services 

for, MH patients. The survey highlights potential 

concerns about the management of physical 

health in this high-risk group; further research is 

required to both identify the burden of physical 

ill health in this group, and to describe their engagement 

with physical and preventative health 

services, including CVD risk assessment and 

management. 

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Suppl 1):S1–6. 


ACKNOWLEDGMENTS 

We would like to 

acknowledge the 

support of the MH 

practitioners and consumer 

representatives who were 

interviewed, piloted and 

who provided feedback 

in the development 

of the survey. We 

also acknowledge the 

support of the DHBs 

and PHOs in distributing 

the survey. Finally, we 

are very grateful to the 

respondents for their time 

participating in the survey. 

COMPETING INTERESTS 

None declared. 




1 Muar District of Health, 

Muar, Johor, Malaysia 

2 Department of Family 

Medicine, Faculty of 

Medicine, Universiti 

Kebangsaan Malaysia, 

Malaysia 

3 Department of Public 

Health, Faculty of Medicine, 

Universiti Kebangsaan 

Malaysia, Malaysia 


2009;1(1):20–25. 

CORRESPONDENCE TO: 

Arshad Hanisah 

Family Medicine Specialist, 

Muar District of Health, 

Jalan Othman, 84000 

Muar, Johor, Malaysia 

ihanisah@hotmail.com 

Prevalence of acne and its impact on the 

quality of life in school-aged adolescents 

in Malaysia 

Arshad Hanisah MMed (FamMed UKM); 1 Khairani Omar MMed (FamMed UKM); 2 Shamsul Azhar Shah 3 

ABSTRACT 

AIM: The objective of this study was to determine the prevalence of facial acne and its impact on the 

quality of life among adolescents attending secondary schools in Muar, Malaysia. 

METHODS: A cross-sectional study was conducted where 409 samples were selected using stratified 

cluster random sampling from two secondary schools in Muar, involving Form 1 to Form 5 students. 

Students were diagnosed clinically and the severity of facial acne was assessed using Global Acne Grading 

System. A self-reported Cardiff Acne Disability Index was used to assess the quality of life among 

adolescents who had acne. 

RESULTS: The prevalence of facial acne among the adolescents was 67.5% (n=276). Facial acne increased 

with increasing age (p=0.001). It was more common among males (71.1%) than females (64.6%), 

p=0.165. The males also had a higher prevalence of severe acne (p=0.001). The quality of life was 

affected by the severity of acne. Students with severe acne had higher levels of Cardiff Acne Disability 

Index (rho=0.521). 

CONCLUSION: Facial acne is a common disorder and appears to have a considerable impact on quality 

of life among adolescents. The above findings should alert health care professionals and the school 

authorities to actively identify, manage and educate adolescents with facial acne. 

KEyWORDS: Facial acne, adolescents, Cardiff Acne Disability Index, quality of life 

Introduction 

Acne vulgaris is the most common dermatological 

condition encountered in adolescents. It affects 

almost 85% of people 12–24 years of age. 1 It 

commonly affects young people during the time 

when they are undergoing maximum psychological, 

social and physical changes. 

Acne commonly involves the face. Facial appearance 

represents important aspects of one’s 

perception of body image. Therefore, it is not 

surprising that a susceptible individual with 

facial acne may develop significant psychosocial 

disability. Emotional stress can also exacerbate 

acne, and patients with acne may develop 

psychiatric problems as a consequence of their 

problem. 2 

Skin disease can have a major impact on one’s 

quality of life. Overall quality of life is an all 

inclusive concept incorporating all factors that 

impact upon an individual life. The concept 

can be divided into several components, including 

psychological, social and physical domains. 3 

The impact of acne on a particular patient is not 

always easy to judge clinically. It was found that 

both women and men find the effects of acne 

on appearance to be the most bothersome aspect 

of their disease and the negative effects of acne 

occur in both older and younger patients. 4 Even 

mild acne can pose a significant problem for some 

patients, diminishing their quality of life and in 

some cases their social functioning. 5,6 

Acne may also be associated with decreased selfesteem/self-confidence, 

interpersonal difficulties, 


unemployment and increased prevalence of anxiety 

and depression. 7,8 A study of 111 acne patients 

aged 16 years and over attending a United Kingdom 

dermatology outpatient clinic found levels 

of social and emotional problems are comparable 

with those in people with severe chronic disabling 

disease such as arthritis and epilepsy. 9 

However, the relationship between the severity 

of acne and emotional distress is poorly understood 

although it is known that acne is a source 

of distress and embarrassment. 10 Therefore there 

is a need to study the psychosocial impact and 

the quality of life of young people with acne 

using validated and age appropriate measures and 

an objective assessment of acne status. Thus the 

aim of this study is to determine the prevalence 

of acne and its impact on the quality of life in 

adolescents. 

Materials and methods 

This was a cross-sectional study conducted in two 

secondary schools in Muar, Malaysia. Muar is a 

district in one of the states in Malaysia. It has a 

multiethnic population. There are about 17 secondary 

schools in the district. The two secondary 

schools were selected randomly. These schools are 

co-educational schools which comprise Form 1 to 

Form 5 students. 

The calculation of sample size was performed 

using Epi info Statistical Package, using the formula 

n=[ z / s ] 2 x p [ 1-p ], where n is a sample 

size, z is the confidence interval taken as 1.96, s 

is taken as 0.05 and p is the probability in this 

study and taken as prevalence of acne vulgaris in 

Malaysia which is about 85%. 11 Considering the 

drop off rate as 10%, the minimum sample size 

calculated was 196. The sample size was then 

doubled to 400 due to stratified cluster sampling 

method. 

With the approval of the headmasters of the 

two secondary schools, the lists of students were 

obtained from the school registration books. The 

study population was stratified into five strata 

based on their forms; Form 1 to Form 5. In each 

stratum, the samples were selected randomly. The 

informed consent letter describing the research 

was given to the selected students and their par- 



What we already know: Acne vulgaris is the most common dermatological 

condition encountered in adolescents, affecting them at a time when they 

are undergoing maximum psychological, social and physical changes. Acne 

can pose a significant problem for some patients, diminishing their social 

functioning and may be associated with decreased self-esteem/self-confidence, 

interpersonal difficulties, unemployment and increased prevalence of 

anxiety and depression. 

What this study adds: Facial acne is a common disorder and appears to 

have a considerable impact on quality of life among adolescents attending 

secondary schools, particularly in severe cases. Primary health care professionals 

and school authorities should actively identify, manage and educate 

adolescents on facial acne. 

ents. The students were excluded from the study 

if they or their parents refused to give consent. 

Absentees during the data collection day were 

also excluded from the study. 

On the data collection day, schools were visited 

by the researcher and school health nurse. Each 

student was examined for acne. In this study, the 

examination for acne included the head and neck 

only. All the manifestations of acne from comedone 

to nodules, not only by its presence but also 

number was reported. The acne severity was then 

graded using Global Acne Grading System. The 

students with acne were then given self-reported 

Cardiff Acne Disability Index questionnaire. 

Clinical diagnosis was used to determine presence 

of acne. Facial acne was graded using 

the Global Acne Grading System (GAGS). 12 

The GAGS consider five locations on the face, 

with a factor at each location based roughly 

on surface area, distribution, and density of 

pilosebaceous units. The borders on the face are 

delineated by the hairline, jaw line and ears. 

No magnifying glass or skin stretching was 

allowed, and good lighting was suggested. In 

this study all the manifestations of acne from 

comedones to nodules, not only by its presence 

but also number, were reported. Each of the 

location was graded separately on 0–4 scale, 

with the most severe lesion within that location 

determining the local score. The researcher 

then graded acne severity according to the 





Table 1. Prevalence of acne among the adolescents 

Gender 

global score which is the summation of all local 

scores. The maximum score was 32. 

Cardiff Acne Disability Index (CADI) is a wellvalidated 

self-reported questionnaire consisting 

of five questions with a Likert scale, four 

response categories (0–3). 13 The final score ranges 

from 0–15. The Cardiff Acne Disability Index is 

designed for use in teenagers and young adults 

with acne. The five questions relate to feeling of 

aggression, frustration, interference with social 

life, avoidance of public changing facilities and 

appearance of the skin—all over the last month— 

and an indication of how bad the acne was now. 

The CADI score was calculated by summing 

the score of each question resulting in a possible 

maximum of 15 and minimum of 0. CADI scores 

were graded as low (0–4), medium (5–9) and high 

(10–15). The lower the cumulative CADI score, 

the lower the level of disability experienced 

by the student while a higher score indicated 

a higher level of disability. The CADI identifies 

area of concern in patients with acne. The 

patients’ response to the questionnaire is significantly 

correlated with the clinicians’ assessment 

of acne severity. 

Presence of acne No acne Total p value 

n % n % n % 

Male 128 71.1 52 28.9 180 100 0.165 

Female 148 64.6 81 36.4 229 100 

Age (years) 

13 31 44.2 39 55.7 70 100 0.001 

14 57 64.0 32 36.0 89 100 

15 54 66.7 27 33.3 81 100 

16 65 76.5 20 23.5 85 100 

17 60 81.0 14 19 74 100 

18 9 90.0 1 10 10 100 

Ethnicity 

Malay 155 64.3 86 35.7 241 100 0.084 

Chinese 121 72.5 46 27.5 167 100 

Total 276 67.5 133 32.5 409 100 

The majority of students from age 13 to 18 years old had mild facial acne (90.2%) 

(refer table 2) 

Data was analysed using SPSS (Statistical Package 

for Social Studies) programme (version 11; SPSS 

Inc., Chicago). The level of significance was set at 

p

There was a significant difference between acne 

severity and gender (c 2 = 16.47, p=0.001). However, 

there was no significant difference between 

facial acne severity and ethnicity (c 2 = 1.56, 

p>0.05) (refer to Tables 4 and 5). 

There was a moderately strong correlation 

between facial acne severity and Cardiff Acne 

Disability Index (rho=0.521) at p=0.01 (Figure 1). 

(Correlation coefficient, rho0.8 very strong). 

The impact on quality of life increased with the 

facial acne severity. 

There was no association between CADI score 

and gender: Mann–Whitney test (z score=0.046, 

p=0.964). It is an important finding, as there may 

be a perception among some health professional 

that facial acne will have less impact on males. It 

showed that males were also aware of their skin 

problems. 

Discussion 

This study showed that facial acne is a common 

problem among adolescents in Muar, affecting 

71.1% of boys and 64.6% of girls. A study done 

in Turkey using Global Acne Grading System, 

reported that the prevalence of acne among high 

school students was 23.1%. 14 The difference in 

prevalence rates between these two studies may 

reflect ethnic differences or the involvement of 

trunk examination which may limit participation 

of the adolescents. An Australian study showed 

that overall prevalence of acne was 36.1%. 15 In 

another study using Leeds Acne Grading Scale, 

reported the prevalence of acne in UK teenagers 

as 50%. 16 Comparisons of prevalence rate between 

studies are hampered by the varied methods of 

acne grading used by different studies and the 

wide range of diagnostic criteria used. For this 

reason, in this study it was best to report all the 

manifestations of acne from comedone to nodules, 

not only by its presence but also number. 

The researcher then graded acne severity according 

to the global score which is the summation of 

all local scores. Again, there is no internationally 

agreed system for reporting severity, although 

various systems have been recommended. Nevertheless, 

Global Acne Grading System has been 

Table 2. Severity of facial acne by age, gender and ethnicity 

Age (years) 

Acne Severity Total 


Mild 

n (%) 

Moderate 

n (%) 

Severe 

n (%) n (%) 

13 29 (93.5) 2 (6.5) 0 (0) 31 (100) 

14 53 (93.0) 4 (7.0) 0 (0) 57 (100) 

15 47 (87.0) 4 (7.4) 3 (5.6) 54 (100) 

16 57 (87.7) 6 (9.2) 2 (3.1) 65 (100) 

17 55 (91.7) 3 (5.0) 2 (3.3) 60 (100) 

18 8 (88.9) 1 (11.1) 0 (0) 9 (100) 

Overall 249 (90.2) 20 (7.3) 7 (2.5) 276 (100) 

Gender 

Males 106 (82.8) 15 (11.7) 7 (5.5) 128 (100) 

Females 143 (96.6) 5 (3.4) 0 (0) 148 (100) 

Ethnicity 


Malay 136 (87.7) 13 (8.4) 6 (3.7) 155 (100) 

Chinese 113 (93.4) 7 (5.8) 19 (0.8) 139 (100) 

Table 3. Specific responses of Cardiff Acne Disability Index 

Specific responses of CADI 

(N = 276) 

Frequency 

(n ) 

Percentage 

(%) 

Felt aggressive, frustrated 196 71.0 

Social interference 162 58.7 

Avoidance of public changing 49 17.8 

Patient psychological state 225 81.9 

Subjective assessment of acne severity 

(perceived as problem) 

Table 4. Relationship between acne severity and gender 

251 90.9 

Acne severity Male (n) Female (n ) Test p value 

Mild acne 106 143 c2 = 16.47 0.001 

Moderate to severe acne 22 5 

TOTAL 128 148 

Table 5. Relationship between facial acne severity and ethnicity 

Acne severity Malay (n) Non-Malay (n) Test p value 

Mild acne 136 113 c2 = 1.56 0.21 

Moderate to severe acne 19 26 

TOTAL 155 139 

qUANTITATIVE RESEARCH



found to be accurate and have minimal inter- and 

intra-rater variability. 11 

The findings in this study showed that acne prevalence 

increased with increasing age. This finding 

is similar to a previous study done in Australia. 14 

In this study, the male students were found to 

have more moderately severe acne compared to 

female students. The findings are consistent with 

previous studies done in other countries. 14,15,16,17 

Males tend to have more severe acne compared to 

females because they have oilier complexion and 

their androgen levels are higher. 18,19 

Cardiff Acne Disability Index helps to assess 

the quality of life in students with acne. The 

subscales include feeling of aggression, frustration, 

interference with social life, avoidance of 

public changing facilities and appearance of the 

skin. In this study, analysis of the subscales 

showed that the adolescents had particular 

difficulties in the areas of emotion (felt aggressive, 

frustrated), social interference/difficulties 

and psychological state disturbance. A study 

among teenage Scottish schoolchildren reported 

that 50% of pupils were emotionally affected by 

their acne. Twenty percent of pupils were affected 

in their personal and social lives because 

Figure 1. Spearman’s rho coefficient demonstrating correlation between Global Acne 

Grading Score and Cardiff Acne Disability Index. 

of their acne and 10% avoided swimming and 

other sports because of embarrassment. 20 In 

this study, five students (1.8%) scored 13 in Cardiff 

Acne Disability Index which was equal to 

severely impaired. It implied that the students 

had severe psychological impact from facial acne 

problem. However, the median score of CADI 

was 4, which was low. This implied that overall 

the students were mildly affected psychologically. 

This could be due to the higher prevalence 

of mild acne among the students. It also showed 

that the impact of acne on the students was 

influenced by the acne severity. 

This study demonstrated a moderately strong correlation 

between the total score of Cardiff Acne 

Disability Index and acne severity. The impact 

on quality of life increased with the facial acne 

severity. This result is consistent with previous 

studies which also demonstrated a fairly good 

correlation between facial acne severity and 

Cardiff Acne Disability Index. 15,20,21 This implies 

that impact of acne on quality of life must be 

considered in the management of facial acne. 

Overall, there was no significant difference in 

the CADI score between the genders (Mann– 

Whitney test, p>0.5). The impact of acne on 

quality of life was similar between genders. 

However, this contradicts results from previous 

studies which found that girls generally experience 

more psychological morbidity than boys. 22 

The finding in this study is important as there 

may be perception among some health professionals 

that facial acne will have less impact on males. 

This study showed that male adolescents were 

also aware of their skin problems. 

The major limitation of this study is its crosssectional 

design. A prospective study would be 

better to demonstrate a direct causal link between 

acne and quality of life. Although we obtained 

a good response rate, it is possible that students 

who either refused to take part or who were 

absent represent more vulnerable adolescents or 

those most embarrassed by their skin. The study 

is likely therefore to have underestimated the 

impact of acne on quality of life. In this study, 

the CADI and GAG scores (especially the CADI) 

were quite skewed. Dichotomising the scores 

would perhaps demonstrate better results. 


Conclusion 

Facial acne is common among adolescents and can 

cause major impact on their quality of life. It is important 

for the health professionals to incorporate 

quality of life measurements when managing adolescents 

with acne. Cardiff Acne Disability Index 

is a useful tool to identify individual with facial 

acne who had poor quality of life. Health education 

is needed in our secondary schools to ensure 

that adolescents understand their disease, know 

what treatments are available and from whom they 

should seek advice. Health professionals should 

be aware that early acne treatment can prevent 

progression of the disease and its complication. 

References 

1. Krowchuck DP. Managing Acne in Adolescent. Pediatr Clin 

North Am 2000;47(4):841–857. 

2. Koo JYM, Smith LL. Psychological aspects of acne. Pediatr J 

Dermatol 1991;8:185–188. 

3. Price P, Harding KG. Delining quality of life. J Wound Care 

1993;2:304–306. 

4. Jowett S, Ryan T. Skin disease and handicap: Analysis of the 

impact of skin condition. Soc Sci Med 1985;20:425–429. 

5. Lasek RJ, Chren MM. Acne vulgaris and the quality of life of 

adult dermatology patients. Arch Dermatol 1998;134:454–458. 

6. Picardi A, Abeni D, Melchi CF, Puddu P, Pasquini P. Psychiatri 

morbidity in dermatological outpatients: an issue to be recognized. 

Br J Dermatol 2000;143:983–991. 

7. Koo J. The psychosocial impact of acne: Patient’s perceptions. 

J Am Acad Dermatol 1995;32:26–30. 

8. Wu SF, Kinder BN. Role of anxiety and anger in acne patients: 

a relationship with severity of the disorder. J Am Acad Dermatol 

1988;18:325–332. 

9. Mallon E, Newton JN. The quality of life in acne. J Am Acad 

Dermatol 1999;140:672–676. 

10. Lowe JG. The stigma of acne. Br J Hosp Med 1993;49:809–812. 

11. Khairani O, Zaiton S, Faridah MN. Do adolescents attending 

Bandar Mas Primary Care Clinic consult health professional 

for their common health problems? Med J Malaysia 

2005;60(2):134–139. 

12. Doshi A, Zaheer A, Stiller MJ. A comparison of current acne 

grading systems and proposal of novel system. Int J Dermatol 

1997;36:416–418. 

13. Motley RJ, Finlay AY. Practical use of disability index in the 

routine management of acne. Clin Exp Dermatol 1992;17:1–3. 

14. Atkan S, Ozmen E, Sanli B. Anxiety, depression and nature of 

acne vulgaris in adolescents. Int J Dermatol 2000;39:354–357. 

15. Killkenny M, Merlin K. Prevalence of common skin condition 

in Australia school student: Acne vulgaris. Br J Dermatol 1998; 

139:840–845. 

16. Smithard A, Glazebrook C, Williams HC. Acne prevalence, 

knowledge about acne and psychological morbidity in mid 

adolescence: A community base study. Br J Dermatol 2001; 

145:274–279. 

17. Stathakis V, Kilkenny M, Marks R. Descriptive epidemiology 

of acne vulgaris in the community. Australas J Dermatol 

1997;38:115–123. 

18. Lucky AW, Biro FM. Acne vulgaris in early adolescent boys 

correlation with pubertal maturation and age. Arch Dermatol 

1991;172:210–216. 


19. Burton JL, Cunliffe WJ, Stafford I, Shuster S. The prevalence of 

acne vulgaris in adolescence. Br J Dermatol 1971;85:119–126. 

20. Walker N, Lewis Jones MS. quality of life and acne in Scottish 

adolescent children: use of the Children’s Dermatology Life 

quality Index (CDLqI) and the Cardiff Acne Disability Index 

(CADI). J Eur Acad Dermatol Venereol 2006;20:45–50. 

21. Motley RJ, Finlay AY. How much disability cause by acne. Clin 

Exp Dermatol 1989;14:194–198. 

22. Cotteril JA, Cunliffe WJ. Suicide in dermatological patients. Br 

J Dermatol 1997;137:246–250. 


AKNOWLEDGEMENTS 

Permission to use the Cardiff 

Acne Disability Index was 

obtained from Prof Andrew 

Finlay, Department of 

Dermatology, University of 

Wales College of Medicine, 

Cardiff, UK and permission 

to use the Acne Management 

questionnaire was obtained 

from Dr Cris Glazebrook, 

Behavioural Section, Division 

of Psychiatry, queens Medical 

Centre, Nottingham, UK. 






1 Department of General 

Practice & Primary Health 

Care, Faculty of Medical 

and Health Science, The 

University of Auckland, 


2 Department of Maori Health 

(Te Kupenga Hauora Maori), 

Faculty of Medical and Health 

Science, The University of 

Auckland 


Practice, University of 

Melbourne, Victoria, Australia 

4 Department of Psychological 

Medicine, University of 

Auckland 

5 Department of Statistics, 

University of Auckland 


2009;1(1):26–29. 


Bruce Arroll 

Head of the Department 

of General Practice and 

Primary Health Care, 

Faculty of Medical and 

Health Sciences, The 


PB 92019, Auckland, 

New Zealand 

b.arroll@auckland.ac.nz 

The prevalence of depression among Maori 

patients in Auckland general practice 

Bruce Arroll MBChB, PhD, FRNZCGP; 1 Felicity Goodyear-Smith MBChB, MGP, FRNZCGP; 1 Ngaire Kerse 

MBChB, PhD, FRNZCGP; 1 Melanie Hwang; 1 Susan Crengle MBChB FAFPHM (RACP); 2 Jane Gunn MBBS, 

PHD; 3 Tana Fishman DO, Am Osteo Bd Cert Fam Prac, FRNZCGP; 1 Simon Hatcher MBBS, MRCPsych, 

FRANZCP; 4 Sanat Pradhan MSc; 5 Karishma Sidhu MSc 5 

ABSTRACT 

INTRODUCTION: There has been concern over high rates of mental illness in Maori. Previous studies in 

general practice have had small sample sizes. 

AIM: To determine the prevalence of major depression among Maori patients in Auckland general practice 

using the CIDI and the PHq as measurement tools. 

METHODS: This prevalence study is part of a larger randomised trial. The patients were recruited from 

77 general practitioners from around Auckland who could provide a private room for interviewing. The 

patients were invited to participate in the waiting room and all consecutive patients were approached. For 

this study all patients received a computerised CIDI examination and one third received a PHq assessment 

prior to getting the CIDI. The interviewer was blind to the questionnaire results when the patient 

did the CIDI. 

RESULTS: There were 7994 patients approached from whom there were data on 7432. The prevalence 

of Maori in the study was 9.7%. The overall 12-month prevalence of major depression based on the CIDI 

was 10.1% 95%CI (8.8 to 11.4). For Maori the prevalence was 11.5% 95%CI (8.8 to 14.2) and for non- 

Maori 10.1% 95%CI (8.6 to 11.3). For Maori men and Maori women the prevalence was 8.5% and 13.4% 

and for non-Maori men and non-Maori women it was 8.3% and 11.1%. The prevalence of depression over 

at least the previous two weeks on the PHq ≥9 for all participants was 12.9% 95%CI (11.2 to 14.5). 

DISCUSSION: The prevalence of depression among Maori is high, but not as high as earlier studies. This 

may be due to the bigger sample size of this study. 

KEyWORDS: Maori, prevalence, depression, primary care, general practice, New Zealand 

Introduction 

Maori have had poorer mental health for decades 

while clear evidence has been collected in the 

last 20 years. 1,2 In particular, a concern about 

high rates of depression among Maori has been 

suggested, with few confirming studies. Increasingly, 

differences in mental health service use 

and clinical characteristics between different 

ethnic groups have been reflected in the official 

statistics, while recent studies have found 

positive evidence of disparities between Maori 

and non-Maori populations at both primary and 

secondary levels of care. 3,4 

The most recent investigation on mental health 

in general practice found higher rates of major 

depression among Maori general practice attenders 

(46.4% in Maori while 15.4% in non-Maori 

in the last 12 months) 5 with the highest rates of 

depression in female Maori patients (55.2%) and 

the greatest ethnological disparity between Maori 

and non-Maori women. However, these findings 


were based on a small number (n=81) of Maori 

respondents; therefore it is not clear how generalisable 

this information is. The New Zealand 

Mental Health survey was a national study which 

included 2595 Maori. The results from this community 

sample reported a mood disorder in Maori 

of 11.4% (12-month prevalence) versus 7.4% in the 

general population. 6 

Our study looks at the prevalence of depression 

among Maori patients in Auckland general 

practices in participants recruited as part of a 

randomised trial. 

Methods 

This paper uses data from a randomised control 

trial of the Patient Health Questionnaire (PHQ), 7 

the Two Question With Help Questionnaire 

(TQWHQ) 8 and no screening in general practice. 

The PHQ has nine questions based on the DSM- 

IV. The TQWHQ is a three-question screening 

tool. This paper reports the prevalence of depression 

as detected in recruited participants. All 

participants completed the computerised CIDI 

(Composite International Diagnostic Interview) 

to evaluate the presence of depression as a gold 

standard. 9,10 The PHQ was administered to one 

third of the sample. RCT methodology and 

results will be reported in mid-2009. 

Recruitment of general practitioners 

All general practitioners in Auckland who 

worked greater than four-tenths in practice were 

eligible for the study. All eligible patients who 

gave informed consent were enrolled. A fee of $9 

per patient was paid to each GP to compensate for 

time spent asking the patient to meet with the 

interviewer, and reassessing patients found to be 

suicidal on the questionnaires. General practices 

in Auckland had to be able to provide a separate 

room for patient interviews. The study took place 

from 2006 to 2009. 

Recruitment of patients/index consultation 

Patients were eligible for the study if they were 

able to communicate in English, were aged over 

16 years, and were not suffering from any brain 

injury, dementia, terminal illness or intoxication. 


What we already know: Based on small studies, the prevalence of depression 

in Maori patients is high compared to non-Maori. 

What this study adds: The rates of depression in a larger group of Maori 

are high, but lower than previously estimated. 

Consecutive patients were approached in the waiting 

room and asked to participate in the study. 

Patients were recruited consecutively in order to 

obtain an adequate spectrum of disease as part of 

screening and diagnostic test studies. After providing 

written informed consent they were asked 

to go to a private room to complete the study 

procedures. The interviewer was blind to the 

screening questionnaire results when the patients 

did the CIDI. The study was conducted according 

the principles of the STARD statement. 11 

Ethnicity was determined by self-selection as part 

of the screening questionnaire based on the 2006 

New Zealand census. Individuals could pick more 

than one ethnicity. Those who chose Maori only 

or Maori in addition to other ethnicities were 

considered Maori and those who did not chose 

Maori at all were considered to be non-Maori. A 

subgroup analysis was conducted of those who 

chose only Maori. 

Ethics approval 

The methods and procedures used in this study 

were approved by the Northern Y Regional 

Ethics Committee, Ministry of Health. (Ethics 

approval number NTY/06/09/080). 

Statistical methods 

All statistical analyses were carried out using 

STATA data analysis and statistical software version. 

The analysis was done using STATA v3 to 

take into account the effect of clustering by GP. 

Results 


The number of patients approached was 7994 

from whom there were 337 refusals (4.2%) and 

225 incomplete interviews (either patients did not 

complete the screening questionnaire or did not 





get the CIDI). On average, 96 participants (range 

4–228) were recruited from each of 77 general 

practitioners and 67 of the GPs contributed Maori 

patients (average of 11 Maori per GP, range 1–48). 

The demographics are shown in Table 1 which 

shows that 9.7% of the sample were Maori and 

Maori patients were younger than non-Maori patients. 

Table 2 shows the major depression in the 

previous 12 months in terms of a Diagnostic and 

Statistical Manual (DSM) IV diagnosis reported 

on the CIDI computer and for PHQ score ≥ 9, 12 

and 14 (available on one third of participants). 12 

The prevalence of depression as recorded by the 

PHQ for more than two weeks is higher than 

the CIDI for the previous 12 months. A PHQ 

score ≥ 9 indicates major depression. A sensitivity 

analysis was conducted using those who chose 

Maori as their only ethnic group. This resulted 

Table 1. Demographic characteristics of general practice attenders by ethnicity 

Overall 

n = 7432 

Maori 

n = 721 

Non-Maori 

n = 6711 

Mean age 49 39 50 

Median age 48 37 49 

Age range 16–99 16–82 16–99 

Gender 

Female 4460 (60%) 449 (62%) 4208 (63%) 

Male 2973 (40%) 272 (38%) 2504 (37%) 

in a slightly lower prevalence for only Maori (on 

CIDI) 9.6% versus 11.5% for all Maori for overall 

depression; 11.9% versus 13.4% for Maori women 

and 5.9% versus 8.4% for Maori men respectively. 

Discussion 

Our results show that depression is a significant issue 

for Maori and consistent with the New Zealand 

Mental Health survey and the MaGPIe study, 

although the differences between Maori and non- 

Maori were not significantly different in our study. 

Qualitatively our results were lower than those 

reported in the MaGPIe study. A sensitivity 

analysis using those who chose Maori as their 

only ethnicity had a slightly lower prevalence of 

depression than with those who chose Maori and 

at least one other. The numbers are too small for 

interpretation to be made. 

The strengths of this study include the high 

response rate and the large number of Maori 

recruited from general practice. The methodology 

was simple with recruitment followed immediately 

by a computerised gold standard CIDI 

interview. Thus the PHQ findings and the CIDI 

findings are from the same day. 

A weakness of this study is that the GPs were 

not chosen randomly. However it was necessary 

Table 2. Prevalence of depression according to CIDI-DSM-IV major depressive disorder and PHQ scores among general practice attenders by gender 

and ethnicity. Proportion (95% confidence interval) 

Overall All non-Maori All Maori Non-Maori 

men 

28 VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE 

Maori 

men 

Non-Maori 

women 

Maori 

women 

CIDI N = 7432 N = 6711 N = 721 N = 2697 N = 272 N = 4014 N = 449 

CIDI +ve* 10.1% 

(8.8, 11.4) 

10.1% 

(8.6, 11.3) 

11.5% 

(8.8,14.2) 

8.3% 

(6.9, 9.8) 

8.5% 

(4.7, 12.2) 

11.1% 

(9.5, 12.7) 

13.4% 

(10.2, 16.5) 

PHQ** N = 2497 N = 2240 N = 257 N = 903 N = 84 N = 1337 N = 173 

> 9 12.9% 

(11.2, 14.5) 

≥ 12 9.2% 

(7.7, 10.7) 

>14 5.2% 

(4.2, 6.2) 

12.6% 

(10.9, 14.2) 

9.0% 

(7.5, 10.5) 

* Positive for major depression in the last 12 months. 

15.2% 

(10.3, 20.0) 

11.3% 

(6.6, 15.9) 

10.2% 

(8.3, 12.1) 

** Sub-sample assessed with the PHq depression screen—relates to at least the past two weeks. 

( ) = 95% confidence interval adjusted for clustering by GP. 

11.9% 

(5.9, 17.9) 

12.7% 

(9.2, 16.2) 

16.8% 

(10.7, 22.7)

to have practices with a spare room available to 

conduct the gold standard interviews. The other 

weakness is that this study may be underpowered 

to find true differences. The CIDI has been criticised 

for use in surveys other than those wanting 

an epidemiological estimate. In one review of the 

PHQ it was thought that a cut point of ≥ 12 for 

the PHQ may give a closer estimate to the CIDI. 13 

In our study a cut point of ≥ 12 would make a 

prevalence of 9.2% (on PHQ) versus 10.1% (CIDI) 

versus 12.9% with a cut point of ≥ 9. The PHQ 

relates to at least the previous two weeks while 

the CIDI can be the previous month to the previous 

year. It is not clear which is the better gold 

standard and further work may be required. 

The other NZ general practice study is the 

MaGPIe study. 5 It reported 12-month major 

depression prevalence rates for Maori women as 

55.2% (95%CI 33%–77.4%) and for Maori men as 

21.3% (95% CI 2.3%–40.3%). While the confidence 

interval estimates for Maori men in the MaGPIe 

study include our point estimate, the rate for 

women does not. The difference may lie in the 

different location (Wellington versus Auckland) 

or in the different sample sizes (MaGPIe n=81) 

and our study (721). There have also been a 

number of national depression initiatives which 

may have reduced the burden of depression and 

the national unemployment rate was dropping 

until the final quarter of 2008. The other issue 

is that of the methodology. The MaGPIe study 

screened patients with the GHQ (General Health 

Questionnaire) and then required the patient to 

return for a second interview. This more complicated 

methodology may have biased the results 

toward a higher prevalence estimate. 

These findings on prevalence of depression 

were consistent with other studies investigating 

similar issues overseas, as minority populations 

in other countries, including native Americans 

and US Hispanics, have higher rates of mental 

disorders 14,15 and the disparities were also shown 

in migrant populations in the United Kingdom. 16 

The picture of depression among Maori patients 

in general practice suggests that it is at least as 

high as that in non-Maori and most likely to be 

higher, particularly for women. The previous 

estimates may have overestimated the prevalence 

but it may be better to research interventions 

acceptable to and effective for Maori rather than 

obtaining a more precise estimate of the problem. 

References 


1. Durie M. Mental health and Maori development. ANZ J Psychiatry 

1999;33:5–12. 

2. Edmonds LK, Williams S, Walsh AES. Trends in Maori mental 

health in Otago. ANZ J Psychiatry 2000;36:677–683. 

3. Trauer T, Eagar K , GM. Ethnicity, deprivation and mental 

health outcomes. Aust Health Rev 2006;30(3):310–321. 

4. Bushnell J. Mental disorders among Maori attending their 

general practitioner. ANZ J Psychiatry 2005;39:401–406. 

5. The MaGPIe Research Group UoOaWSoMaHS. Mental disorders 

among Maori attending their general practitioner. ANZ J 

Psychiatry 2005;39:401–406. 

6. Oakley-Browne MA, Wells EJ, Scott KMe. Te Rau Hinengaro: 

The New Zealand mental health survey. Wellington, New 

Zealand: Ministry of Health; 2006. 

7. Nease DE, Malouin JM. Depression screening:a practical 

strategy. J Fam Pract 2003;52:118–26. 

8. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect 

of the addition of a ‘help’ question to two screening questions 

on specificity for diagnosis of depression in general practice: 

diagnostic validity study. BMJ 2005;15 Sept 2005(http://bmj. 

com/cgi/content/abstract/bmj.38607.464537.7Cv1?ecoll). 

9. Andrews G, Peters L, Guzman AM, Bird K. A comparison of 

two structured diagnostic interviews: CIDI and SCAN. Aust 

NZ J Psychiatry 1995;29:124–32. 

10. Peters L, Andrews G. Procedural validity of the computerised 

version of the Composite International Diagnostic 

Interview (CIDI-Auto) in the anxiety disorders. Psychol Med 

1995;25:1269–80. 

11. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou 

PP, Irwig LM, et al. Towards complete and accurate reporting 

of studies of diagnostic accuracy: the STARD initiative. BMJ 

2003;326:41–4. 

12. American Psychiatric Association. Diagnostic and statistical 

manual of mental disorders (fourth edition) DSM-IV-TR. APA 

Washington, DC; 2000. 

13. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for 

depression in medical settings with the Patient Health questionnaire 

(PHq): a diagnostic meta-analysis. J Genl Intl Med 

2007;22(11):1596–602. 

14. Lewis-Fernandez R, Das AK, Alfonso C, Weissman MM, Olfson 

M. Depression in US Hispanics: Diagnostic and Management 

Considerations in Family Practice. J Am Board Fam Pract 

2005;18:282–296. 

15. Office SGs. Mental Health: A Report of The Surgeon General. 

Washington, DC: Office of the Surgeon General; 1999. 

16. Bhugra D. Migration and depression. Acta Psychiatrica Scandinavica 

2003;Suppl 418:67–72. 


ACKNOWLEDGEMENTS 

This study was funded 

by a grant from the 

Health Research Council 

of New Zealand. 





MIXED METHOD RESEARCH 

1 School of Pharmacy, 

University of Otago, Dunedin, 


2 Health Services Research 

Centre, Victoria University, 

Wellington 

3 Massey University, Albany, 

Auckland 

4 Maria’s HealthCare 

Pharmacy, Apia, Samoa 


2009;1(1):30–35. 


Pauline Norris 

School of Pharmacy, 

University of Otago, 

Box 913, Dunedin 

pauline.norris@otago.ac.nz 

Understanding and use of antibiotics 

amongst Samoan people in New Zealand 

Pauline Norris MA, PhD; 1 Marianna Churchward; 2 Fuafiva Fa’alau; 3 Cecilia Va’ai 4 

ABSTRACT 

INTRODUCTION: Use of antibiotics is high in Samoa and this may affect the expectations and patterns 

of antibiotic use of Samoans in New Zealand. 

AIM: This study examined the understanding and reported use of antibiotics amongst Samoans in New 

Zealand. 

METHODS: In-depth interviews were held with 13 Samoans in New Zealand. These interviews were 

analysed and used to develop a questionnaire that was administered to 112 Samoans attending health 

care facilities in New Zealand. 

RESULTS: Many participants had little understanding of antibiotics. Less than 2% identified the correct 

purpose for antibiotics, and 66% thought they were used to relieve pain. Respondents regarded a wide 

range of medicines (including some which they regularly took) as antibiotics. They frequently attributed 

colds and flu to environmental conditions (96%), and regarded antibiotics as a useful treatment for them 

(81%). They reported stopping taking antibiotics before finishing the course. Very few (8%) were aware of 

antibiotic resistance. 

DISCUSSION: Health care practitioners cannot assume that patients share a Western scientific understanding 

of which illnesses are caused by microbes, or what antibiotics are or do. People may have 

significant confusion about the medicines they take. Samoans, whether they are born in New Zealand or 

not, may hold traditional Samoan views about health and illness. 

KEyWORDS: Antibiotics, lay knowledge, URTI (upper respiratory tract infections), Samoa, New Zealand 

Introduction 

Antibiotic resistance is a serious and growing 

problem. 1-3 This is due to high overall use, but 

sub-optimal patterns of use, such as incomplete 

treatment courses, may also be important. 2 

There are approximately 130 000 Samoans in 

New Zealand, of whom 60% were born in New 

Zealand. 4 Pacific people in general, of whom 49% 

are Samoan, have shorter life expectancy, poorer 

health, higher rates of diabetes, higher mortality 

rates from cardiovascular disease and stroke than 

the general population. 5 There are several reasons 

to assume that antibiotic use might be high 

amongst Samoans in New Zealand. Pacific people 

have lower socioeconomic and health status and 

higher rates of infectious diseases than other 

New Zealanders. 6 In the general population lower 

socioeconomic status is linked to higher rates of 

infectious diseases 7,8 and higher use of antibiotics. 

9 In Samoa the use of antibiotics is high, and 

antibiotics are available without prescription from 

pharmacies. 10 This may affect Samoan people’s expectations 

of treatment and patterns of antibiotic 

use in New Zealand. One clone of community-acquired 

methicillin-resistant Staphloccocus aureus 

has been labelled Western Samoan Phage Pattern 

(WSPP) MRSA, because its prevalence amongst 

Samoans and other Pacific Islanders suggests that 

it may have emerged in Samoa. 1 In addition, the 

prevalence of traditional beliefs about health 

and illness may mean that Samoan people use 

antibiotics in ways that are not consistent with 

Western scientific beliefs. 


Misunderstandings about antibiotics are common 

in a wide range of populations studied. 12-15 This 

study aimed to investigate understandings and use 

of antibiotics amongst Samoans in New Zealand. 

It did not aim to compare the level of knowledge 

of Samoans and non-Samoans in New Zealand, 

nor does it assume that Samoans have lower levels 

of knowledge than other New Zealanders. 

Methods 

In-depth interviews were held with 13 Samoans 

in New Zealand in 2005–2006. These interviews 

were audio-taped, transcribed, and those 

in Samoan were translated into English. They 

were coded and analysed using nVivo. Themes 

were developed from the aims of the project, 

the results of previous studies, and inductively 

from the interviews. Analysis was discussed 

amongst team members, and the material from 

the interviews was used to develop a questionnaire 

exploring knowledge and use of antibiotics. 

This questionnaire was administered to 112 

Samoans. All interviews (in-depth and questionnaire) 

were carried out by Samoan members of 

the research team. 

Respondents for the in-depth interviews were 

identified through the researchers’ informal 

networks in Auckland and Wellington. Respondents 

for the questionnaire were identified 

through health services catering primarily to 

Pacific people in Auckland and Wellington. All 

Samoan patients using the clinic during the times 

when the researcher was present were invited to 

participate. 

Both in-depth interviews and the survey were 

carried out either in Samoan or English. The seven 

in-depth interviews in Samoan were translated 

into English. An identical questionnaire layout in 

Samoan and English was used, so that translation 

was not necessary for the questionnaire analysis. 

Ethical approval for the study was granted by 

Wellington and Auckland ethics committees 

(AKX/04/07/194). Informed consent was 

obtained from all participants. Information 

sheets and consent forms were provided in 

English or Samoan. 


What we already know: Many studies have shown gaps in public knowledge 

about antibiotics, but none have looked specifically at Samoans. 

What this study adds: Significant misunderstandings by Samoans living 

in New Zealand are common. Primary health care practitioners should not 

assume that patients share their understandings of antibiotics or microbial 

illness. 

Results 

Semi-structured interviews 

Most of the participants (11/13) were female 

and their ages ranged from 29 to 82 years of 

age. Eight were born in Samoa, and five in New 

Zealand. The semi-structured interviews revealed 

significant misunderstandings and lack of knowledge 

of antibiotics. Some respondents consistently 

confused antibiotics with painkillers, while 

others had inconsistent understandings, which 

changed throughout the interview. 

Interviewer: What do you think antibiotics do? 

Participant: They do—they heal don’t they? 

They’re supposed to relieve the pain I guess. 


There were frequent confusions between antibiotics 

and other medication. One respondent, 

speaking of her nephew with epilepsy: 

Interviewer: Do you remember what medication 

he was on? 

Participant: He was definitely on some sort of 

antibiotics but I have no idea what they were, I 

will have to ask my sister. I think it was two lots 

of different ones. 

Antibiotics were frequently confused with paracetamol 

and other analgesics. However, during 

the interviews they were also confused with allopurinol, 

epilepsy medication, topical NSAIDs, 

asthma inhalers, Indocid, fluoxetine, and a 

urinary alkaliniser. This sort of confusion was 

common even in respondents who told us that 

antibiotics were medicines to kill bacteria. 





Figure 1. What do antibiotics do? 

Many respondents reported use of incomplete 

courses, and storing of leftover antibiotics. 

Respondent: I think the way my family uses 

antibiotics is typical. 

Interviewer: What do you mean by that? 

Respondent: They use it and when they feel 

better they stop using them. And they will keep 

them for later use. 

A small number of respondents reported receiving 

advice about appropriate use of antibiotics 

from health professionals, which sometimes appeared 

to have changed their attitudes or behaviour. 

Some perceived that doctors in New Zealand 

had become less likely to prescribe antibiotics: 

Interviewer: So who suggested that you take 

these…who decided that you should use them? 

Respondent: Usually the doctor, but that was in 

the time when they gave them out pretty freely, 

nowadays they’re not as generous with antibiotics 

I find…you even have to ask ‘could we have an 

antibiotic?’ and they would generally say ‘no, let 

your own system fight it’ and they will tell you 

to go home and drink lots of water and fluids. 

Respondents could select more than one option. If they selected both a correct option 

(‘kill bacteria’) and an incorrect one such as ‘relieve pain’, their answer was counted as 

incorrect. Respondents who chose the answer ‘kill bacteria’ with no other option, or ‘kill 

bacteria’ and ‘heal illnesses’ with no other option were classified as correct. 

A minority of respondents remembered being 

told to complete courses of antibiotics, and one 

knew from reading medicine labels: 

Respondent: I remember when I was given antibiotics 

I make sure I take them all before. 

Interviewer: Do you? 

Respondent: It always says on the thing that you 

make sure you take all your antibiotic until you 

finish it off, yeah. 

Interviewer: And you do? 

Respondent: Yeah. 

Survey 

One hundred and twelve people completed the 

questionnaire; an approximate response rate 

of 84%. Fifty-three percent of the sample were 

female. Nine percent were under 20 years old, 

31% were between 20 and 40 years old, 36% were 

40 and 60, and 24% were over 60 years old. Most 

(83%) were born in Samoa, with the others born in 

New Zealand (17%). For those born in Samoa, the 

average length of residence in New Zealand was 

14 years, with a range from six months to 40 years. 

Of those born in New Zealand, only one had lived 

in Samoa for a short time. The others had either 

not been to Samoa, or only been for holidays. 

Only two of the 112 people interviewed gave a 

correct answer to the question ‘What do antibiotics 

do?’ Responses were categorised as correct 

if they were ‘kill bacteria’ or ‘kill bacteria’ and 

‘heal illness’, but no other responses. Although 

half the sample (49%) correctly stated that antibiotics 

kill bacteria, this was a less popular answer 

than ‘kill viruses’ (65%), ‘relieve pain’ (66%), and 

‘strengthen the immune system’ (54%). (Figure 1) 

Just over half the sample (54%) correctly identified 

antibiotics from a list of medicines. Amoxycillin 

was correctly identified as an antibiotic 

by 81% of the sample, and Augmentin by 80%. 

However, the other medicines listed: ‘metformin 

for diabetes’, ‘allopurinol for gout’, paracetamol, 

coldral/coldrex, asthma inhalers, were also identified 

as antibiotics (Figure 2). 


Colds were more commonly attributed to environmental 

rather than microbial causes (96% vs 42%). 

Environmental causes were changes in the weather 

(92% of respondents), dust (57%) and getting cold 

(50%). Thirteen (20%) of those who thought that 

dust caused colds were born in New Zealand. 

Respondents were asked, ‘If you had a cold/ 

fulu* for three days, with coughing, heavy nose, 

and headache, what would you do?’ Almost all 

respondents (99%) said they would see a doctor 

or nurse, and over half reported that they would 

take medicines (46%). Panadol or paracetamol 

was by far the most common medicine reported 

(51/56 medicines listed). Hot drinks (35%), rest 

(28%), and traditional Samoan fofo (29%) were 

also commonly reported responses. 

Participants were asked what medicines they had 

taken in the last month, and what for. Sixteen 

people identified antibiotics (amoxicillin, augmentin, 

doxycycline, penicillin) which they reported 

that they had taken for flu, lung infections, 

infected chest, sore throat, throat infections, fissures, 

‘bad flu’, knee injury, chest pain/infection, 

eczema, boils, and tonsillitis. 

Of the two people who reported taking allopurinol 

in the last month, one had earlier indicated 

that allopurinol was an antibiotic. Of the 11 

people who reported taking metformin, eight had 

earlier indicated that metformin was an antibiotic. 

All but one of these people gave very wide interpretations 

of what antibiotics did, saying that they 

relieved pain, strengthened the immune system, 

killed viruses and bacteria, and healed illness. 

Of the 57 people who reported taking paracetamol 

in the last month, three thought this was an 

antibiotic. None of these three thought antibiotics 

relieved pain. Two thought they killed bacteria, 

and two thought they killed viruses. Two took the 

paracetamol for flu and one for a headache. 

Eighty-one percent of the sample believed antibiotics 

were useful for colds and flu, and four 

percent were not sure. Antibiotics were believed 

to prevent colds and flu getting worse (68%), help 

people get better sooner (62%), relieve symptoms 

(57%), and prevent serious illness (35%). 

* ‘Fulu’ is Samoan for cold or flu. 

Figure 2. Which medicines are antibiotics? 

Forty-six percent of people said they would stop 

taking antibiotics when they got better (rather 

than when the course was finished). When asked 

what they would do with leftover antibiotics, 

54% said they would keep them, 46% said they 

would throw them out, and 3% said they would 

give them to someone else. No one said they 

would return them to a pharmacy. 

When asked if antibiotics have any bad effects, 

half of the sample were unsure, and 39% thought 

they did. The ‘bad effects’ identified were allergy 

(34% of the whole sample), diarrhoea (31%), 

thrush (14%), damaging the immune system 

(13%), germs getting used to antibiotics (8%), 

‘people start to dependent on them’ (3%), inability 

to drink alcohol (1%), and overdose (1%). 

Discussion 


Respondents could select more than one option. Respondents’ answers were classified 

as correct if they chose ‘Amoxil/amoxycillin’ with no other option, or ‘Augmentin’ with 

no other option, or ‘Amoxil/amoxycillin’ and ‘Augmentin’ with no other option. If, for 

example, a respondent said panadol and amoxil were antibiotics, their answer was 

counted as ‘incorrect’. 

Both the in-depth interviews and the questionnaire 

suggest that many Samoan people have 

little understanding of antibiotics, and regard 

a wide range of medicines as antibiotics (even 

medicines they have personal experience of). The 

responses suggest that Samoan people frequently 





attribute colds and flu to environmental conditions, 

rather than microbes. They regard antibiotics 

as a useful treatment for colds and flu, 

frequently stop taking them before finishing 

the course, and very few are aware of antibiotic 

resistance. Ironically, stopping taking antibiotics 

‘prematurely’ for those with a common cold will 

probably reduce resistance while such behaviour 

could be harmful for diseases with serious consequences 

such as streptococcal tonsillitis (and its 

relation to rheumatic fever). 

The survey involved a small sample of people 

who were visiting health care practitioners. The 

interview process was very time-consuming and 

so the sample size of 112 was decided by practical 

constraints rather than a power calculation. Thus 

caution should be used when extrapolating to the 

general Samoan population, and further research 

is needed. However, this is the first information 

available on Samoan knowledge and understanding 

of antibiotics. There were some difficulties 

in translating the terms ‘bacteria’ and ‘virus’ into 

It cannot be assumed that patients share Western 

scientific understandings about which illnesses are 

caused by microbes, which illnesses are viral, and 

which are bacterial, or what antibiotics are or do 

Samoan, so caution should also be used in interpreting 

results concerning these. 

Studies overseas have also found misconceptions 

and lack of knowledge about antibiotics. For example, 

8% of people interviewed in 1976 thought 

aspirin was an antibiotic 12 and only half of the 

respondents in another knew that codeine was 

not an antibiotic and some thought Robitussin 

was an antibiotic. 13 

The interviews reported here are part of a larger 

study looking at knowledge and use of antibiotics 

amongst Samoan people in Samoa and New 

Zealand. In Samoa itself, participants reported 

routine use of antibiotics for colds and flu. This 

seems to be encouraged by prescribing patterns. 

Antibiotics are also available without prescription 

from pharmacies. 10 

The belief that exposure to cold and changes in 

weather can cause colds may also be common in 

Western cultures. 16 However, to our knowledge, 

the belief that dust causes colds and flu has not 

been reported elsewhere, although it may have 

been part of medical orthodoxy some time ago. 17 

In this study, Samoans born in New Zealand 

were just as likely to report this belief as those 

born in Samoa. This suggests that health care 

professionals cannot assume that New Zealand– 

born Samoans completely share Western ideas 

about health. 

A previous study found that 42% of the population 

of a New Zealand town had taken antibiotics 

in the last year. 9 In this study, 14% reported 

taking antibiotics in the last month. It is difficult 

to compare these numbers because the survey 

was administered with a sample of those visiting 

health care providers, rather than a general 

population sample. 

Curry et al. found that most people taking 

antibiotics for URTI believe that they help 

symptoms (85%) and shorten the course of URTI 

(80%). 14 Respondents in our study of Samoan 

people also commonly believe that antibiotics 

have these effects, and they also believe antibiotics 

prevent URTIs getting worse, and prevent 

serious illness. 

Respondents in our study of Samoan people 

reported a very high level of use of health care 

providers for colds/flu (99% said they would see 

a doctor or nurse for a cold lasting three days). In 

contrast, Curry et al. reported that only 15% of 

their general population–based sample said they 

would usually see a doctor about an URTI. 14 

This study provides several messages for health 

care professionals. It cannot be assumed that 

patients share Western scientific understandings 

about which illnesses are caused by microbes, 

which illnesses are viral, and which are bacterial, 

or what antibiotics are or do. People may have 

significant confusions about what the medicines 

they take actually do. Even Samoans who are 


orn in New Zealand may hold traditional Samoan 

views about health and illness, rather than 

Western ones. However there is some evidence 

that explanations about appropriate use of antibiotics 

given by individual doctors and pharmacists 

make a difference. 

While the results show the need for targeted 

health promotion about antibiotics in the Samoan 

community, they also suggest that caution is 

needed. Because many Samoan people were unable 

to distinguish antibiotics from other medicines, 

there is a risk that they may reduce use of 

other essential medicines, such as metformin if 

they are warned about the dangers of antibiotic 

use. Messages about appropriate (non-antibiotic) 

management of colds and flu, building on existing 

culturally-based practices, would be safest 

strategy in this context. 

References 

1. Standing Medical Advisory Committee Sub-Group on Antimicrobial 

Resistance. The Path of Least Resistance. Department 

of Health (UK); 1998. 

2. World Health Organization. WHO Global Strategy for Containment 

of Antimicrobial Resistance. WHO; 2001. 

3. Ellis-Pegler R. Editorial: Antimicrobial resistance—can we, 

should we do anything about it? NZ Med J 1999;112:249–351. 

4. Ministry of Health NZ. Tagata Pasifika—Pacific Health. New 

Zealand: Ministry of Health; 2007. 

5. Ministry of Health NZ. Pacific People’s Health. New Zealand: 

Ministry of Health; 2007. 

6. Ministry of Health NZ. Pacific Health: Pacific People’s Health. 

7. Davey Smith G, Neaton J, Wentworth D, Stamler R, Stamler 

J. Socioeconomic differentials in mortality risk among men 

screened for the Multiple Risk Factor Intervention Trial: 

Part 1—results for 300,685 white men. Am J Public Health 

1996;86:486–96. 

8. Salmond C, Crampton P. Deprivation and health. In: Howden- 

Chapman P, Tobias M, editors. Social inequalities in health: 

New Zealand 1999. Wellington: Ministry of Health; 2000. 

9. Norris P, Ecke D, Becket G. Demographic Variation in the use 

of antibiotics in a New Zealand town. NZ Med J 2005;118. 

10. Norris P, Nguyen H. Consumption of antibiotics in a small Pacific 

Island nation: Samoa. Pharmacy Practice 2007. 5: http:// 

www.pharmacypractice.org/vol05/01/toc.htm. 

11. Smith S, Cook G. A decade of community MRSA in New 

Zealand. Epidemiol Infect 2005;1–6. 

12. Chandler D, Dougdale A. What do patients know about antibiotics? 

Lancet 1976;2:422. 

13. Hong J, Philbrick J, Schorling J. Treatment of upper respiratory 

infections: do patients really want antibiotics? Am J Med 

1999;107:511–515. 

14. Curry M, Sung L, Arroll B, Goodyear-Smith F, Kerse N, Norris 

P. Public views and use of antibiotics for the common cold 

before and after an education campaign in New Zealand. NZ 

Med J 2006;119. 

15. Eng JV, Marcus R, Hadler JL, Imhoff B, Vugia DJ, Cieslak PR, 

Zell E, Deneen V, McCombs KG, Zansky SM, Hawkins MA, 

Besser RE. Consumer attitudes and use of antibiotics. Emerg 

Infect Dis 2003;9:1128–1135. 


16. Lee GM, Friedman JF, Ross-Degnan D, Hibberd PL,Goldmann 

DA. Misconceptions about colds and predictors of health 

service utilization 10.1542/peds.111.2.231. Pediatrics 2003; 

111:231–236. 

17. Neuwelt L. How to avoid colds. Am J Nurs 1918;18:371–373. 



We wish to thank the 

Health Research Council of 

New Zealand for funding 

the study, the health care 

providers who allowed us 

to interview their patients, 

and the participants. 





SYSTEMATIC REVIEW 

1 Section of Epidemiology 

& Biostatistics, School of 

Population Health, Faculty of 

Medical and Health Science, 

The University of Auckland, 



Practice and Primary Health 

Care, School of Population 

Health, Faculty of Medical 




3 School of Rehabilitation and 

Occupation Studies, AUT 

University, Auckland 


2009;1(1):36–41. 


Gillian Robb 

Section of Epidemiology 

& Biostatistics, School 

of Population Health, 


Private Bag 92019, 


g.robb@auckland.ac.nz 

Summary of an evidence-based guideline 

on soft tissue shoulder injuries and related 

disorders—Part 1: Assessment 

Gillian Robb MPH (Hons), Dip Physiotherapy, Dip Ergonomics; 1 Bruce Arroll MBChB, PhD, FRNZCGP; 2 Duncan 

Reid MHSc (Hons), PGD (Manip Physiotherapy), MNZCP; 3 Felicity Goodyear-Smith MBChB, MGP, FRNZCGP 2 

ABSTRACT 

AIM: To provide a succinct summary of the diagnosis of soft tissue injuries to the shoulder for primary 

health care practitioners based on the New Zealand guideline. 

METHODS: A multidisciplinary team developed the guideline by critically appraising and grading 

retrieved literature using the Graphic Appraisal Tool for Epidemiology (GATE). Recommendations were 

derived from resulting evidence tables. 

RESULTS: Diagnostic ultrasound is a valid tool for the diagnosis of a full thickness rotator cuff tear. If 

a significant tear is suspected, referral for diagnostic ultrasound is recommended. There is a paucity of 

evidence for the diagnosis of soft tissue shoulder injuries and most recommendations are based on the 

consensus of the guideline team. 

CONCLUSION: Assessment relies on thorough history-taking and physician examination with appropriate 

referral where there is evidence of serious damage or the diagnosis remains unclear. 

KEyWORDS: Shoulder, shoulder pain, diagnosis, soft tissue injuries 

Introduction 

Soft tissue shoulder injuries rank within the top 

three injury sites for nearly all major sport and 

recreational activities. 1 Not only do they represent 

a significant cost to the Accident Compensation 

Corporation (ACC), if poorly managed they can 

result in significant disability and loss of quality 

of life. In 2003 ACC commissioned a guideline 

for the diagnosis and management of common 

soft tissue shoulder injuries to reduce identified 

variation in diagnosis and management and to 

improve outcomes for claimants. 2 

The diagnosis and management of shoulder 

injuries is one of the most challenging areas of 

musculoskeletal medicine. Pathologies and their 

clinical manifestations vary widely from person 

to person and pathologies often co-exist, further 

compounding the diagnostic complexity. 

This paper is the first of a two-part series which 

summarises the evidence for the diagnosis of soft 

tissue shoulder injuries based on the evidencebased 

guideline The diagnosis and management of 

soft tissue shoulder injuries and related disorders. 2 

This guideline was developed in New Zealand 

(NZ), led by Effective Practice, Informatics & 

Quality improvement (EPIQ), University of 

Auckland under the auspices of the New Zealand 

Guidelines Group (NZGG). The guideline was 

endorsed by the Royal New Zealand College of 

General Practitioners, the NZ Orthopaedic Asso- 


ciation, the NZ Society of Physiotherapists Inc., 

the NZ Association of Musculoskeletal Medicine, 

Sports Medicine NZ and the Royal Australasian 

and New Zealand College of Radiologists. 

The aim of this paper is to provide a succinct 

summary of the assessment of soft tissue injuries 

to the shoulder in a form that is readily accessible 

to primary health care practitioners. 

Method 

The target group for the guideline is primary 

care practitioners. In NZ this group includes 

primary care medical practitioners, physiotherapists 

and osteopaths who are able to assess soft 

tissue injuries of the shoulder and decide initial 

management. 

A broad-based multidisciplinary team (orthopaedic 

surgery, general practice, musculoskeletal 

radiology, musculoskeletal medicine, sports 

medicine, emergency medicine, physiotherapy, 

osteopathy) was convened in 2003, including 

nominated professionals and representatives for 

Maori, Pacific people and consumers. 

The team met on two occasions over a 12-month 

period. There were numerous consultations 

between members of the group throughout the 

guideline process, including several additional 

small group meetings to discuss various aspects 

of the guideline. 

This guideline summary addresses the diagnosis 

and referral of adults with the following 

shoulder injuries. Adolescents were also included 

for shoulder instabilities given that dislocation 

and recurrent dislocation are more common in 

this age group. Five pathological groupings were 

considered as reflective of the main soft tissue 

disorders seen in primary care. These were: 

1. Rotator cuff disorders (including 

impingement, subacromial bursitis, tendinosis, 

painful arc syndrome, partial, full thickness 

and massive tears of the rotator cuff, long 

head of biceps rupture and calcific tendonitis) 

2. Frozen shoulder (also known as adhesive 

capsulitis) 


What we already know: Shoulder injuries are both common and difficult 

to diagnose. 

What this study adds: The evidence base to diagnosis of soft tissue 

injuries to the shoulder is limited. This review offers recommendations largely 

based on expert consensus. Assessment relies on thorough history-taking 

and physician examination, with appropriate referral where there is evidence 

of serious damage or the diagnosis remains unclear. 

3. Glenohumeral instabilities (acute and 

recurrent dislocation, labral injuries and other 

instabilities) 

4. Acromioclavicular (AC) joint injuries 

(including stress osteolysis, osteoarthritis and 

dislocation) 

5. Sternoclavicular (SC) joint injuries (including 

sprains, dislocation and arthritis and related 

conditions). 

The guideline specifically excluded fractures, inflammatory 

conditions, degenerative conditions, 

endocrinological and neurological conditions, 

hemiplegic shoulder and chronic shoulder pain 

including occupational overuse disorders. 

The following diagnostic and referral questions 

were considered by the team: 

• What aspects of the history are 

diagnostic—e.g. mechanisms of injury; 

a sensation of ‘popping out’? 

• What symptoms are diagnostic, e.g. 

location of pain; dead arm? 

• What aspects of the clinical examination / 

specific tests are valid and reliable for the 

diagnosis of the included shoulder conditions? 

• What are the red flags? 

• What imaging is appropriate to 

use in making the diagnosis? 

• What are the appropriate plain films to use 

in the diagnosis of soft tissue injuries? 

• What is the place of diagnostic ultrasound? 

• What are the indications for referral 

for further evaluation? 

For each question a comprehensive literature 

search was undertaken in all major electronic 






data bases (Medline, CINAHL, EMBASE, 

AMED, SPORTdiscus and Current Contents). 

Relevant Internet sites were searched, including 

PEDro, NHS clinical trials, Health Technology 

Assessments for NHS, Bandolier and National 

Guideline Clearing House. Reference lists of 

included studies were checked for additional 

studies. Only published studies in the English 

language were considered for inclusion. 

Quality was assessed using the Generic Appraisal 

Tool for Epidemiology (GATE) available at: http:// 

www.epiq.co.nz (modified since this guideline 

was developed). 

Diagnostic studies were included only if they had 

at least 35 or more participants which represented 

an appropriate spectrum or defined clinical group, 

included blind independent assessment of the 

new test and reference standard and compared the 

reference test with the new test in at least 90% of 

people. 

Evidence from the relevant studies was summarised 

into evidence tables (http://www.nzgg. 

org.nz/guidelines/0083/040610_Final_Guideline_methodology_and_evidence_tables_ 

dia%E2%80%A6.pdf ). Recommendations were developed 

using the SIGN ‘Considered Judgement’ 

process. (SIGN Guideline development process: 

http://www.sign.ac.uk/guidelines/fulltext/50/ 

compjudgement.html). 

Table 1. Evidence summary—diagnosis 

Evidence summary 

Grading is based on the strength of the evidence 

and does not indicate the relative importance of 

the recommendations. 

Results 

There is a paucity of evidence for the diagnosis of 

soft tissue shoulder injuries. Recommendations 

have therefore been based primarily on the 

consensus of the guideline development team 

(Table 1). 

Routine x-rays and diagnostic ultrasound are 

the imaging techniques available to NZ primary 

health care practitioners. Referral to a specialist is 

required for other diagnostic imaging procedures 

including MRI and MR arthrography, which 

are the additional diagnostic imaging techniques 

most commonly used for soft tissue injuries of 

the shoulder. The evidence for these modalities 

has therefore not been included for this summary. 

‘A’ recommendation for the diagnosis 

of soft tissue shoulder injuries 

Diagnostic ultrasound 

If a significant rotator cuff tear is suspected, refer 

for diagnostic ultrasound. Diagnostic ultrasound 

should be undertaken by a radiologist with appropriate 

expertise using equipment with sufficient 

resolution. 

History There is no evidence that any particular aspect of the history is both reliable and valid for 

the diagnosis of any shoulder injury. 

Physical examination There is no evidence that any specific diagnostic test is both valid and reliable for the 

diagnosis of any soft tissue shoulder injury. 

There is no evidence that any particular combination of tests is useful in the diagnosis of 

shoulder disorders. 

Radiography No validated clinical decisions rules were located for the use of plain radiography for soft 

tissue shoulder injuries. 

Diagnostic ultrasound There is good evidence that diagnostic ultrasound is a valid diagnostic tool in the diagnosis 

of full thickness rotator cuff tears in a secondary care setting with a likelihood ratio of 13.6 

(95% CI 9.13-18.95). 5 

Its ability to rule out rotator cuff disease is yet to be determined and there is no conclusive 

evidence for the validity of diagnostic ultrasound in the diagnosis of partial tears. 5 

There is insufficient evidence to determine the validity of diagnostic ultrasound for rotator 

cuff tears in a primary care setting. 


Consensus recommendations for the 

diagnosis of soft tissue shoulder injuries 

1. Carry out a full clinical assessment, including 

a neurological examination if required 

The clinical manifestations of shoulder disorders 

are many and varied. A thorough clinical 

examination will help establish an accurate and 

definitive diagnosis (Table 2). 

2. Exclude red flags and other significant 

structural damage 

People with red flags and other significant structural 

damage require urgent referral to a specialist 

(Table 3). 

3. Screen for extrinsic causes of shoulder pain 

The site of pain may not be the source of the 

problem. Noting the onset, periodicity, site, character, 

radiation, associated symptoms and relieving 

and aggravating factors will alert the clinician 

to the severity of the disorder and the possible 

source of pain (Table 4). Provide appropriate treatment 

or refer to a specialist for further evaluation 

and management. 

4. Establish a provisional diagnosis 

The clinical diagnosis of shoulder disorders is 

difficult. There is often overlap between commonly 

described conditions and variation in 

presentation of symptoms. The following key 

points should be kept in mind when diagnosing 

acute soft tissue shoulder disorders: 

• Rotator cuff disorders: 

– Age >35 years 

– Upper arm pain/night pain 

– Painful arc 

– Limited active range of movement (ROM) 

– Full passive ROM 

– Possible weakness 

– +ve impingement sign. 

• Frozen shoulder 

– Gradual onset 

– Increasing severity of pain 

– Global limitation active and passive ROM 

– Possible diabetic 

Table 2. Clinical assessment of the shoulder 

History 

Inquiry Key Features Consider 

Age >35 year 

< 35 years 

Mechanism of injury Fall/direct trauma 

Fall onto point of shoulder 

Abduction/external 

rotation 

Head away (traction) 

Pain location/ 

radiation 

Physical examination 

Above shoulder joint 

Upper arm/deltoid 

Anterior upper arm 

Below elbow (shooting) 

Night Pain 

Rotator cuff 

Instability 

Clavicle fracture 

AC joint 

Rotator cuff/dislocation 

Brachial Plexus 

AC Joint 

Rotator cuff 

Biceps tendonitis 

Nerve/neck 

Rotator cuff tendon 

Action Key features Consider 

Look Asymmetry/deformity 

Wasting 

Bruising 

Scars 

Feel SC joint/clavicle/AC joint 

Long head biceps 

Greater tuberosity 

Spine of scapula 

Test active ROM Limited active/full passive 

Painful arc 

Test passive ROM Limited active and passive 

Hypermobile/positive 

apprehension 

Test strength Weak abduction/wasting 

deltoid 

Weak abduction/external 

rotation 

Weak internal rotation 

Dislocation/fracture/AC joint 

dislocation 

Rotator cuff tear/nerve injury 

Dislocation/fracture 

Previous injury/surgery 

Local tenderness/prominence 

Local tenderness bicipital 

groove 

Local tenderness/fracture 

Local tenderness/fracture 

Rotator cuff disorder 

(impingement/tear) 

Rotator cuff disorder 

Frozen shoulder 

Instability 

Axillary nerve injury 

(dislocation) 

Rotator cuff tear 

Subscapularis/pectoralis 

major tear 

Special tests There is no evidence that any specific test is both valid and 

reliable for the diagnosis of shoulder injuries. 

Neurological examination 



Level Motor Sensory Reflex 

C5 Deltoid/biceps Upper arm Biceps 

C6 Wrist extension Thumb Brachioradialis 

C7 Wrist extension/finger extension Middle finger Triceps 

C8 Finger grip Fifth finger None 

T1 Hand intrinsics Medial elbow None 




• Anterior/recurrent dislocation 

– History of trauma 

– Pain and muscle spasm 

– Empty space below acromion 

– Humeral head anterior 

– Limited movement 

– Plus/minus +ve x-ray confirmation. 

• Instability disorders 

– Age 40 years 

Table 4. Possible extrinsic causes of shoulder pain 

Screen for the following: 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

Cervical spine disorders 

Nerve disorders 

Nerve root irritation 

Nerve compression/entrapment 

Brachial plexus injuries 

Neuralgic amyotrophy 

Inflammatory disorders 

Rheumatoid arthritis 

Polymyalgia rheumatica 

Complex regional pain syndrome 

Myofascial pain syndrome 

Scapulothoracic articulation 

Thoracic and rib injuries 

Visceral disorders 

Table 3. People requiring urgent referral for specialist 

evaluation 

Red flags (signs or symptoms which alert the clinician 

to serious pathology) 

Unexplained deformity or swelling 

• Consideration of surgery as management 

option (plain films are best requested by 

a specialist where surgery is being considered 

as a management option. 

Recommended views 

• AP glenoid fossa (Grashey View) 

• Either outlet or lateral scapular 

• Axial. 

Indications for diagnostic ultrasound 

Refer for diagnostic ultrasound where the clinical 

diagnosis is uncertain and it is important to 

exclude a significant rotator cuff tear. 

6. Refer for specialist referral where appropriate 

Appropriate and timely referral for a specialist 

evaluation is important where indicated to 

achieve optimal outcomes. 

Early referral is recommended for the following: 

• Two or more traumatic dislocations 

• Recurrent posterior/other instabilities 

• Where the diagnosis is in doubt. 

A number of specialist groups are competent to 

evaluate shoulder problems. The decision about to 


• 

• 

• 

• 

• 

Significant weakness not due to pain 

Suspected malignancy 

Significant unexplained sensory/motor deficit 

Pulmonary or vascular compromise 

Other significant structural damage 

• 

• 

• 

• 

• 

• 

Displaced or unstable fracture 

Failed attempt (x2) reduction of dislocated shoulder 

Massive tear of the rotator cuff (>5 cm) 

Isolated rupture of subscapularis or pectoralis major 

Severe dislocation GH, AC or SC joints 

Undiagnosed severe shoulder pain

whom to refer a patient will vary depending on 

the nature of the shoulder injury, the availability 

of specialist groups and the preferences of the 

patient and referring health professional. 

Discussion 

While there is an abundance of diagnostic tests 

in clinical practice, this guideline indicates that 

no one test or combination of tests has been 

shown to accurately and reliability discriminate 

soft tissue shoulder disorders. However diagnostic 

ultrasound is a modality available to primary 

care practitioners and this has been found to be 

useful in confirming a diagnosis of a full thickness 

rotator cuff tear, but less useful for partial 

thickness rotator cuff tears. 

Since the publication of the guideline two systematic 

reviews relevant to the diagnosis of key 

shoulder pathologies have been published. The 

first investigated the diagnosis of instability and 

labral tears, 3 and the second the diagnosis of superior 

glenoid labral lesions only (SLAP lesions). 4 

The first review evaluated tests to distinguish 

between shoulder instability classified on the 

basis of degree (subluxation or dislocation) and 

direction (anterior, posterior, inferior or multidirectional) 

and labral lesions classified on the basis 

of location and type of tear. 3 This review evaluated 

four provocation and three laxity tests for 

instability of the shoulder, and 14 tests for labral 

tears. The evidence suggests that the relocation 

and anterior release tests are best for establishing 

the diagnosis of instability while the biceps load 

I and II test, the pain provocation test of Mimori 

and the internal rotation resistance strength 

tests are best for the diagnosis of a SLAP lesion. 

It should be noted that these studies were all 

located in specialised care centres and may have 

limited applicability to primary care. Limitations 

regarding methodology of individual studies were 

also noted. 

The second review evaluated nine tests for superior 

glenoid labral lesions (SLAP lesions) from 

11 studies. 4 The authors concluded that physical 

examination cannot provide a definitive diagnosis 

for SLAP lesions at this stage. Limited reliability 

due to the inherent difficulties in performing 

these tests and the heterogeneity of the patient 

populations studied contributed to the lack of 

evidence for any one test or combination of tests 

to accurately diagnose SLAP lesions. 

Even with this additional evidence, the evidence 

base to diagnosis of soft tissue injuries to the 

shoulder is limited. Assessment relies on thorough 

history-taking and physician examination, 

with appropriate referral where there is evidence 

of serious damage or the diagnosis remains 

unclear. 

References 


1. Accident Compensation Corporation. Injury Statistics. ACC 

Injury Statistics 2006. Wellington: ACC; 2006. 

2. New Zealand Guideline Group. Diagnosis and management of 

soft tissue shoulder injuries and related disorders: Best practice 

evidence-based guideline. Wellington: NZGG; 2004. p.86. 

3. Luime JJ, Verhagen AP, Miedema HS, Kuiper JI, Burdorf A, 

Verhaar JAN, et al. Does this patient have an instability of the 

shoulder or a labrum lesion? JAMA 2004;292(16):1989–99. 

4. Jones GL, Galluch DB. Clinical assessment of superior glenoid 

labral lesions: a systematic review. Clin Orthop Relat Res 

2007;455:45–51. 

5. Dinnes J, Loveman E, McIntyre LF, Waugh N. The effectiveness 

of diagnostic tests for the assessment of shoulder pain 

due to soft tissue disorders: a systematic review. Health 

Technol Assess 2003;7(29). 



Funded by the Accident 

Compensation Corporation 



None declared 




1 Section of Epidemiology 

& Biostatistics, School of 

Population Health, Faculty of 

Medical and Health Science, 

The University of Auckland, 



Practice and Primary Health 

Care, School of Population 

Health, Faculty of Medical 




3 School of Rehabilitation and 

Occupation Studies, AUT 

University, Auckland 


2009;1(1):42–49. 


Gillian Robb 

Section of Epidemiology 

& Biostatistics, School 

of Population Health, 




g.robb@auckland.ac.nz 

Summary of an evidence-based guideline 

on soft tissue shoulder injuries and related 

disorders—Part 2: Management 

Gillian Robb MPH (Hons), Dip Physiotherapy, Dip Ergonomics; 1 Bruce Arroll MBChB, PhD, FRNZCGP; 2 Duncan 

Reid MHSc (Hons), PGD (Manip Physiotherapy), MNZCP; 3 Felicity Goodyear-Smith MBChB, MGP, FRNZCGP 2 

ABSTRACT 

AIM: To provide a succinct summary of the management of soft tissue injuries to the shoulder for primary 

health care practitioners based on the New Zealand guideline. 

METHODS: A multidisciplinary team developed the guideline by critically appraising and grading retrieved 

literature using the Graphic Appraisal Tool for Epidemiology (GATE); and the Scottish Intercollegiate 

Guideline Network. Recommendations were derived from resulting evidence tables. 

RESULTS: For the management of soft tissue shoulder disorders there is little evidence to support or 

refute the efficacy of common interventions for shoulder disorders in general and rotator cuff disorders in 

particular. For rotator cuff tendinosis and partial tears, use NSAIDs and subacromial corticosteroid injections 

with caution and provide a trial of supervised exercise. For frozen shoulders, intra-articular corticosteroid 

injection should be considered and refer for supervised exercise after acute pain has settled. For 

shoulder instability, good evidence supports the referral of physically active young adults for orthopaedic 

intervention following a first traumatic shoulder dislocation. 

CONCLUSION: While there is a dearth of good evidence, this guideline does provide a framework for 

the management of common soft tissue injuries of the shoulder. 

KEyWORDS: Shoulder, soft tissue injuries, primary health care 

Introduction 

Diagnosis and management of shoulder injuries is 

one of the most challenging areas of musculoskeletal 

medicine. Prevalence figures for shoulder 

disorders vary widely for point prevalence 

(7–26%), one month prevalence (19–31%), one 

year prevalence (5–47%) and lifetime prevalence 

(7–66%). 1 Shoulder disorders are therefore relatively 

common, but only 50% of new episodes of 

shoulder complaints presented in primary care are 

completely recovered within six months, increasing 

to only 60% at one year. 2 

It is likely that suboptimal management contributes 

to unfavourable outcomes for patients. This 

paper is the second of a two-part series which 

summarises the evidence for assessment and management 

of soft tissue shoulder injuries based on 

the evidence-based guideline The diagnosis and 

management of soft tissue shoulder injuries and 

related disorders developed in New Zealand (NZ), 

led by EPIQ, University of Auckland under the 

auspices of the New Zealand Guidelines Group 

(NZGG). 3 This guideline was commissioned by 

ACC in 2003 to reduce identified variation in 

both diagnosis and management and to improve 

outcomes for claimants. 

This guideline was endorsed by the Royal New 

Zealand College of General Practitioners, the 

NZ Orthopaedic Association, the NZ Society of 

Physiotherapists Inc., the NZ Association of Mus- 


culoskeletal Medicine, Sports Medicine NZ, and 

the Royal Australasian and New Zealand College 

of Radiologists. The full document is available on 

the NZGG website (http://www.nzgg.org.nz). 

The aim of this paper is to provide a succinct 

summary of the management of soft tissue 

injuries to the shoulder in a form that is readily 

accessible to primary health care practitioners. 

Methods 

Methods have been described in Part 1. Part 2 

of this summary addresses the management of 

adults with the following shoulder injuries. Adolescents 

were included for shoulder instabilities 

given that dislocation and recurrent dislocation 

are more common in this age group. 

1. Rotator cuff and related disorders (including 

impingement, subacromial bursitis, tendinosis, 

painful arc syndrome, partial, full thickness 

and massive tears of the rotator cuff, long 

head of biceps rupture and calcific tendonitis) 

2. Frozen shoulder (also known as adhesive 

capsulitis) 

3. Glenohumeral instabilities (acute and 

recurrent dislocation, labral injuries and other 

instabilities) 

4. Acromioclavicular (AC) joint injuries 

(including stress osteolysis, osteoarthritis and 

dislocation) 

5. Sternoclavicular (SC) joint injuries (including 

sprains, dislocation and arthritis and related 

conditions). 

This guideline specifically excludes fractures, inflammatory 

conditions, degenerative conditions, 

endocrinological and neurological conditions. 

hemiplegic shoulder and chronic shoulder pain 

including occupational overuse disorders. 

For each of the included conditions evidence for 

management was sought based on searches relating 

to interventions commonly used in practice. 

For each condition a comprehensive literature 

search was undertaken in the major electronic 

databases (Medline, CINAHL, EMBASE, AMED, 

SPORTdiscus and Current Contents). Searching 

also included the Cochrane Database of Systematic 

Reviews, Cochrane Controlled Trials Register, 


What we already know: In general, the evidence for the management of 

acute soft tissue shoulder injuries is weak and limited. 

What this study adds: For rotator cuff tendinosis and partial tears, use 

NSAIDs and subacromial corticosteroid injections with caution and provide 

a trial of supervised exercise. For frozen shoulders, intra-articular corticosteroid 

injection should be considered and refer for supervised exercise after 

acute pain has settled. For shoulder instability, good evidence supports the 

referral of physically active young adults for orthopaedic intervention following 

a first traumatic shoulder dislocation. 

the Database of Reviews of Effectiveness (DARE) 

and relevant Internet sites including PEDro, NHS 

clinical trials, Health Technology Assessments for 

NHS, Bandolier and National Guideline Clearing 

House. Reference lists of included studies were 

checked for additional studies. 

Only published randomised controlled trials, 

meta-analyses and systematic reviews in the 

English language were considered for inclusion. 

Quality was assessed using the Generic Appraisal 

Tool for Epidemiology (GATE) available at: http:// 

www.epiq.co.nz (modified since this guideline 

developed). 

Evidence from the relevant studies was summarised 

into evidence tables. Recommendations 

were developed using the SIGN ‘Considered 

Judgment’ process. (SIGN Guideline development 

process: http://www.sign.ac.uk/guidelines/fulltext/50/compjudgement.html) 

Grading is based on the strength of the evidence 

and does not indicate the relative importance of 

the recommendations. 

Results 

Results are presented for each condition according 

to the grade of recommendation as follows: 

• A Recommendation: 

Supported by good evidence 

• B Recommendation: 

Supported by fair evidence 

• Good practice point: 

Consensus of the guideline team. 






In general, due to lack of agreement in defining 

shoulder disorders, poor quality of studies, 

and heterogeneity of studies with respect 

to participants, interventions, and outcomes, 

there is little evidence to support or refute the 

efficacy of common interventions for shoulder 

disorders in general 4,5 and rotator cuff disorders 

in particular. 6 

1. Rotator cuff and related disorders 

Rotator cuff disorders are the most common 

sources of shoulder problems. They range from 

mild strain causing impingement-type symptoms 

to massive tears and total absence of the cuff 

with severe loss of function. 7 

Tendinosis causing impingement-type symptoms 

(painful arc) is due to collagen fatigue resulting 

from repetitive overhead activities. 8 In contrast, 

rotator cuff tears typically result from trauma 

and are more common in people over the age of 

35 years. 

Partial thickness tears can occur on the bursal 

or articular side of the rotator cuff and do not 

extend through the full thickness of the tendon. 

These are more common than full thickness tears 

which extend through the full thickness of the 

tendon and are often more symptomatic. 9 Full 

thickness tears increase with advancing age, frequently 

occurring as a result of minimal trauma. 

These tears are often asymptomatic and compatible 

with normal painless functional activity. 10 

Massive tears have been defined as tears >5cm or 

tears involving two or more tendons (more often 

supraspinatus and infraspinatus, but also supraspinatus 

with subscapularis). 11 

Weakness is the primary sign of loss of integrity 

of the rotator cuff, but should be distinguished 

from weakness due to pain inhibition. 10 

B recommendations 

• Prescribe NSAIDS with caution. They 

provide short-term symptomatic pain relief 

but can have serious consequences. 12 

• Use subacromial corticosteroid injection 

with caution. It provides short-term 

symptomatic relief for people with tendinosis 

and partial thickness tears. 13,14 

There is insufficient evidence to determine 

the benefits or harms of subacromial steroid 

injection for full thickness rotator cuff tears. 6 

Provide a trial of supervised exercise 

by a recognised treatment provider for 

people with rotator cuff disorders. 4 

Avoid the use of therapeutic ultrasound 

(no additional benefit over 

and above exercise alone). 4 

For calcific tendonitis, there is limited 

evidence for the use of ultrasound for pain 

relief, 15 and weak evidence for the use of Extracorporeal 

Shock Wave Therapy (ESWT). 16-19 


• 

• 

• 

• 

Good practice points for 

rotator cuff and related disorders 

• Simple analgesics provide pain relief with 

potential for less serious side effects. 

• Subacromial corticosteroid injections may 

be appropriate for full thickness tears as 

part of long-term management where surgery 

is not considered as a treatment option. 

• If there is no significant improvement 

in patients with a full thickness 

tear of the rotator cuff after four to six 

weeks of non-operative management, 

refer to an orthopaedic specialist. 

• Early surgical management for a rotator 

cuff tears has the most to offer people 

with otherwise healthy tissue and who 

are physiologically young and active. 

There are a number of disorders closely related to 

rotator cuff tears which should be considered as 

part of the differential diagnosis. 

• Biceps tendinosis is part of the spectrum of 

pathological processes of rotator cuff disorders 

and should be managed in the same 

way as rotator cuff tendinosis. Rupture of 

the biceps tendon is more common with 

increasing age. 20 Management is symptomatic 

with almost no indication for operative 

repair. Where instability (subluxation 

or dislocation of the biceps tendon) is suspected, 

refer to an orthopaedic surgeon. 

• Calcific tendonitis usually occurs spontaneously 

and is self-limiting. 16 People with

severe pain and dysfunction may require 

urgent referral to an orthopaedic specialist. 

• Isolated muscle tears, 

while rare, occur 

most commonly in the subscapularis 21 

and pectoralis major. 22 Both require urgent 

referral for orthopaedic evaluation. 

2. Frozen shoulder 

The true frozen shoulder is characterised by an 

unknown aetiology, spontaneous and gradual 

onset of pain and global restriction of movement. 

23,24 The clinical presentation is described as 

involving three phases. An initial painful phase 

lasting two to three months in which pain is 

severe and movement severely restricted is 

followed by a second phase also lasting two to 

three months where pain diminishes and the 

predominant feature is stiffness. Resolution 

typically occurs over the next six to 12 months in 

which there is a gradual gain in range of movement 

with less discomfort. In contrast with rotator 

cuff impingement or tear, a key diagnostic feature 

of frozen shoulder is stiffness (limitation of both 

passive and active range), lack of discomfort with 

resisted movement and no weakness. There is 

frequently substantial functional limitation with 

respect to activities of daily living. 25 

B recommendations 

• In the painful phase actively consider intraarticular 

corticosteroid injection performed by 

an experienced clinician. 14,26 

• After the acute pain has settled offer supervised 

exercise by a recognised treatment provider to 

improve range of movement. 26 Mobilisation 

does not offer any additional benefit. 14 

• Laser therapy and acupuncture may be beneficial 

in the treatment of frozen shoulder. 4,27 

• Hydrodilation has not been found to be 

effective. 5 


frozen shoulder 

• Avoid vigorous stretching in the early 

phase as this will exacerbate pain. 

• It is important that people with a frozen 

shoulder understand the time it 

takes for this condition to resolve. 

3. Glenohumeral instabilities 

Instabilities are symptomatic manifestation 

of pathological movement of one joint surface 

in relation to another and should be contrasted 

with laxity which is the non-pathological 

linear displacement of one articular surface 

in relation to the other. 28 Instabilities include 

acute glenohumeral dislocations (anterior, posterior 

and inferior), multidirectional instability 

(global laxity of the shoulder) and tears of the 

glenoid labrum. 

Anterior dislocations are the most common 

acute traumatic dislocation. In younger people 

these are often associated with detachment of 

the labrum from the rim (Bankart lesions) with 

a 90% chance of recurrence in people under 20 

years. 29 Dislocations are also common in the 

sixth decade of life 30 but are more likely to be 

associated with capsular tear and concomitant 

rotator cuff tears. 31 

Labral injuries (including detachment of the 

superior labrum either anteriorly, superiorly 

or both) are common in overhead athletes as 

progressive failure of the labrum or may occur 

as a traumatic event in association with anterior 

dislocation. 32 These are often associated with 

vague symptoms of impingement associated with 

activity, clicking, locking and in some a ‘dead 

arm’ which is the sudden sharp paralysing pain 

or sense of subluxation associated with weakness, 

tingling and numbness. 33 

A recommendations 

• Young adults engaged in demanding 

physical activities with a first traumatic 

shoulder dislocation should be 

referred for orthopaedic evaluation. 34 


glenohumeral instabilities 

• Investigations for acute dislocations: 

– Pre-reduction x-ray is recommended 

for people >40 years of age. 

– Post-reduction x-ray is recommended 

for all people with a first time 

dislocation to confirm the reduction 

and assess for bony injury. 






– X-ray is required for all people with 

a failed attempt at reduction. 

– X-ray is recommended for those with 

recurrent dislocation where surgical stabilisation 

may be a management option. 

• Acute management of dislocations: 

– Only clinicians with expertise should 

reduce anterior or posterior dislocations. 

– Relaxation is critical for successful reduction. 

Ensure adequate analgesia is given 

as required before attempting reduction. 

– Attempt slow steady traction for at least 

30 seconds, avoiding excessive force while 

attempting to reduce a dislocated shoulder. 

– Urgent referral to an orthopaedic specialist 

is required when reduction is 

unsuccessful after two attempts. 

• Post-reduction management of dislocations: 

– In people with a primary dislocation 

for whom non-operative management 

is appropriate apply a sling, 

provide analgesia and refer for a supervised 

exercise programme. 

– Following dislocation, people should 

not return to sport for at least six 

weeks, or when they have achieved 

near normal muscle strength. 

• Recurrent dislocation: 

– People with recurrent dislocation 

(>2) should be referred to an orthopaedic 

specialist to evaluate the 

need for surgical stabilisation. 

• Multidirectional instability: 

– A comprehensive rehabilitation programme 

focusing on strengthening 

the scapular stabilisers and rotator 

cuff muscle may improve function. 

– Where treatment fails to improve 

function by six months, surgical intervention 

may be considered. 

• Labral tears: 

– Labral injuries should be referred to an 

orthopaedic surgeon for evaluation. 

4. Acromioclavicular joint injuries 

Acromioclavicular (AC) joint injuries are common 

in men between the second and fourth decade of 

life, frequently occurring during sport from a fall 

on the point of the shoulder. 35 AC joint injuries 

are classified as Grade I (intact joint), Grade II (up 

to 50% vertical subluxation of the clavicle with 

rupture of the AC ligament) and Grade III (more 

than 50% vertical subluxation of the clavicle and 

complete rupture of both the AC and coracoclavicular 

ligaments). 35,36 


acromioclavicular joint injuries 

• People with Grade I and II sprains can be 

provided with a sling and analgesics for 

five to seven days until comfortable. 

• There is a lack of evidence to support 

any particular method of taping. 

• Advise gradual return to activity as 

symptoms settle, avoiding heavy lifting 

and contact sports for eight to 12 weeks. 

• People with Grade III AC joint sprains 

can be managed non-operatively, but 

if this is not successful after three 

months, consider referral to a specialist 

for further evaluation. 

• More serious AC joint dislocations require 

referral for orthopaedic evaluation. 

5. Sternoclavicular joint injuries 

The most common sternoclavicular (SC) disorders 

are strains sustained from motor vehicle and 

sporting injuries. 37,38 In mild strains, the ligaments 

are intact and the joint stable. In moderate 

strains, the ligaments may be partially disrupted 

and the joint is subluxed. Severe strains (dislocations) 

are rare, the most common being anterior 

dislocations. Posterior dislocations, however, 

while uncommon, may compromise major vessels, 

the trachea and oesophagus which are in close 

proximity. 39,40 

Local tenderness and swelling characterise milder 

strains, whereas a palpable gap may be present in 

more serious injuries. CT may be the best radiological 

technique for SC joints. 



sternoclavicular joint injuries 

• Although rare, clinicians should watch 

for pulmonary or vascular compromise 

due to a posterior dislocation of the SC 

joint usually resulting from severe compression 

trauma. Immediate referral to 

an appropriate specialist is required. 

• Most injures of the SC joint are mild 

and can be managed with a sling, analgesics 

and return to activity as tolerated. 

Discussion 

In general, the evidence for the management of 

acute soft tissue shoulder injuries is weak and 

limited. Little has been added in the years since 

publication of the guideline. 

A brief search for guidelines, systematic reviews 

or meta-analyses published since the development 

of the NZ guideline 3 revealed an additional three 

Cochrane reviews 41-43 and a number of reviews 

published in other journals. 44,45,46-53 

The first of the three Cochrane reviews found 

little evidence to support or refute the use of 

acupuncture for shoulder pain in general, but 

suggested there may be short-term benefit with 

respect to pain and function. 41 

The second Cochrane review was suggestive that 

oral steroids confer a worthwhile short-term 

(six weeks) benefit for pain, range of movement 

and function in people with adhesive capsulitis. 

42 The stage at which this was most effective 

was not specified, but the median duration of 

symptoms of participants in the included studies 

was six months. While adverse effects reported 

were minor, the potential risk of oral steroids 

should be considered when making treatment 

decisions. 42 

The third Cochrane review reported a lack of 

evidence to inform choices for conservative 

management following closed reduction of traumatic 

anterior dislocation of the shoulder. 43 

This review was based on one small, preliminary, 

poor quality study which was also included in 

the shoulder guideline. 54 While the review reported 

no significant differences between groups 

for any outcome, the study did claim that 

fixation in external rotation was effective in 

reducing redislocation at 15-months’ follow-up 

(p=0.008). Given that this was a small, poor quality 

study, the conclusions of the review 

are relevant. 

Of the additional reviews located, seven related 

to disorders of the rotator cuff, 44, 45,46-49,53 one 

related to adhesive capsulitis, 50 one focused on 

instability, 51 and one reviewed the management 

of Grade III acromioclavicular injuries. 52 For 

disorders of the rotator cuff, the findings of 

these reviews are consistent with the guideline 

and no new evidence was reported for treatment 

options. One review, however, investigated factors 

influencing the decisions to surgically repair 

symptomatic full thickness rotator cuff tears, 

including demographic variables (age and gender), 

duration of symptoms, non-operative treatment, 

timing of surgery, physical examination findings, 

In general, the evidence for the management 

of acute soft tissue shoulder injuries is weak 

and limited 


size of the tear and pending workers compensation 

claims. While there was no randomised trial 

evidence for any one factor, they suggested that 

older chronological age should not be considered 

a barrier to operative repair as studies have reported 

good outcomes for older patients and that 

pending workers’ compensation claims did not 

appear to influence treatment results. 53 

A systematic review of randomised trials using 

multiple corticosteroid injections for adhesive 

capsulitis evaluated nine trials, of which four 

were considered to be of high methodological 

quality. This review found a benefit for up 

to three corticosteroid injections and limited 

evidence that six injections were beneficial. There 

was no evidence that more than six injections 

were of benefit. It should be noted that while five 

different corticosteroids were used, all were given 





intra-articularly. Also, only two of these studies 

were based in general practice. 50 

A review of the effectiveness of rehabilitation for 

non-operative management of shoulder instability 

found only weak evidence to support immobilisation 

for three to four weeks followed by a 

structured rehabilitation programme for people 

with a primary dislocation. 51 Instability in this 

review was defined as symptomatic hypermobility 

(single plane or multidirectional) resulting 

from traumatic and atraumatic subluxation or 

dislocation. 

For Grade III acromioclavicular injuries, nonoperative 

treatment is the preferred option based 

on three randomised trials included in a review 

which concluded that while surgical results were 

‘no better’ they were associated with more complications, 

increased convalescence and time away 

from work. 52 

Conclusion 

As with diagnosis of shoulder injuries, the 

evidence for management of soft tissue shoulder 

injuries is limited and largely determined by the 

collective experience and expertise of practitioners 

in the field. 

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Funded by the Accident 

Compensation Corporation 





iMPROViNg PERfORMANCE 

1 Harbour Health Primary 

Health Organisation, 


2 HealthWEST Primary Health 

Organisation, Auckland, 



Angela Verhoeven 

PO Box 104 098, 

Lincoln North, Auckland 

0654, New Zealand 

Angela@healthwest.co.nz 

A patient-centred referral pathway for mild 

to moderate lifestyle and mental health 

problems: Does this model work in practice? 

Jill Calveley MBChB; 1 Angela Verhoeven PGDipHSc; 2 David Hopcroft MBChB, FRNZCGP, PhD 1 

Harbour Health and HealthWEST Primary Health Organisations in collaboration with the University of Auckland 

ABSTRACT 

BACkgROUND AND CONTExT: The Primary Lifestyle Options Programme was an innovative eightmonth, 

patient-centred, early primary care–based pilot aimed at identifying and promptly enabling 

people with mild to moderate mental health and lifestyle problems to access a range of free interventions 

as soon as possible. 

PROBLEMS: Mild to moderate mental health and lifestyle issues are easily overlooked in primary care. Patients 

with these problems, once identified, often need support to choose and access treatment providers. 

STRATEgiES fOR iMPROVEMENT: During a GP visit a patient requests help by completing a CHAT 

(Case-finding and Help Assessment Tool) which assesses depression, anxiety, abuse, anger, exercise 

level, insomnia, and addictions (gambling, tobacco, alcohol and other substances). Patients subsequently 

have a 30-minute GP consultation where a range of services to address identified problem(s) is offered; 

this choice is assisted by a comprehensive resource manual. A programme coordinator facilitates access 

to services by making appointments and liaising between patients and providers. A follow-up GP consult 

is available. 

RESULTS: 456 patients (6% Maori) aged from 15 to 84 years requested help via the CHAT for one to 

seven issues per patient, over an eight-month period. Anxiety, depression and insomnia were the commonest 

reasons for requesting help. A feedback questionnaire focussed on the usefulness and practicality 

of the pathway, showing widespread approval from patients, GPs and other treatment providers. 

CONCLUSiONS: This programme enables a patient to identify and request help for mental health and 

lifestyle problems at a mild–moderate stage, and to be supported through an intervention pathway that 

otherwise is unlikely to be available in a busy primary care environment. 

kEywORDS: Primary care, patient-centred, mental health 

Background 

Mild to moderate mental health and lifestyle 

problems are ubiquitous and pervasive 1 and can be 

overlooked not only by patients and their families 

but also by their primary caregivers. While GPs 

are well placed to identify such problems, 

historically they have been thwarted in doing so 

by time constraints 2 and referral uncertainties. 

Furthermore, mild or sub-threshold mental 

disorders can be diagnostically challenging, 

especially in the absence of concomitant disability. 

3 Mental health screening in primary care has 

been widely advocated to address these concerns. 

However, reliable means of doing so have been 

less forthcoming and concerns have been raised 

about the efficacy of routine screening and the 

degree to which a single screening tool can be a 

diagnostic ‘gold standard’. 4 In this regard the 


CHAT (Case-finding and Health Assessment 

Tool), a short, self-administered screening 

questionnaire, has been developed and trialled in 

New Zealand to expedite screening of adults for 

lifestyle and mental health problems in the GP 

setting. 5 The largest trial was in Auckland, 

demonstrating high sensitivity and specificity for 

depression, anxiety and stress, abuse, anger 

problems, and tobacco, alcohol and other drug 

misuse, but had lower levels for exercise and 

eating disorders. The tool also assesses whether 

patients want help with these issues, which 

reduces the chance of false positives. 6 

Having detected a lifestyle/mental health issue, 

what does the GP then do? Case-finding is one 

thing; prompt and appropriate intervention can be 

quite another. Traditional referral pathways are to 

hospital outpatient clinics (depression, anxiety, 

eating disorders), community clinics (for example 

community alcohol and drugs clinic or CADs), 

and private specialists (psychiatrists, psychologists). 

Often however, and especially in public 

mental health services, only those patients with 

significant acute illness will be seen. Private 

clinics are expensive, especially for multiple visits. 

Thus, people with mild to moderate lifestyle and/ 

or mental health disorders are often left untreated, 

adversely affecting their well-being. 7 

The Primary Lifestyle Options programme was 

initiated to enable people with mild to moderate 

mental health and lifestyle problems to be 

reliably identified and then to have access to 

appropriate services as soon as possible. A sense 

of engagement in a programme increases patients’ 

likelihood that they will attend. 8 Telephone 

prompting can also improve attendance rates. 9 

The pathway described in this paper is patientcentric—the 

patient identifies a problem and 

participates in the selection of interventions appropriate 

to the treatment of that problem. This 

evaluation focused on the utility of the model 

in primary care—is it practicable, does it fit in 

with general practice workflow, and does it meet 

patient requirements for choice and timeframes? 

Is it a viable model for people providing the 

interventions (those who the GP refers the patient 

on to)? Essentially, is the Primary Lifestyle 

Options programme a feasible, sensible workable 

model of care? 

wHAT gAP THiS fiLLS 

What is already known: The current public mental health system focuses 

more on patients with significant illness. Those with mild–moderate mental 

health and lifestyle issues are often overlooked in primary care, and have 

a limited choice of interventions and/or support. The CHAT (Case-finding 

and Health Assessment Tool) has been validated as a reliable screening tool 

for many of these issues. A sense of engagement in a programme increases 

patients’ likelihood that they will attend, and telephone prompting can also 

improve attendance rates. 

What this study adds: The Primary Lifestyle Options programme provides 

a patient-centric prompt intervention pathway—the patient identifies 

and requests help for a problem and participates in the selection of treatment 

options. Feedback from patients, GPs and other treatment providers indicate 

that this is a practicable, timely, and useful model in primary care. 

Purpose 

To identify those people with mild to moderate 

mental health and lifestyle problems attending 

their GP and to follow this with prompt access to 

appropriate services, within available resources. 

Model 


Patients who were school leavers and older 

were asked by their GPs to complete a CHAT 

Lifestyle Assessment Tool. This was slightly 

modified from the original CHAT by replacing 

Eating Disorders with Insomnia, a known 

risk factor for, and consequence of, depression. 

10 Selection of these patients was at the 

discretion of the GP. The patient discussed the 

completed CHAT with the GP. Those patients 

who answered ‘Yes’ to the question ‘Do you 

want help with this?’ were asked whether they 

would like to make a 30-minute appointment to 

see the GP, to discuss intervention options for 

the mental health/lifestyle problem revealed by 

the CHAT assessment. GPs were assisted in this 

by a comprehensive Resource Manual. Intervention, 

either internal or external (see below) was 

started within one month of referral and completed 

within three months. A programme coordinator 

based at Harbour Health PHO assisted 

at various stages in this process by (1) providing 

information and support to patients, GPs, 

practices and service providers; (2) facilitating 

patient access to services, and (3) following up 



Figure 1. Primary Lifestyle Options referral pathways 

PN = Practice nurse; FU = Follow-up; DNA = Did not attend 

Table 1. External treatment provider examples 

Provider examples only 

(full list given to GPs in Resource Manual) 

Exercise Green Prescription Waitakere or North Shore; 

10 weeks’ local gym 

Smoking Smokefree Harbour Health; Quitline; Asian Smokefree 

Alcohol/ 

illicit drugs 

Individual sessions with psychologist/psychotherapist/counsellor; 

Community, Alcohol and Drugs Service (CADS); Alcoholics 

Anonymous (AA); The Alcohol and Drug Helpline etc. 

gambling Individual sessions with psychologist/psychotherapist/counsellor; 

Problem Gambling Foundation hotline or Internet 

Depression/ 

anxiety 

Violence, abuse, 

anger 


Essentially Men Weekend Course; Youthlink Family Programme; 

Life Line; Youth Line; Phobic Trust and many other family and 

community service organisations 


Victim Support; Man Alive; North Harbour Living Without 

Violence; North Shore Women’s Centre 

insomnia Refer for CBT—four sessions, or five if extra GP consult used 

those patients who did not attend these services. 

Those patients requiring or already receiving 

secondary care–level mental health interventions 

were not eligible. The overall pathway is summarised 

in Figure 1. 

Intervention referral options 

(1) Internal 

Patients with lifestyle/mental health conditions 

could be seen by a GP for up to four consults (in 

addition to the first 30-minute and 15-minute 

follow-up consults) for problem-solving or behavioural 

change management. 

(2) External (Table 1) 

Approximately 150 different providers were 

available for selection, including individual, 

group, community and support services specifically 

for Maori, Pacific Island, and Asian patients. 

This new model therefore introduced four processes 

to primary care: 

1. Patient identification of problem area(s) 

and request for ‘help’ using the CHAT 

questionnaire. 

2. A 30-minute extended GP consultation. 

3. A PHO-based Programme Coordinator. 

4. A 15-minute GP follow-up appointment after 

the intervention stage. 

All services were free for patients. The pilot, 

a joint initiative between Harbour Health and 

HealthWEST Primary Health Organisations 

(PHOs), was funded by the Waitemata District 

Health Board (DHB) and was approved by their 

Ethics Committee. 

Results 

Utilisation 

Sixty-nine GPs participated in the pilot, each 

enrolling from one to 35 patients. Between 15 

October 2007 and 30 June 2008 a total of 456 patients 

were referred for one of the interventions. 

Of these: 


• 357 patients (78%) were referred 

to external providers. 

• 99 patients (22%) were referred internally 

(i.e. GP or practice nurse); 20 of these 

were for smoking cessation and eight for 

Green Prescription/exercise counselling. 

• 91 (20%) completed the full course of interventions 

and the ‘exit consult’ with 

their GP. Approximately 40 had not attended 

their final ‘exit’ consult with their 

GP despite completing their interventions, 

by the time this report was prepared. 

• 60 (13%) patients had not attended 

any intervention session by the 

time this report was prepared. 

People requested help in all 10 problem areas on 

CHAT (only one for gambling, but there have 

been several more requests for help with this 

since 30 June 2008). The commonest amongst 

the 839 listed reasons for referral were depression 

(37%) and anxiety (26%). Sixty-seven percent of 

referred patients had depression as at least one of 

their referral reasons, and 35% had anxiety as at 

least one of their reasons (Figure 2). Fifty-seven 

percent of patients had two or more reasons for 

referral; the commonest (35%) coexisting conditions 

were anxiety–depression. 

Table 2. Enrolled patient demographics 

N % 

Gender female 292 64 

Male 164 46 

Ethnicity Asian 8 1.8 

Maori 26 5.7 

NZ European 379 83.1 

Pacific 5 1.1 

Other 38 8.3 

Age in years 15–24 72 15.8 

25–34 117 25.7 

35–44 116 25.4 

45–54 74 16.2 

55–64 52 11.4 

65–74 14 3.1 

75–84 11 2.4 

Figure 2. Reasons for referral; N=839 

Figure 3. Patient rating of CHAT Lifestyle Assessment Form; N=48* 

* Two people could not recall; two did not answer. 

Where people indicated a range e.g. ‘7–8’, the lower of the two was recorded 

Patient feedback 


Fifty-two of the 91 patients who had completed 

the PLO programme gave feedback via a confidential 

written questionnaire. 

• Most patients rated the CHAT assessment form 

as being ‘helpful or very helpful’ (Figure 3). 

• 89% felt that the initial 30-minute consult 

with their GP was enough time to discuss 

options for getting help. 

• 87% rated the assistance to get appointments 

with external providers as being ‘helpful or 

very helpful’. 

• Most patients (82%) referred to external 

providers were seen within two weeks, and 

91% felt that the waiting time to be seen was 

acceptable. 



Patient comments about use of the CHAT tool 

mainly related to it being simple to use and helpful 

in identifying problems: 

‘Helped me to positively identify the areas where 

I was not coping and required focus.’ 

‘Simple questions—all part of the realisation 

process that there was something wrong. It was 

good to not have too long with the form to think 

too deeply, better to just answer straight away.’ 

‘General questions were asked, nothing too over 

the top. It was helpful because it was on paper, 

sometimes it’s easier to write things down.’ 

‘Helpful in the way that it asked you a short, to 

the point relevant question for you to respond 

with a simple YES/NO answer.’ 

‘It covered a broad range of questions. It was 

quick and easy to fill out.’ 

‘Helped to specify problems, to identify stressors—made 

me think about it.’ 

Some patients remarked that the CHAT form 

should be made more available: 

‘I felt a little under pressure at the doctor’s because 

of how I was feeling; maybe if I had taken 

the form home to consider it would have been 

more comfortable.’ 

‘Having forms in the waiting room would have 

been good.’ 

‘An idea might be [to put] these forms on display 

to increase awareness.’ 

Patient comments regarding the programme 

coordinator’s role were all favourable and related 

to proximity and timing of referrals: 

‘Being new to Auckland, every assistance 

was given in finding an appointment close to 

where I lived.’ 

‘The whole process was very quick and easy— 

superb that help could come close to home. All 

organised well.’ 

‘I didn’t have to do anything. If it was left up to 

me I wouldn’t organise anything.’ 

‘The extra time spent and care shown made me 

feel that somebody cared about me when I was 

very depressed.’ 

Many patients made very favourable, often quite 

heartfelt remarks about their involvement in this 

programme. 

‘I hope the programme keeps running—I don’t 

know what I would have done if something like 

this wasn’t available.’ 

‘This programme made a huge difference to me 

and my family. I felt throughout that I was being 

looked after (from my doctor onwards) and the 

results were awesome…Huge thumbs up for the 

programme from me!’ 

‘I am very grateful that it exists and that it was 

available to me. It made me feel that financial 

hardship was dealt with in a sensitive way that 

recognised the need for treatment despite this 

barrier.’ 

GP feedback 

Thirty-seven of the 69 GPs who enrolled their 

patients in the PLO programme gave feedback via 

a confidential online questionnaire. 

• 90% felt that the steps in the programme 

were clearly described, and 81% 

felt they were easy to implement. 

• 76% felt that the programme’s Resource Manual 

was ‘useful’ or ‘very useful’ and a further 

21% indicated that ‘some parts were useful’. 

• 71% introduced the CHAT form to their 

patients during the course of a consult; the 

remainder indicated that their practice nurse 

introduced this to a proportion of the patients. 

Practice receptionists were not involved. 

• 70% (of the foregoing 71%) gave the CHAT 

to those patients they thought would 

benefit, i.e. opportunistically. However, 

a further 22% selected patients specifically 

and invited their participation. No GP 

gave the form to every waiting patient. 

• 57% felt that the initial 30-minute PLO 


• 

• 

• 

• 

• 

• 

consult was ‘easily’ long enough, and a further 

41% felt that it was ‘just’ long enough. 

80% felt that the referral process to outside 

providers ‘went smoothly’. 

36% felt that the final 15-minute follow-up 

consult was ‘plenty’ and 55% 

felt it was ‘just’ long enough. 

Most felt that the role of the programme 

coordinator was helpful, with 

39% regarding this as ‘essential’. 

The invoicing/payment system relating to 

the PLO programme was generally regarded 

satisfactorily by GPs, with 79% rating this as 

3 or more out of 5 (where 5 was ‘very easy’). 

94% of GPs felt that this programme 

enabled their patients to access appropriate 

interventions, and 85% felt that 

this was within suitable timeframes. 

95% indicated that they would continue 

their involvement with this programme, 

and 74% would increase their 

involvement if funding permitted. 

GP criticisms related to too much paperwork/ 

too many forms/needs to be electronic (x3), slow 

feedback from external providers (x2), and the 

funding period not being long enough (x2). 

Provider feedback 

Forty-four of the 49 external providers who had 

patients referred to them through the PLO programme 

gave feedback via a confidential online 

questionnaire. 

• All respondents indicated that the referrals 

made by GPs were ‘entirely’ (84%) 

or ‘mostly’ (16%) appropriate to the particular 

service they provided, and most 

felt that the referring information was 

always (34%) or mostly (58%) adequate. 

• Respondents felt that the timeframe between 

the patient seeing the GP and 

then being seen by the provider was 

‘very timely’ (36%) or ‘timely (61%). 

• 78% felt that the role of the programme 

coordinator was ‘very useful’ in assisting 

them, with 68% indicating that the coordinator 

was ‘very useful’ in following up 

patients who did not attend appointments. 

• Overall, 55% of providers felt that 

the PLO programme was ‘very useful’ 

as a model of care, and a further 

29% that it was ‘quite useful’. 

‘I believe the programme only touches the surface 

of the true need. It is evident to me most of the 

people that came for counselling would not have 

accessed help if they did not have this programme. 

The outcomes for the clients appeared in the main 

to have made a significant difference to their lives.’ 

Lessons and messages 


This pilot programme did not seek to demonstrate 

efficacy (upskilling, manage problems, 

reduce escalation). Rather, it focused on the 

utility of the model in primary care—is it practicable; 

does it work as a referral pathway within 

primary care? It introduced a number of new 

processes for both GPs and patients. Firstly, it 

utilised a now well-validated screening tool, the 

CHAT, 7 and, secondly, it gave the GP 30 minutes 

of dedicated time to discuss this and work 

with the patient to select a treatment provider. 

Thirdly, a coordinator facilitated the patient’s 

entrée to a wide choice of treatment providers external 

to their GP, and was available to deal with 

any follow-up issues with the provider. Fourthly, 

the pathway was able to be ‘wrapped up’ by the 

patient seeing their GP for a dedicated follow-up 

consult to review progress. The whole process 

was funded, thereby enabling people who otherwise 

could not access this amount of treatment 

time to do so, at an earlier stage in their mental 

health/lifestyle problem than would otherwise 

be possible under existing referral pathways. It is 

a novel approach to an old problem. Does it work 

in practice? 

Feedback from all parties concerned has clearly 

shown widespread approval. Patients regarded 

the programme favourably, and some poignant 

comments were given in their feedback. It was 

important that the processes were practicable 

from the GP perspective, and generally the 

participating GPs rated the process well; 95% 

indicated they would continue their involvement 

with the programme. Likewise, external 

treatment providers—counsellors, psychologists, 

etc.—were generally approving of the programme, 

with 84% rating it as ‘very’ or ‘quite’ useful and 



ACkNOwLEDgEMENTS 

The authors warmly 

thank Maureen Langwell, 

Programme Coordinator, 

Primary Lifestyle Options 

at Harbour Health PHO, 

for her enthusiastic work 

on this project. The 

support of participating 

Harbour Health and 

HealthWEST PHO GPs is 

gratefully acknowledged. 

This study was funded 

by the Waitemata 

District Health Board. 

COMPETiNg iNTERESTS 


100% felt they were referred appropriate patients 

for the services they provided. 

As such, the basic model does not require major 

changes as all processes were acceptable and 

practicable for the majority of patients, providers 

and GPs. However, there are some caveats to address 

if this programme is to move forward. Some 

patients felt under pressure at the time of consultation, 

preferring to take the CHAT home to answer; 

in future they need to be given this option. 

Completion of the programme by attending the 

follow-up GP consult was variable, and has continued 

to be so post–30 June. This appears to be 

redundant for those who were referred internally, 

i.e. consulted their GP for interventions or when 

they have had their needs adequately met by an 

external provider who has written a report to the 

GP. In future, this will be an optional component 

of the model. Moving to an online version was 

suggested by a number of GPs, so this too will be 

available in the next iteration. 

In conclusion, the Primary Lifestyle Options pilot 

appears to be well regarded by participants— 

patients, GPs and other treatment providers—and 

is realistic and practicable. It could be easily taken 

up by other PHOs, requiring only local adaptation 

of material in the Resource Manual. This 

programme enables identification in the primary 

care setting of mild to moderate mental health or 

lifestyle problems and initiation of a treatment 

pathway that, in many cases at least, would not 

otherwise occur. 

References 

1. MaGPIe Research Group. The nature and prevalence of 

psychological problems in New Zealand primary healthcare: 

a report on Mental Health and General Practice 

Investigation (MaGPIe). NZ Med J 2003;116:U379 

2. Hutton C, Gunn J. Do longer consultations improve the 

management of psychological problems in general practice? 

A systematic literature review. BMC Health Serv Res 

2007:7:71. 

3. Collings S, MaGPIe Research Group. Disability and the 

detection of mental disorder in primary care. Soc Psych 

Psychiatr Epidemiol 2005;40:994–1002. 

4. The MaGPIe Research Group. The effectiveness of casefinding 

for mental health problems in primary care. Br J 

Gen Pract 2005;55:665–9. 

5. Goodyear-Smith F, Coupe N, Arroll B, Elley C, Sullivan 

S, McGill A. Case-finding of lifestyle and mental health 

problems in primary care: validation of the ‘CHAT’. Br J 

Gen Pract 2008;58:26–31. 

6. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. 

Effect of the addition of a ‘help’ question to two screening 

questions on specificity for diagnosis of depression in 

general practice: diagnostic validity study. BMJ 2005; 

331(7521):884. 

7. Lyness JM, Heo M, Datto CJ. Outcomes of minor and subsyndromal 

depression among elderly patients in primary 

care settings. Ann Intern Med 2006;144(7):496–504. 

8. Hawker D. Increasing initial attendance at mental health 

out-patient clinics: opt-in systems and other interventions. 

Psych Bull 2007;31:179–82. 

9. MacDonald J, Brown N, Ellis P. Using telephone prompts 

to improve initial attendance at a community mental health 

center. Psychiatr Serv 2000;51:812–4. 

10. Ohayon MM, Roth T. Place of chronic insomnia in the 

course of depressive and anxiety disorders. J Psychiatric 

Res 2003;37:9–15. 

We were shocked to hear of Jill Calveley’s tragic, unexpected death on 30 December. As well as her role as the Clinical Director 

of Harbour Health PHO, Jill has made significant contributions in numerous parts of the health sector as a rural GP, within primary 

and secondary care organisations, the Accident Compensation Corporation and NGOs. As well as general practice, Jill had 

qualifications in epidemiology, public health and philosophy and was able to engage with the health sector from a wide range of 

perspectives. She passionately believed that the sole purpose of the health service is to improve the health of people. She brought 

her compassion and her critical appraisal skills to all her many roles. Her legacy is huge and she is sadly missed—Editor. 


gPs should prescribe more 


yES 

We should stop moralizing and start prescribing 

benzodiazepines when required (for the 

elderly and others). 

I am currently cautious about prescribing 

benzodiazepines as I am concerned that, if I am 

too liberal, my colleagues may think I am a low 

quality physician. I am sure this is the prevailing 

mood amongst GPs, although I sense that 

psychiatrists are less cautious than we are. Many 

years ago I was involved in a practice where we 

(the new GPs) thought too many of the patients 

were on benzodiazepines and proceeded to wean 

them off. This was a difficult task that required 

a lot of confrontation and conflict with the 

patients and, in many cases, we were unsuccessful 

in ‘assisting’ them to stop. The patients were 

functioning well and the problem seemed to be 

ours not theirs. Their only concern was getting 

their repeat prescriptions as they realised they 

would have uncomfortable nights of sleep if 

they stopped them suddenly. Thus the ‘harm’ 

for these patients was my/our high moral stance 

of thinking they should stop. Over the years I 

have seen many patients on long-term benzodiazepines, 

rarely prescribed by myself, and have 

had to suppress the mild irritation I feel if my 

colleagues start patients on these medications. 

In recent times I have had a rethink. I recently 

wrote a chapter on anxiety for a British medical 

textbook (in press) and was aware that benzodiazepines 

are effective for anxiety but there is 

concern about habituation and ‘addiction’. The 

issue came to light recently when I was confronted 

by a 71-year-old patient who was having 

nightmares so severe they were affecting her the 

next day. She was not clinically depressed, nor 

did she have anxiety on gold standard questionnaires. 

I discussed with her the options. She 

could try a low dose tricyclic, a benzodiazepine 

or even quetiapine. I said the benzodiazepine 

would probably eliminate her nightmares but she 

would probably be on it forever and that when 

she was in her 80s she may be more prone to fall 

and break her hip (the numbers needed to harm, 

i.e break a hip in this situation is 91). 1 She was 

not concerned by the falling and I felt I had fully 

informed her of her options. Even more recently 

I spoke to an 87-year-old man who is on 0.5mg of 

lorazepam prescribed by his GP. He is sleeping 

well now, but previously complained endlessly 

about his poor sleep. He has also had a number 

of falls since starting this medication. I asked 

him what would he prefer: having a good night’s 

sleep and having falls, or not sleeping and having 

While evidence can help inform best practice, it needs to be placed in context. 

There may be no evidence available or applicable for a specific patient with 

his or her own set of conditions, capabilities, beliefs, expectations and social 

circumstances. There are areas of uncertainty, ethics and aspects of care for which 

there is no one right answer. General practice is an art as well as a science. Quality 

of care also lies with the nature of the clinical relationship, with communication and 

with truly informed decision-making. The BACk to BACk section stimulates 

debate, with two professionals presenting their opposing views regarding a clinical, 

ethical or political issue. 

Bruce Arroll 

BACk TO BACk 

Bruce Arroll 

MBChB, PhD, FRNZCGP 

Professor of General 


Health Care, 



Auckland; 

b.arroll@ 


Ngaire Kerse 


BACk to BACk this issue:

BACk TO BACk 

fewer/no falls? He chose the former. He now goes 

to the toilet at night with his walking stick to ensure 

that he does not fall. I have asked a number 

of elderly patients about their benzodiazepines 

and they all prefer the good night’s sleep. Sleeping 

poorly is a considerable bother to those that 

suffer from it and the promise of sleeping well 

is immediate and welcomed. I would contend 

most would choose the short-term option against 

the hazard of a (small chance of) fractured hip at 

some distant point in the future. 

Insomnia and anxiety are often chronic conditions. 

It is interesting to consider that we consider 

diabetes a chronic condition and are happy to 

give long-term metformin, aspirin and statins to 

all, in spite of the (small) harms that accompany 

Insomnia is only a trivial condition 

for those who don’t have it 

these medications. Anxiety is a long-term condition, 

yet when standard treatments fail, we are 

reluctant to consider long-term benzodiazepine. 

Is this moralizing on our part or perhaps can 

we be a bit more rational? We know that the 

numbers needed to treat for cognitive behavioural 

therapy are about five for anxiety 2 and that for 

SSRIs they are also about five. 3 For some patients 

no other treatment works, so in those situations 

we should consider offering benzodiazepines. 

We need to fully inform the patients. We need 

to say: this will help you sleep, but you may not 

be able to stop taking it (hence you will be on it 

indefinitely) and you may be more likely to fall 

when you are older. The risk of breaking your 

hip when not taking these medications (antidepressants 

and anxiolytics) is 10.1% and with these 

medications 11.2%. 1 What would you like to do? 

I would imagine most insomniac elderly patients 

would go for the benzodiazepines and take the 

risk. Insomnia is only a trivial condition for those 

who don’t have it. Philosophically I am not sure 

I want the whole nation on benezodiazepines as 

in Aldous Huxley’s Brave New World where the 

citizens were on their soma, but anxiety and insomnia 

are two conditions that are very prevalent 

in primary care (4.9% of men over 65 and 7.8% 

of women over 65 have anxiety 4 ) and 44% report 

insomnia from our unpublished data (2008). 

How should we do it? There is evidence that falls 

are more likely in the first five days of starting 

benzodiazepines (odds ratio 3.43), but after 30 

days this risk becomes non-significant. 5 What I 

would take from this is that we should start with 

a low dose (e.g. 0.25mg lorazepam) and slowly 

increase as necessary. We should also monitor the 

risk of falling and encourage the use of walkers 

and walking sticks. 

Summary 

For the elderly (and for any age) I think it is 

worth trying other treatments for insomnia and 

anxiety. Where those treatments do not work, I 

think we should abandon our moral superiority 

and fully inform patients about a legal and therapeutically-effective 

medication that has some 

adverse effects (like any medication). We need to 

be more patient-focused and less concerned about 

what our colleagues think of us. We should stop 

moralizing and start prescribing benzodiazepines 

when required (for the elderly and others). 

References 

1. Robbins J, Aragaki AK, Kooperberg C, Watts N, Wactawski-Wende 

J, Jackson RD, LeBoff MS, Lewis CE, Chen Z, 

Stefanick ML, Cauley J. Factors associated with 5-year 

risk of hip fracture in postmenopausal women. JAMA 

2007;298(20):2389–98. 

2. http://clinicalevidence.bmj.com.ezproxy.auckland.ac.nz/ 

ceweb/conditions/meh/1002/1002_I1.jsp; accessed 27 

June 2008. 

3. Kapczinski F, Lima MS, Souza JS, Cunha A, Schmitt 

R. Antidepressants for generalized anxiety disorder. 

Cochrane Database of Sys Rev 2003, Issue 2. Art. No.: 

CD003592. DOI: 10.1002/14651858.CD003592. 

4. MaGPIe Research Group. The nature and prevalence 

of psychological problems in New Zealand primary 

healthcare: a report on mental health and general practice 

investigation (MAGPIE). NZ Med J 2003;116:1171–1185. 

5. Hoffmann, F. Glaeske, G. New use of benzodiazepines and 

the risk of hip fracture: A case-crossover study. Z Gerontol 

Geriatr 2006;39(2):143–8. 


gPs should prescribe more 


NO 

The answer is undoubtedly ‘no’, we are using too 

many of these dangerous, unnecessary medications 

and should be prescribing fewer. Resist 

the urge to take the easy way out—undoubtedly 

proposed by Professor Arroll—and to use these 

drugs for inappropriate indications where the 

risks clearly outweigh the benefits. The risk for 

older people from using benzodiazepines is high. 

How much are we using them? 

Taking residential care as a key setting: 46% of 

residents in 1999 took psychotropic medication. 1 

In 2005, 25% were taking short-acting sedatives, 2 

with benzodiazepines being one of the most commonly 

used. In the community it is more difficult 

to gauge accurate estimates of benzodiazepine use. 

The age standardised prevalence rate of benzodiazepine 

use in Auckland general practice was 3.4% 

for patients over 20 years of age in 1992; however 

use was predominantly in the elderly (70% were 

over 60 years of age) and female (62.5%). 

In the 2004–2005 Australian National Health 

Survey, anxiolytics, hypnotics and sedative 

prescriptions make up approximately 4–5% of the 

total prescriptions written by Australian general 

practitioners and 10% of patients used medication 

for anxiety or nerves. 3 

How much should we be using them? 

Anxiety disorder may be one of the only appropriate 

indications, where the benefits outweigh 

the risks of prescribing benzodiazepines. 

The prevalence of anxiety in the community is 

14.8% over one year and only 9.8 for the previous 

month. 4 The MaGPIe study primary care mental 

health survey in New Zealand shows that 15% of 

all people get treated with psychotropic medication; 

5 however 12-month prevalence of anxiety 

disorder in general practice attenders aged 65+ 

was only 4.9% for men and 7.8% for women in 

2003. There is a clear mismatch between diagnosis 

and prescribing and it is likely that much of 

the benzodiazepines use observed in community 

dwelling older people is related to treatment of 

sleep disorder. 

what’s wrong with using 

them in late life? 

There is little right with using benzodiazepines 

in late life. Reactions to benzodiazepines are 

often paradoxical and long-term management is 

notoriously problematic. 6 Apart from the risk of 

confusion and development of tolerance, falls are 

the most problematic result of benzodiazepine 

use. The effects of hypnotics on balance, gait and 

equilibrium are the consequence of differential 

negative impacts on vigilance and cognitive functions, 

and are highly dose- and time-dependent. 

It is not surprising that almost no guideline 

recommends use of benzodiazepines for older 

people, i.e. Beers criteria for appropriate use of 

medications. 7 

More importantly, the risk of fracture is increased 

by over 30%. The RR of fracture associated 

with use of benzodiazepines was 1.34 (95% 

CI 1.24, 1.45) in one systematic review of 23 

studies. 8 While any benzodiazepines carried the 

risk, it was higher for those taking the short-acting 

high-potency benzodiazepine (IRR, 1.27; 95% 

CI, 1.01–1.59), during the first two weeks after 

starting a benzodiazepine (IRR, 2.05; 95% CI, 

1.28–3.28), during the second two weeks after 

starting a benzodiazepine (IRR, 1.88; 95% CI, 

1.15–3.07), and for continued use (IRR, 1.18; 95% 

CI, 1.03–1.35), so short half-life benzodiazepines 

BACk TO BACk 

Ngaire kerse 

MBChB, PhD, FRNZCGP 

Associate Professor of 

General Practice and 

Primary Health Care, 



Auckland; 

n.kerse@auckland.ac.nz 


BACk TO BACk 

are not safer than long half-life benzodiazepines. 

Hip fracture risk is highest during the first two 

weeks after starting a benzodiazepine. Those older 

people that just want something in the shortterm 

as a result of a recent stress are at highest 

risk of hip fracture from your prescriptions. Even 

with a reasonably high NNT, hip fracture is a 

devastating event. Less than 50% of those with 

hip fracture regain pre-fracture function and 20% 

die within 12 months after hip fracture. 

In a large group of cognitively normal Canadians, 

the frequency of falls was 60% greater in benzodiazepine 

users compared to non-users. Our own 

Professor John Campbell successfully reduced the 

risk of falls to 18% (an NNT to cause a fall of 2), 

in an RCT of older people on benzodiazepines, 

by reducing the dose of benzodiazepine gradually 

over six months and continuing a placebo tablet. 

Unfortunately after unblinding, half of the 

older people in the intervention group returned 

to the GP to get their prescription successfully 

renewed! Systematic reviews also identified that 

chronic consumers of benzodiazepines are more 

susceptible to the appearance and progression of 

many acute and chronic diseases (infectious and 

malignant diseases). 

The risk of using this medication usually far outweighs 

the benefits and use should be restricted to 

those with moderate to severe anxiety disorders. 

Are they needed for insomnia? 

Benzodiazepines do improve sleep; however more 

patients receiving benzodiazepines reported adverse 

effects, especially daytime drowsiness and 

dizziness or light-headedness (common odds ratio 

1.8, 95% CI 1.4 to 2.4) compared with other sleep 

treatments. Cognitive function decline including 

memory impairment was reported in several of 

the studies and Zopiclone was not found to be superior 

to benzodiazepines on any of the outcome 

measures examined. 

A large systematic review compared sleep 

pharmacotreatments. Benzodiazepines were no 

better than non-benzodiazepines in reducing time 

to sleep. All drug groups had a statistically significant 

higher risk of harm compared to placebo, but 

benzodiazepines had the highest risk difference. 

Non-pharmacological treatment for insomnia is 

very effective. When identified accurately, primary 

insomnia responds best to sleep restriction 

techniques and medications are seldom needed for 

those in late life. If it is not primary insomnia 

then an underlying disorder, such as pain, 

depression or restless leg syndrome should be 

sought and appropriate treatment started. 

Can we stop them? 

It is relatively easy to encourage stopping benzodiazepines. 

A simple letter to patients using 

these drugs may be effective in reducing useage. 

Recognised tapering protocols are available and 

reasonably successful. Older people sleep less and 

relaxation and sleep hygiene along with sleep 

restriction can be very successful in improving 

satisfaction with sleep. Take it slow and make 

sure the older person wants to stop. 

So don’t be persuaded by the Professor. We are 

currently using too many benzodiazepines in 

older people and exposing them to unacceptable 

risk associated with their use. 

We are definitely NOT under-prescribing 

benzodiazepines for older people. 

References 

1. Kerse N. Medication use in residential care. NZ Fam Phys 

2005;32:251–5. 

2. Peri K, Kerse N, Kiata L, Wilkinson T, Robinson E, Parsons 

J, et al. Promoting independence in residential care: 

Successful recruitment for a randomised controlled trial. 

JAMDA. 2007:doi10.1016/j.jamda.2007.11.008. 

3. Australian Institute of Health and Welfare. General practice 

activity in Australia 2004-05. Canberra: AIHW; 2005. 

4. Browne MO, Wells J, Scott K. Te Rau Hinengaro: The New 

Zealand Mental Health Survey. Wellington: Ministry of 

Health; 2006. 

5. Bushnell J, McLeod D, Dowell A, Salmond C, Ramage S, 

Collings S, et al. The treatment of common mental health 

problems in general practice. Fam Pract 2006;23(1):53–9. 

6. Mathew VM, Dursun SM, Reveley MA. Increased aggressive, 

violent, and impulsive behaviour in patients during 

chronic-prolonged benzodiazepine use. Can J Psychiatr - 

Revue Canadienne de Psychiatrie 2000 Feb;45(1):89–90. 

7. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, 

Beers MH. Updating the Beers criteria for potentially inappropriate 

medication use in older adults: results of a US consensus 

panel of experts. Arch Int Med 2003;163:2716–24. 

8. Takkouche B, Montes-Martinez A, Gill SS, Etminan M. 

Psychotropic medications and the risk of fracture: a metaanalysis. 

Drug Safety 2007;30(2):171–84. 

(Further references available from: n.kerse@auckland.ac.nz) 


Patient Oriented Evidence that Matters 

Psychological interventions reduce onset 

of depression 

CLiNiCAL qUEsTiON: Do behavioural interventions reduce 

the risk of new onset depression? 

BOTTOM LiNE: Behavioural interventions to prevent depression 

reduce the incidence of newly diagnosed depression. Most 

of the studies included in this report were of cognitive behavioural 

therapy interventions in group format for individuals at 

increased risk for major depression. (LOE=1a-) 

REfERENCE: Cuijpers P, van Straten A, Smit F, Mihalopoulos 

C. Beekman A. Preventing the onset of depressive distorders: 

A meta-analytic review of psychological interventions. Am J 

Psychiatry 2008;165(10):1272–1280. 

sTUdy dEsigN: Meta-analysis (randomised controlled trials) 

fUNdiNg: Unknown/not stated 

ALLOCATiON: Concealed 

sETTiNg: Various (meta-analysis) 

syNOPsis: This is a meta-analysis of randomised trials to 

prevent depression using behavioural interventions. The 

primary outcome was incident cases of depression. Because the 

length of the studies varied, the incidence rates were calculated 

by the authors in person-years. A total of 19 studies with 5806 

participants met inclusion criteria, one of which tested three 

different preventive interventions, for a total of 21 comparisons. 

Seven studies were about preventing postpartum depression, 

and the rest included various other targets, such as school and 

primary care settings. There were three types of prevention; 

universal (two), selective programmes aimed at high-risk groups 

(11), and prevention aimed at individuals with depressive 

symptoms who do not meet the criteria for a diagnosis of major 

depression (eight). The majority of interventions were cognitive 

behavioural therapy (15). Group format was used in 18 

comparisons. The incidence ratio of new depression per 

person-year was 0.78 (95% CI, 0.65–0.93), indicating a reduction 

of the incidence of depressive disorders by 22% in the intervention 

groups compared with control groups. The authors 

calculated the number needed to treat as 22. 

© 1995–2009 John Wiley & Sons Inc. All Rights Reserved. www.infopoems.com 

CONTiNUiNg PROfEssiONAL dEVELOPMENT 

CBT is effective for self-harm 

CLiNiCAL qUEsTiON: Is cognitive behavioural therapy an 

effective treatment for self-harm? 

BOTTOM LiNE: A brief series of cognitive behavioural therapy 

(CBT) sessions reduces the risk of self-harm and improves a 

number of other important psychological outcomes. (LOE=1b-) 

REfERENCE: Slee N, Garnefski N, van der Leeden R, 

Arensman E, Spinhoven P. Cognitive-behavioural intervention 

for self-harm: randomised controlled trial. Br J Psych 

2008;192:202–211. 

sTUdy dEsigN: Randomised controlled trial (nonblinded) 

fUNdiNg: Government 

sETTiNg: Outpatient (specialty) 

ALLOCATiON: Concealed 

POEMs 

syNOPsis: Self-harm is a poorly studied but psychologically 

devastating condition. In this study, 90 patients in the Netherlands 

with a recent history of self-harm were randomised to 

either CBT or treatment as usual. Of the 48 patients assigned 

to CBT, only 40 began the therapy but all 40 attended all 12 

sessions (the first 10 were weekly). Eight of 42 patients in the 

treatment-as-usual group were lost to follow-up because of suicide, 

severe psychological problems, or other reasons. Analysis 

was by modified intention to treat; the patients who did not 

begin the CBT were excluded. Patients were between the ages 

of 15 years and 35 years, and more than 90% were women. At 

nine months, the number of self-harm episodes in the previous 

three months declined more in the CBT group, from 14.4 

to 1.2, compared with a decline from 11.6 to 4.6 in the usual 

treatment group (P < .05). Secondary outcomes (depression, 

anxiety, self-esteem, helplessness, problem-solving, unlovability, 

and poor distress tolerance) all improved significantly more 

in the CBT group. 



PEARLs COCHRANE CORNER 

String of PEARLS 

Practical Evidence About Real Life Situations 

PEARLS are succinct summaries of Cochrane systematic Reviews 

for primary care practitioners—developed by the Cochrane Primary 

Care Field, New Zealand Branch of the Australasian Cochrane Centre 

at the Department of General Practice and Primary Health Care, 

University of Auckland, funded by the New Zealand Guidelines Group 

and published in NZ Doctor. 

Psychological therapy based on CBT is effective 

short-term treatment for generalised anxiety disorder 

Musical therapy for depression may improve mood 

Psychosocial & psychological interventions are 

effective for postpartum depression 

Antidepressants are effective for neuropathic pain 

No evidence supports use of antidepressants for 

nonspecific low-back pain 

CBT for tinnitus improves quality of life 

CBT is possible treatment for children with recurrent 

abdominal pain 

disCLAiMER: PEARLs are for educational use only and are not meant 

to guide clinical activity, nor are they a clinical guideline. 

Benzodiazepines may hasten 

improvement in major 

depression for up to six weeks 

Bruce Arroll MBChB, PhD, FRNZCGP, Professor of General Practice 

and Primary Health Care, University of Auckland, Private Bag 92019, 

Auckland; Email: b.arroll@auckland.ac.nz 

THE PROBLEM: Depression often presents with anxiety. The 

rate of anxiety comorbidity among patients with depression 

varies from 33% to 85%. Reviews of randomised controlled 

trials show, however, that anxiolytic benzodiazepines, with 

the possible exception of some triazolo-benzodiazepines for 

mild to moderate depression, are less effective than standard 

antidepressants in treating major depression. The advantages of 

adding benzodiazepines to antidepressants are unclear. There 

are suggestions that benzodiazepines may lose their efficacy 

with long-term administration and that their chronic use carries 

risks of dependence. 

CLiNiCAL BOTTOM LiNE: Benzodiazepines are effective 

in improving depression symptoms for the first six weeks, 

but after that appear to have no benefit. They seem to work 

in addition to tricylic antidepressants such as imipramine in 

moderate to high doses (100 to 145mg) with triazolam 0.5mg 

and fluoxetine 20 to 40mg with clonazepam 0.5 to 1mg. There 

are concerns about the risk of hip fracture in the elderly but 

the NNH=90 for those on antidepressants/anxiolytics. 1 

Table 1. Major depression 

Benzodiazepines 

in addition to 

antidepressants 

Success Evidence Harms 

At six weeks 

NNT=8 

(range 5 to 29) 

in terms of 

improved 

symptoms 

NNT = numbers needed to treat 

NNH = numbers needed to harm 

References 

Cochrane 

review 2 

No additional 

benefit after six 

weeks plus risk of 

addiction. 

NNH =90 for hip 

fracture in elderly 

1. Robbins J. Aragaki AK. Kooperberg C. Watts N. Wactawski-Wende J. Jackson 

RD. LeBoff Ms. Lewis CE. Chen Z. stefanick ML. Cauley J. Factors associated 

with 5-year risk of hip fracture in postmenopausal women. JAMA 2007; 

298(20):2389–98. 

2. Furukawa TA, streiner DL, Young LT, Kinoshita Y. Antidepressants plus benzodiazepines 

for major depression. Cochrane Database of syst Rev 2001; Issue 3. 

Art. No.: CD001026. DOI: 10.1002/14651858.CD001026. All people residing 

in New Zealand have access to the Cochrane Library via the Ministry website 

www.moh.govt.nz/cochranelibrary 


Bridging two worlds in the interview process 

—the psychiatric assessment and Maori in primary care 

Pamela Ara Bennett MBChB, FRANZCP 

Mental health is an area of 

particular concern for Maori. 

Professor Mason Durie has 

stated that mental health is the greatest 

health problem facing Maori in the first 

two decades of this century. 1 

The assessment of mental health issues 

across cultures is recognised as being 

fraught with difficulty. Psychiatry is 

unlike other medical disciplines in that 

the diagnosis of functional psychiatric 

disorders is based entirely on the clinical 

interaction. The DSM-IV acknowledges 

difficulties may be encountered when 

applying DSM-IV diagnostic criteria 

across cultures, and has produced an 

outline for cultural formulations in 

psychiatric assessment. 2 

This paper aims to assist the primary 

care clinician to (i) develop empathic 

therapeutic relationships with their 

Maori patients and whanau through 

acknowledging difference and building 

CORREsPONdENCE TO: 

Pamela Ara Bennett 

Psychiatrist and senior 

Lecturer, Te Kupenga Hauora 

Maori, school of Population 

Health, The University 



pam.bennett@auckland.ac.nz 

Pounamu 


the notion of cultural difference into the 

clinical assessment process, and (ii) make 

diagnostic and management decisions 

based on their clinical knowledge, enhanced 

by such therapeutic relationships. 

To achieve these aims I use a fictional case 

history, based on my own clinical experience, 

and a modified version of the DSM- 

IV outline for cultural formulation. 3 

Case history 

Matiu, a tall handsome 17-year-old, 

comes into your office with his Aunt 

Estelle and older brother Manu. Matiu 

sits down in the chair the furthest away 

and looks at the ground. He obviously 

is not happy and says nothing. Auntie 

introduces herself and her two nephews. 

She is a retired social worker who 

worked in a large city hospital. She asks 

if the other whanau members outside 

may come in so the meeting can begin 

with karakia. An older man stands and 

prays in Maori. Whanau members then 

introduce themselves. You introduce 

yourself from a professional perspective—‘I 

am Dr McDonald. I have been 

working as a general practitioner in this 

practice for six years. I spent three years 

working down south in Hokitika.’ 

Auntie begins Matiu’s story. Matiu lives 

with his mother and older brother in 

MAoRi PRiMARy HEALtH cARE tREASuRES 

Pounamu (greenstone) is the most precious of stone to Maori. 

POUNAMU 

a large city. His parents divorced years 

ago. Mother never remarried. Two elder 

sisters are married and live elsewhere. 

Matiu is in his last year of secondary 

school, excels in rugby, dreams of being 

an All Black. He has many friends and 

was ‘going steady’ with Ara. Brother 

Manu is doing well at university after 

a year overseas, on a scholarship. Manu 

explains Matiu began to withdraw into 

himself about nine months ago (stayed 

in his bedroom, stopped football, broke 

with Ara, refused to speak to anyone). 

He was suspicious of everyone (mother, 

sisters, football coach, friends). He believed 

‘everyone was against him’. Matiu 

told Manu that he was hearing voices 

talking about him, arguing about him 

and telling him he was no good. The 

voices were telling him that he might 

as well kill himself. Sometimes Matiu 

thought it was the neighbours outside 

his window, but he was never able to 

catch them, and the same voices were 

giving him the same messages through 

music so he had stopped listening. He 

was very distressed. Mother said Matiu 

had stopped eating and had been pacing 

the floor most nights, mumbling to himself. 

She says he is a very good boy and 

had never acted like this before. 

Until this stage in the proceedings you 

have been encouraging the family to tell 

their story and listening. 

‘Ahakoa he iti, he pounamu’ 

(Although it is small, it is valuable) 



POUNAMU 

On direct questioning Matiu just looks 

away. At one stage he mutters something 

unintelligible, looking sharply 

upwards and the older man who is his 

grandfather, puts an arm on his shoulder 

soothing him. 

You enquire if anyone else in the family 

has had difficulty like this. A distant 

cousin was in a psychiatric hospital years 

ago, no one knows why. She has passed 

away now. 

Matiu’s family are certain there is no 

drug involvement. He has been at home 

with no visitors. Manu has been to 

check with their mutual friends. 

The diagnosis is clearly of a psychosis. 

However there are many unanswered 

questions: 

• Is the psychosis functional (e.g. 

schizophreniform), organic (e.g. 

drug induced) or affective (e.g. 

depression, with mood congruent 

hallucinations and delusions)? 

• What role do cultural beliefs 

play in this presentation? 

• If hospitalisation and medication 

are required, as seems likely, 

how should this be managed? 

• What are the long-term needs of 

this patient and his whanau likely 

to include and how should they 

be planned for and managed? 

Key factors in the assessment 

and management of mental 

health problems amongst Maori 

The following are key factors in the 

assessment and management of mental 

health problems amongst Maori necessary 

for the development of a management 

plan which is safe, useful and 

acceptable to the patient, clinician and 

whanau: 

(a) Ascertain the self-defined cultural 

identity of your patient from the 

outset. Cultural identity cannot 

be determined from appearance. 

Matiu looks Maori, but how does 

he identify? Matiu is almost silent 

during the consultation; however he 

should be asked how he identifies, 

culturally, as should his whanau. 

(b) Patient and whanau views of the 

illness. Maori views of well-being 

and illness may differ from those of 

Western medicine. Listening to the 

views of patient and whanau about 

the illness will both assist you in 

the assessment process and enhance 

the therapeutic relationship. Keep in 

mind and bring up as appropriate: 

• What do they think is wrong? 

• Is there a name for it? 

• What may have caused it? 

• What, in their view, 

should be done now? 

• What do they think will 

be the outcome? 

It is important to know if the whanau 

believes the illness to be a Maori 

illness (mate Maori). If this the case, 

a Tohunga probably will have already 

been consulted. Sensitivity is required 

when speaking of such issues. 

However, once you have established 

the whanau view, you can clearly 

explain your view as a Western clinician. 

Mate Maori and a functional 

psychosis may co-exist. Importantly 

they can be treated together safely 

and successfully. 

(c) support and safety—Matiu 

has 

support from his whanau. When 

Maori present to the consultation 

alone they should be asked if they 

would like to have another Maori 

present at the interview. Whanau 

and cultural consultants not only 

support the patient, but also can 

help the clinician and the patient 

understand each other. In Matiu’s 

case, the presence of kaumatua 

and kuia who performed karakia at 

the beginning and the end of the 

interview ensured that everyone 

involved was kept spiritually safe in a 

culturally sanctioned manner. Safety 

is of paramount importance. If the 

whanau feel the patient is not safe 

then mutually agreed steps have to 

be taken to ensure their safety. This 

may involve invoking the Mental 

Health Act. Matiu is experiencing 

command hallucinations telling 

him to kill himself. No one in such 

circumstances can be assumed to 

be safe with respect to themselves 

or others. The clinician may have 

to explain this to the patient and 

whanau. 

(d) The impact of culture (of patient and 

clinician) on the encounter between 

the physician and the patient: In 

order to establish a relationship with 

another person, Maori need to ‘get to 

know’ the other person and be known 

by that person. It is important to 

know who the person is, where they 

come from and who their family is. 

Thus time needs to be set aside for 

the clinician, the patient and whanau/ 

support person to get to know each 

other. This can be difficult, with 

increasing time pressure on all 

clinicians. However it can be the 

difference between a positive outcome 

and treatment failure. Clinicians 

should feel comfortable about what 

they reveal about themselves. There is 

no need to tell your life story. A ‘chat’ 

before getting onto the presenting 

problem is helpful. It is important 

that the patient is given time to tell 

his story in his own way and time. 

(e) Language: 

Do not take it for granted 

that words and expressions in English 

mean the same thing for you and 

your patient. Ways to avoid such 

misunderstanding include: 

• Cultural consultant/interpreter 

at meetings; 

• Develop a therapeutic relationship 

in which the patient feels comfort- 


• 

• 

• 

able asking what you mean, e.g. 

‘what does anxious mean?’ 

Be a good listener; 

Always be respectful; 

Explain your understanding of 

the problem and your management 

plan until sure patient 

and whanau understand. 

in summary 

‘Te whare e kitea, te kokonga ngakau e 

kore e kitea’ is a Maori proverb, which 

literally translated means that we can 

see the corners of a house, but the 

corners of the heart are not visible. Its 

metaphorical meaning is that things 

are not always as they seem at first 

glance. I hope this paper goes some 

way to illustrating the relevance of the 

active acknowledgement of culture and 

difference in the practice of psychiatry 

amongst Maori; of ways to avoid 

misunderstanding and misinterpretation 

and to achieve a positive outcome 

for the patient, the family and the 

clinician. 

References 

1. Durie M. ‘Mauri Ora’. Auckland: Oxford University 

Press; 2001. 

2. American Psychiatric Association. ‘Diagnostic 

and statistical Manual of Mental Disorders: 

Fourth Edition Text Revision.’ Washington DC: 

American Psychiatric Association; 2000. 

3. McKendrick J and Bennett P Te Ara (2006). 

Indigenous issues in GP psychiatry. In: Blashki, 

Judd, Piterman, editors. General practice psychiatry. 

sydney: McGraw Hill Medical. p 72-85. 


st John’s wort 

(Hypericum perforatum) 

Dr Joanne Barnes, Associate Professor in Herbal Medicine, school of Pharmacy, 


PREPARATiONs: Extract of St John’s 

wort flowers or leaves is available in 

many forms, including capsules, tablets 

and tinctures, as well as topical preparations. 

Chopped or powdered forms of 

the dried herb are also available. 

ACTiVE CONsTiTUENTs: Probably 

hypericin, hyperforin and/or flavonoid 

constituents. 

MAiN UsEs: Symptomatic relief in 

mild to moderately severe depression. 

EVidENCE fOR EffiCACy: Systematic 

review and meta-analysis of 30 

RCTs show that certain St John’s wort 

extracts are more effective than placebo 

(NNT=42) and as effective as certain 

conventional antidepressants (including 

selective serotonin reuptake inhibitors 

(SSRIs). 

AdVERsE EffECTs: Adverse effects 

reported in clinical studies are typically 

mild and most commonly gastrointestinal 

symptoms. 

dRUg iNTERACTiONs: Extracts of 

St John’s wort interacts with certain 

prescription medicines through inducing 

several cytochrome P450 drug metabolising 

enzymes, resulting in reduced 

plasma concentrations of medicines 

metabolised by these enzymes, including 

certain anticonvulsants, ciclosporin, 

summary Message 

st John’s wort is about as effective as 

some conventional antidepressants 

(NNT=42) including certain ssRIs for 

treating mild to moderate depression 

and has a favourable adverse effect 

profile, at least with short-term use. 

However, it interacts with several other 

medicines, including digoxin, theophylline, 

warfarin and oral contraceptives. 

As with all herbal medicines, different 

st John’s wort products differ in their 

pharmaceutical quality, and the implications 

of this for efficacy and safety 

should be considered. 

warfarin, digoxin, theophylline and oral 

contraceptives. There is also a risk of 

increased serotonergic effects where St 

John’s wort is taken concomitantly with 

triptans or SSRIs. 

Key references 

CHARMs & HARMs 

Barnes J, Anderson LA, Phillipson JD. Herbal medicines. 

3rd ed. London: Pharmaceutical 

Press; 2007. 

Linde K, Mulrow C, Berner M, et al. st John’s wort for 

depression. Cochrane Database of systematic 

Reviews, issue 2. Art. no. CD000448. Wiley 

Interscience; 2005. 

Izzo AA & Ernst E. Interactions between herbal medicines 

and prescribed drugs: a systematic review. 

Drugs 2001;15:2163–2175. 

Mills E, Montori VM, Wu P, et al. Interaction of st 

John’s wort with conventional drugs: systematic 

review of clinical trials. BMJ 2005;329:27–30. 

Herbal medicines are a popular health care choice, but few have been tested to 

contemporary standards. cHARMS & HARMS summarises the evidence for the 

potential benefits and possible harms of well-known herbal medicines. 



REsOURCE sUMMARY 

destination: Recovery 

Te Unga Ki Uta:Te Oranga 

future responses to mental distress and loss of well-being 

—a discussion paper from the Mental Health Advocacy Coalition 

Helen Rodenburg MBChB, FRNZCGP 

Ko te pae tawhiti whaia ki a tata—Seek your aspirations on the horizons 

This recent discussion paper is 

important for general practice and 

primary health care as it recognises 

the role we play in improving the 

mental health of our population: 

Easy access: Individuals and families know 

where to find independent information 

on the availability and quality of services. 

There are many doors into services—a lot 

of them open into primary health settings 

which act as the hubs of service delivery 

and referral. People are not denied access 

to help on the basis that their distress 

or loss of well-being are insufficiently 

severe; they are either provided for or immediately 

referred elsewhere. 

The paper provides challenges for all 

health professionals to change and improve 

the care we offer and is part of an 

international movement in the provision 

of services. With the developments in 

New Zealand in primary mental health 

care it is important that we, as GPs, are 

aware of developments and able to take 

advantage of opportunities. 

‘When you’re trying to create things 

that are new, you have to be prepared to 

be on the edge of risk.’—Michael Eisner 

I have been the RNZCGP representative 

on the Coalition and appreciate the opportunity 

to contribute to improvement 

in mental health services, and for the 

support given to primary care. ‘Destination 

Recovery’ supports integrated 

collaborative approaches to service provision 

across both specialist clinical and 

support organisational boundaries, and 

the secondary-primary interface. Leadership 

is recognised as being important, as 

is support for change management. 

‘There are risks and costs to a program 

of action. But they are far less than the 

long-range risks and costs of comfortable 

inaction.’—John F Kennedy 

Executive summary 

‘Vision is perhaps our greatest strength… 

it makes us peer into the future and lends 

shape to the unknown.’—Li Ka Shing 

The Mental Health Advocacy Coalition 

has a vision for society’s well-being. 

We believe everyone should experience 

not only good mental health, but the 

benefits of being able to cope with life 

stressors and enjoy a productive working 

life and fulfilling relationships. We believe 

mental health services have a major 

role to play in bringing about well-being 

for all; but only if these services are 

transformed. 

Forces for transformation 

The rise in human rights awareness, 

self-determination, the consumer soci- 

ety, multiculturalism and the Maori renaissance 

have all impacted on the mental 

health arena. Deinstitutionalisation, 

awareness of the social determinants of 

distress, and the service-user movement 

are all drivers for mental health service 

transformation. Expectations are also 

changing—people with mental distress 

want the same from life as everyone 

else. There is already change at mental 

health policy level in many countries, 

including New Zealand. 

in our vision: 

Values and people 

• Madness is a fully human experience. 

• The purpose of services is recovery. 

• Self-determination is the foundation 

of service delivery. 

Adopting these values changes the way 

people think. Everyone is encouraged to 

be informed, active and competent—this 

includes the workforce, people who use 

services, their families and the wider 

community. 

Services 

• Primary services are the most 

common point of access, and offer 

service negotiation, navigation, 

drug and talking therapies 

and other forms of support. 


• Niche mental health services 

include acute, forensic, and early 

intervention services, and services 

for specific client groups. 

• Other sectors are structurally aligned 

and work closely with primary 

services and mental health services 

to promote well-being for all. 

• All agencies are accountable to 

powerful and well-resourced 

district leadership groups. 

Systems in our vision: 

• Policy is profoundly influenced by 

service users, families and those 

most affected by mental distress, and 

funding is planned and responsive. 

• Measures of effectiveness of services 

are simple and focus on outcomes 

that are important to service users. 

• Coordinated service development, 

workforce development 

and research lead to adaptive, 

responsive services for all. 

An independent national agency 

monitors services and provides 

information on quality and advocacy 

for service users and whanau. 


• 

The discussion paper is available at: 

http://www.mentalhealth.org.nz/file/down 

loads/pdf/Destination%20Recovery_FINAL 

_low%20res.pdf 

Effective communication strategies to enhance 

patient self-care 

Fiona Moir MBChB; Renske van den Brink MBChB, FRNZCGP; Richard Fox MBChB, FRNZCGP; Susan Hawken MBChB, FRNZCGP 

introduction 

Can primary care practitioners influence 

and improve patient self-care, simply by 

the way they communicate with their 

patients? If so, can this be done within 

the consultation, even when practitioners 

already feel constrained by lack of time? 1 

Currently in New Zealand (NZ) there 

is significant morbidity and mortality 

associated with lifestyle-related disease, 

and constraints on health resources 

increasingly mean that patients need to 

be more responsible for their own health. 

After indicating the general context of 

lifestyle-related illness, this paper will 

outline the different approaches available 

to primary care practitioners. The prin- 

CORREsPONdENCE TO: 

fiona Moir 

Department of General 


Health Care, Faculty 


sciences, The University 



f.moir@auckland.ac.nz 


ciples of motivational interviewing, the 

stages of change model, the ‘catastrophe 

theory’ model, 2 and the essential elements 

of brief intervention in primary 

care settings will be outlined. This will 

be followed by practical examples on 

how to communicate with the patient 

in ways that will enhance behavioural 

change and self-care. 

Background 

There are some concerning trends in the 

rates of lifestyle-related disease. The 

prevalence of obesity has more than 

doubled from 1982 to 2003, 3 and the 

future impact of the obesity epidemic 

on the NZ population and health system 

will be significant. 4 Smoking rates are no 

longer dropping. 3 Although the overall 

ischaemic heart disease mortality rate for 

2011–15 is predicted to decline, there is 

an expected actual increase in the mortality 

rate for Maori. 5 Disparities across a 

range of risk factors and health outcomes 

for Maori and Pacific peoples, compared 

to the total population, persist and are of 

grave concern. 6 With effective lifestyle 

REsOURCE sUMMARY 

PRACTICAL POINTERs 

intervention targeting obesity, smoking, 

exercise, and alcohol use, such lifestylerelated 

conditions could be reduced. 

A NZ study identified patients with lifestyle 

issues by using a short screening 

tool consisting of lifestyle and mental 

health risk factors. It was found to be acceptable 

to patients and not burdensome 

to practitioners. 7 It is well known that 

offering patients information only does 

not necessarily effect behaviour change, 

so other approaches are needed. An 

intervention that is currently being trialled 

and evaluated 8 involves a ‘lifestyle 

script’ administered by primary care 

nurses and followed up with telephone 

counselling. Utilising programmes that 

are culturally appropriate is important 

to success. 9 Other studies have shown 

that although there is acceptability 

and recognition of the value of chronic 

disease management programmes, there 

is still concern by practitioners about the 

amount of time involved. 10 

Promoting patient self-care ideally is 

the responsibility of all members of the



multi-disciplinary team. For example, a 

current initiative to improve medication 

adherence involves pharmacists undertaking 

a ‘Medicine Use Review’ (MUR), 

and discussing all of the patient’s 

medications with them. Central to the 

MUR consultation is the way in which 

the pharmacist communicates with the 

patient, exploring their health beliefs 

and their illness perspective. An exploration 

of the patient’s illness perspective 

involves finding out their ideas, concerns 

and expectations relating to their illness 

and medications. 11 Once this information 

has been gathered, the pharmacist and 

the patient use joint decision-making to 

agree on the next step. This is a good 

example of how communication can aid 

patient behaviour change. 

A variety of models have attempted to 

facilitate patient self-care in the context 

of the patient-centred interview, but one 

of their limitations in primary care is 

the amount of time they take to deliver. 

In this paper we briefly describe four of 

these models, and then indicate stylistic 

elements within them, which may usefully 

be used within a time-constrained 

interview. 

Motivational interviewing 

Motivational interviewing is a directive 

client-centered style of counselling 

for eliciting behaviour change. It has 

its roots in the drug and alcohol field, 

and has been used for many years in 

addictions counselling, predominantly 

focusing on problem drinking. Although 

initially developed for longer consultations, 

elements of it have been adapted 

for use in shorter interactions in many 

other areas of health behaviour change. 12 

The underlying ethos or spirit of motivational 

interviewing is that the practitioner–patient 

relationship works best as a 

partnership, that the quality of that relationship 

is the key to behaviour change, 

and that the motivation and ideas about 

change come from the patient, not from 

the practitioner. For example, the patient 

can be asked to identify and explore any 

ambivalence they have to the particular 

behaviour, e.g. ‘what are the good 

things and the not so good things about 

smoking?’ In motivational interviewing, 

it is the practitioner’s job to direct the 

patient towards exploring and discussing 

ambivalence and to summarise this 

for them, and it is the patient’s job to 

examine the ambivalence and to decide 

on the next step. 

The main aspects of motivational interviewing 

13 are summarised in Table 1. 

The stages of change 

Another model, referred to as ‘the stages 

of change’, played a vital role in the 

development of both motivational interviewing 

and brief intervention. 15 Central 

to this model is the idea that behaviour 

change is incremental and involves specific 

tasks. The model describes a series 

of changes progressing from pre-contemplative 

(unaware, unable or unwilling to 

change), to contemplative (evaluating pros 

and cons of change), to preparation, then 

action and maintenance. The model recognises 

that relapse is common, and that 

many people will have several attempts 

before achieving a successful outcome. 

Table 1 

Motivational interviewing 14 

spirit Autonomy 

collaboration 

Evocation 

Principles Roll with resistance and 

Counselling 

skills required 

avoid arguments 

Express empathy 

Develop discrepancy 

Support Self-efficacy 

open questions 

Affirm 

Reflect 

Summarise 

Catastrophe theory model 

Critics of the stages of change model 

state that the boundaries between the 

stages are arbitrary, and furthermore that 

often behaviour change does not actually 

involve any planning or preparation. 16 In 

a recent study, almost half of smokers’ 

attempts to stop involved no previous 

planning, and unplanned attempts to 

stop were more likely to be successful. 2 

A new model in 2006, based on ‘catastrophe 

theory’, hypothesizes that behaviour 

change is influenced by ‘motivational 

tension’ (the levels of which depend on 

beliefs, past experiences, and the current 

situation), and that in the presence of 

this tension, even a small trigger can 

lead to a sudden change. 2 

Brief intervention 

The stages of change can be a helpful 

model to use alongside motivational 

interviewing, but where does brief 

intervention come into play? Brief 

interventions are those practices that 

aim to identify a problem and motivate 

an individual to do something about it, 

which can often be used in the course 

of routine practice without requiring 

significantly more time. 17 Multiple trials 

have shown the effectiveness of brief 

intervention. 18 Successful brief interventions 

have been found to contain six key 

elements in common. 19 

Brief intervention: FRAMES 20 

Feedback given about impairment/current 

risks, e.g. giving test results 

Responsibility is the patient’s 

Advice about change 

Menu of options—alternative strategies 

Empathy 

Self-efficacy and optimism for change 

A brief (five to 10 minute) smoking 

intervention has been developed based 

on motivational interviewing, assessing 

the patient’s confidence and their level 


of motivation. 12 A patient was ‘ready 

to change’ if they had a high level of 

confidence and felt that the change was 

important to them. 

integrating the models 

in practice 

By calling on our experience, we have 

identified ways in which elements of 

each of these models can be used in dayto-day 

practice. 

First, it is important to bring up the topic 

of possible health behaviour change 

carefully, especially if we are introducing 

the idea opportunistically. A good 

transition into this is to ask permission 

to discuss the topic: ‘Could we talk 

about smoking for a couple of minutes?’ 

This approach avoids an abrupt change 

the rapport by using reflection, state 

our concern about the health behaviour 

and its implications, and leave the 

door open for future discussion of the 

behaviour should the patient wish to 

pursue this. Some argue that we can also 

offer an intervention at this stage if it 

is appropriate. 16 However, enthusiastic 

suggestions by the doctor to think about 

behaviour change, or an offer to try a 

new treatment, can sometimes come 

at the expense of connection with the 

patient. For this reason it is important 

to be very aware of the patient’s verbal 

and non-verbal reaction throughout the 

discussion and to respond to this appropriately 

for individual situations. 

If the patient is contemplative, we can 

encourage them to explore the pros and 

cons of the behaviour, whilst we reflect 

When styles and strategies from motivational 

interviewing are employed with skill, it begins to feel 

like a dance instead of a struggle 

into a potentially sensitive area for the 

patient. As emphasised in the FRAMES 

model, the timing of this can be important. 

For instance, giving a patient their 

abnormal liver function test results may 

provide an opportunity to introduce the 

topic of alcohol consumption. 

Next we can assess the patient’s ‘readiness 

to change’. This is best done with 

an open question: ‘What are your 

thoughts about smoking?’ In this way, 

we avoid making assumptions about 

what the patient thinks or ‘should’ be 

thinking. 

The next step can be dictated by where 

the patient is in the stages of change. 

Using a motivational interviewing style 

in our discussion for all of the stages of 

change can be beneficial. If the patient 

is precontemplative, we can maintain 


their ambivalence or discrepancy about 

their current behaviour and their goals. 

We want the patient to take responsibility, 

and to come up with the motivation 

and ideas about change, whilst we listen 

and summarise. The practitioner and the 

patient can also work together in the 

preparation, action and maintenance 

stages. The practitioner can enable the 

patient to work out a personal action 

plan, anticipate barriers and triggers, and 

to identify supports and enablers. A 

vital part of the practitioner’s role is to 

increase self-efficacy and reinforce any 

accomplishments. In relapse, we must 

empathise and normalise the reality of 

relapse, whilst not assuming the 

patient’s next step. 

Brief intervention can be useful with 

someone who is in the action or preparation 

stage, as we will be exploring a list 


of possible options of behaviour change 

they could pursue—some of which have 

been suggested by the doctor, and some 

by the patient. The recent model based 

on ‘catastrophe’ theory 2 illustrates that 

many patients’ attempts to stop will not 

involve planning, and that immediate 

availability of treatment is important to 

support those attempts. 

When time is short, the main idea is to 

use the underlying spirit of motivational 

interviewing, 11 and to remember that 

the practitioner–patient relationship and 

interaction is the vital component of the 

success of health behaviour change. 

Practitioner–patient 

relationship 

Judgement, lecturing and advice giving 

has been shown to be less effective in 

health behaviour change than genuine 

empathic use of motivational interviewing 

styles and strategies. Empathy is a 

powerful relational skill which helps 

patients to feel connected with their 

practitioner even when there is mutual 

disagreement over issues such as smoking 

or medication compliance. 21 

The capacity to influence patients hinges 

upon the quality of rapport between 

practitioner and patient, and rapport is 

perceived by the patient as the ability of 

the practitioner to relate to the patient’s 

world. 22 

Empathy is fairly easy to master when 

we agree with the patient and we can 

relate to their culture, their social status 

and their world view. However, when we 

disagree or disapprove of our patients, 

empathy is much more difficult. How 

can we be empathic when we know that 

the patient’s smoking is making their 

chest disease worse, and all we want to 

do is to tell them to stop? Firstly we can 

remind ourselves that the way in which 

we communicate can have an impact on 

the likelihood of the patient changing 




their behaviour. A useful technique to 

use when we notice ourselves feeling 

disapproving or annoyed by our patients 

is to try to ‘park’ that feeling and to first 

offer the patient an empathic reflection. 

Contrast the difference in these two responses 

to a patient bothered by lithium 

side effects: 

Practitioner A: How about trying to split 

the dose, as well as having it with food? 

That should help cut down the nausea. 

Practitioner B: It sounds like the nausea 

is really awful for you and taking the 

lithium regularly is the last thing you 

feel like doing. 

Practitioner A has got their own agenda 

in the foreground, and the patient is likely 

to feel isolated and perhaps even irritated. 

Practitioner B however is putting 

the patient’s concern at centre stage. This 

is not the same as approving of their 

behaviour. It just demonstrates to the 

patient that Practitioner B understands 

them in a non-judgemental way. After 

that, once the rapport is more strongly 

established, Practitioner B can go on to 

let them know their medical concerns. 

When styles and strategies from motivational 

interviewing are employed 

with skill, it begins to feel like a dance 

instead of a struggle. Rather than trying 

to convince the patient to change, the 

practitioner uses a Socratic questioning 

style to evoke the patient’s own problemsolving 

skills and to galvanise them into 

action. The patient is doing all the work, 

and the practitioner’s genuine non-judgemental 

reflective style steadily builds 

rapport. If it feels more like a struggle 

then usually this is because the practitioner 

is working very hard to convince 

the patient to change, resulting in either 

a confrontation or the patient ceasing to 

play an active part in the process. 

Compare the following interventions for 

someone who needs more exercise: 

Practitioner A: How about trying to get 

off the bus two stops early so that you 

can get in a bit of exercise that way? 

Practitioner B: If you were to find a way 

to increase your exercise even a little bit, 

what would you choose to try? 

Working in a motivational interviewing 

style challenges the practitioner to initially 

hold back their own opinions and 

advice, giving priority to the patient’s 

ideas and reflection of the patient’s illness 

experience, in order to strengthen 

the therapeutic relationship. Once this 

is established, the strong therapeutic 

relationship can then withstand the 

challenge of the practitioner’s medical 

opinion, even when this is in direct 

conflict with the patient’s view. 

Conclusion 

Lifestyle-related disease is of significant 

concern in NZ, and there is a need to raise 

awareness of opportunities for intervention. 

Brief intervention, motivational 

interviewing, stages of change, and the 

‘catastrophe model’ are all useful frameworks 

for promoting behavioural change, 

and elements from all four may be 

adapted for use in primary care settings. 

In a short consultation the most important 

factor is the skilful use of empathy to 

strengthen rapport in the practitioner–patient 

relationship. Good rapport creates a 

platform from which the practitioner can 

enhance their capacity to influence health 

behaviour and optimise patient self-care. 

References 

1. Goodyear-smith F, Wearn A, Everts H, Huggard P, 

Halliwell J. Communication in practice: Auckland 

general practitioners reflect on communication 

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2006;33(1):30–38. 

2. West R, sohal T. ‘Catastrophic’ pathways to smoking 

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P, Jackson R. Trends in major cardiovascular 

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2002–2003. N Z Med J 2006;119(1245):U2308. 

4. Turley M, Tobias M, Paul s. Non-fatal disease 

burden associated with excess body mass index 

and waist circumference in New Zealand adults. 

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5. Tobias M, sexton K, Mann s, sharpe N. How 

low can it go? Projecting ischaemic heart disease 

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Docherty B, Janes R. Lifestyle screening: development 

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8. Rose sB, Lawton BA, Elley CR, Dowell AC, 

Fenton AJ. The ‘Women’s Lifestyle study’, 2-year 

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story G, Mann JI, et al. Implementation of a successful 

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and cardiovascular disease. Asia Pac J Clin Nutr 

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IR, McWilliam CL, Freeman TR. Patient-centered 

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Uncertainty, fear and whistling 

happy tunes 

Katherine Wallis MBChB, MBHL, FRNZCGP 

ABstRACt 

Uncertainty in medical practice is 

ineradicable, despite great scientific 

advances over the last century. Uncertainty 

provokes fear, not just in patients 

but also in doctors. Patients cope with 

their fear by seeking the advice and reassurance 

of doctors; doctors, on the other 

hand, cope by denial and self-deception. 

But today, in this scientific, truth-seeking 

age doctors are encouraged to share 

their uncertainty with patients in order 

to ‘empower’ patients and improve doctor–patient 

relations. While in theory 

doctors might agree with this approach, 

in practice they continue to deny it and 

instead whistle happy tunes—deceiving 

both themselves and their patients. 

A disclosure of uncertainty requires an 

acknowledgement of uncertainty and, 

in practice, the ability of doctors to acknowledge 

and to tolerate uncertainty 

is limited. 

Whenever I feel afraid, I hold my head 

erect 

And whistle a happy tune, So no one 

will suspect 

I’m afraid. 

While shivering in my shoes, I strike a 

careless pose 

And whistle a happy tune, And no one 

ever knows 

I’m afraid. 

The result of this deception, Is very 

strange to tell 

For when I fool the people I fear, I fool 

myself as well! 1 

If one thing in this life is certain, it 

is that the practice of medicine is a 

practice in uncertainty. Renée Fox, 2 in 

her landmark studies of uncertainty in 

medical practice in the 1950s, characterised 

three types of uncertainty: the 

uncertainty of medical knowledge, the 

uncertainty of the practitioner, and the 

uncertainty in discerning between these 

two types of uncertainty (is the answer 

out there somewhere and I just haven’t 

come across it, or has the answer not 

been discovered yet?). In clinical practice 

we face uncertainty about the diagnosis, 

compounded by the inherent variability 

in how patients perceive and describe 

their problems; uncertainty about the 

treatment, as we know patients respond 

differently to treatments and that applying 

general knowledge to individuals 

is flawed; and uncertainty about the 

role that we are expected to play today: 

are we to be rational scientist, shaman, 

social worker or counsellor? 

Over the last century great advances 

in medical knowledge have been made, 

leading some enthusiasts to believe 

that uncertainty in medicine could 

be eradicated. It was hoped that, 

with enough research, all questions 

would be answered and that illness 

and suffering could be dealt with by 

EtHiCs 

a rational scientific approach, making 

intuition and spiritualism redundant. 

Such hopes, however, look increasingly 

unlikely ever to be fulfilled, in part 

because medicine, if it is a science at 

all, is a science of individuals. There 

are no great generalisable truths to be 

discovered and applied; the expression 

and the experience of illness will 

always remain unique. Randomised 

controlled trials will never be able 

to tell us how a particular individual 

will respond to a particular treatment. 

As Kant once remarked, ‘Out of the 

crooked timber of humanity no straight 

thing was ever made’. 3 

Uncertainty exists in all facets of life, 

but in the health care context in particular, 

uncertainty breeds anxiety and fear. 

There is a Chinese proverb claiming that 

‘more people die of fear of their illness 

than die of the illness itself’. As often 

as not it is fear, born of uncertainty, that 

prompts a patient to seek the opinion of 

a doctor. Patients want to know whether 

their symptoms are significant, what 

can be done and, preferably, also to be 

reassured that all will be well. However, 

given that we must all die one day, there 

will come a day when all will not be 

well. It is the doctor’s role to sort out 

and communicate the known from the 

The ethics column explores issues around practising ethically in primary health care 

and aims to encourage thoughtfulness about ethical dilemmas that we may face. 

tHis issUE: Our guest ethicist and GP Katherine Wallis discusses balancing the acknowledgment 

to patients that medical practice is uncertain with managing their fears 

and anxieties. 


EtHiCs 

unknown, and to manage the patient’s 

anxiety and fear. 

For the doctor’s part too, there is fear. 

From the confusing, inaccurate, or even 

contradictory information 4 presented 

we must sort the relevant from the 

irrelevant and establish a management 

plan. We can never be certain and yet 

still we must act, even if only to advise 

a ‘wait and see’ approach. And with 

action, of course, comes responsibility. 

We can be guided by probabilities, 

but individual differences reduce our 

ability to predict from generalities and 

there is the constant risk of error. Error 

is unavoidable, not only because of the 

limitations of medical knowledge and 

the limits of the human intellect, but 

also because of the ‘necessary fallibility 

of a knowledge of particulars’. 5 The fact 

that we must act before certainty can 

be established (if it ever can be) makes 

clinical medicine, not a rational science 

nor an art, but a ‘practice’. 6 

Elstein, who spent much of his life 

studying diagnostic decision-making, estimated 

that the rate of diagnostic error 

in medical practice was approximately 

15%. 7 This figure has subsequently been 

corroborated. 8 These diagnostic errors, 

however, are only errors in hindsight: 

At the time the diagnosis was made it 

seemed the most likely, most reasonable 

and therefore the most correct diagnosis 

to make. As a doctor in Paget’s study 

remarked ‘…the errors are errors now, 

but they weren’t errors then’. 9 

Experienced practitioners use heuristics 

(rapid pattern recognition processes) 3 to 

reach a diagnosis. This intuitive decision-making 

process saves time and gives 

the correct diagnosis most of the time; 10 

however there is a price to pay for this 

efficiency: Predictable error. Sometimes 

the most likely diagnosis, rather than 

the correct diagnosis, is made. As James 

Reason says: ‘Our propensity for certain 

types of error is the price we pay for the 

brain’s remarkable ability to think and 

act intuitively.’ 11 

In hindsight the correct diagnosis is 

obvious, but in the complex, chaotic, and 

uncertain world of clinical practice the 

most likely diagnosis at the time seems 

the most reasonable one to make. Thus 

there is a trade off between efficiency 

and accuracy. 

In such a mire of uncertainty and error, 

how can either doctor or patient make 

a rational decision about treatment, 

let alone continue to practise? To cope 

with the fear, doctors employ various 

strategies designed to reduce either the 

responsibility or the uncertainty. 12 Responsibility 

can be reduced by referral, 

healing to take place, a profession of 

certainty is required. 

Today, while doctors might accept 

(in theory) that medical knowledge is 

uncertain, in practice they continue 

to profess certainty. In practice the art 

of self-deception is alive and well. In 

front of patients, doctors instinctively 

suppress and deny their knowledge of 

uncertainty 6,14 in favour of providing 

reassurance and hope. And, given the 

patient’s desire for reassurance, and the 

essential uncertainty of clinical practice, 

whistling such a happy tune might just 

be the pragmatic approach to take. 

Katz considers that the denial of uncertainty 

in medicine has something 

In hindsight the correct diagnosis is obvious, but in the 

complex, chaotic, and uncertain world of clinical 

practice the most likely diagnosis at the time seems the 

most reasonable one to make. Thus there is a trade off 

between efficiency and accuracy 

by deferring to guidelines and protocols, 

or by abandoning the patient in a misconstruing 

of patient-centred medicine. 

Uncertainty, on the other hand, can be 

reduced by specialisation (developing 

‘special interests’), or by an appeal to ‘in 

my clinical experience’ arguments; in 

other words, the long-favoured technique 

of denial and self-deception. 

Self-deception is not, of course, unique 

to doctors. Most drivers consider themselves 

‘better than average’ drivers and 

94% of college professors rate themselves 

in the top half of their profession. 13 

Nevertheless, in medicine there is a 

particularly long and entrenched tradition 

of self (and patient) deception. The 

justification has been that, in order for 

to do with making sense in a complex 

and confusing world so that action 

is possible. There are limits to living 

with uncertainty; the resultant fear can 

paralyse. In practice, given that we must 

act in uncertainty, 14 self-deception might 

just be essential. 

Today, however, doctors are encouraged 

to take a different approach. They are 

encouraged to share their uncertainty 

with patients as a means to improving 

doctor–patient relations. 15 Disclosure of 

uncertainty, or truth-telling, is about 

empowerment, about setting patients 

free to decide and to act rationally according 

to their true nature. But does 

knowledge of uncertainty, the truth, 

really set patients free? 


The view of the classical Greek philosophers, 

shared by much, though perhaps 

not all, Christian theology, is that it 

does. ‘And ye shall know the truth, and 

the truth shall make you free.’ (Gospel 

according to St John, chapter 8, verse 32). 

Ancient Stoics and most modern rationalists 

are at one with Christian teaching on 

this issue. 3 

Telling the truth is ‘good’. Doctors 

believe this (in theory) and medical 

regulators promote it. 

And yet, for some reason, arguments 

against truth-telling in medical practice 

have persisted for centuries. In 1672, 

French physician, priest and philosopher 

Samuel de Sorbiere cautioned young doctors 

looking to establish themselves in 

practice ‘what not to say’: 

…in order to safeguard your interests, 

I must tell you that medicine is a very 

imperfect science, that it is quite full of 

guesswork, that it scarcely understands its 

subject matter, nor is it familiar with the 

things employed to maintain it; that the 

more enlightened only feel their way in 

it groping amidst a thick gloom; and that 

after having considered seriously all the 

matters which may be useful, collected all 

one’s thoughts, examined all one’s experiences, 

it will indeed be a wise physician 

who can promise relief to a poor patient. 16 

Of course medical knowledge has 

progressed dramatically since 1672; 

nevertheless, the net amount of disease 

and suffering does not appear to have 

been reduced. 17 Much remains unknown 

about how best to ‘promise relief to a 

[particular] poor patient’. Thus critics of 

the uncertainty-sharing doctrine persist, 

arguing that patients want to deceive 

themselves, and to be deceived about the 

deficiencies of medicine, and that, rather 

than improving doctor–patient relations, 

such disclosure actually damages the relationship 

reducing trust, confidence and 

patient satisfaction. 18 Questions remain, 

however, as to whether the noted deleterious 

effect of the disclosure of uncertainty 

is due to the way the uncertainty 

was disclosed or the uncertainty itself. 

Despite the scientific commitment to 

truth and the increased access to information 

today, healing is not a rational 

science. In practice, we can eliminate 

neither the uncertainty nor the fear; 

there will always be room for clinical 

judgment, for appeals to ‘in my experience…’ 

arguments. It is possible that 

the knowledge of uncertainty might 

set patients free to choose, but it won’t 

set them free from fear. Nor will such 

knowledge set doctors free from fear and 

enable them to act. Perhaps the disclosure 

of uncertainty does interfere with 

our effectiveness as healers? Perhaps 

patients do still need to be set free from 

anxiety so that they can heal? 

The problem with the disclosure of 

uncertainty is that, not only might it 

kill off our patients and our practice, but 

that it might also kill off us. Doctors 

have some of the worst statistics when it 

comes to suicide, divorce and substance 

abuse. Perhaps we should be bolstering, 

rather than tearing down, the strategies 

developed over millennia to aid survival 

in practice? As that well-known physician 

Dr Hibbert, who chuckles rather 

than whistles, says: ‘Before I learned to 

chuckle mindlessly, I was headed to an 

early grave myself.’ 

Hibbert: Lisa, I’m afraid your tummy 

ache may be caused by stress. 

Homer: Well, that’s a relief. 

Hibbert: Heh, yeah. Anyway, when it 

comes to stress, I believe laughter is the 

best medicine. You know, before I learned 

to chuckle mindlessly, I was headed for 

an early grave myself. (chuckles) 

Homer: Give it a try, honey. (Lisa tries 

to chuckle). 19 

References 

EtHiCs 

1. Rodgers R, Hammerstein O. Whistle a happy tune. 

Lyrics from The King And I Musical; 1951. 

2. Fox R. Experiment Perilous: physicians and patients 

facing the unknown. Glencoe, Ill: Free Press; 

1959. 

3. Berlin I. Two concepts of liberty. In: Hardy H, 

editor. Liberty: Isaiah Berlin. New York: Oxford 

University Press; 2002. p 166–217. 

4. Graber M, Gordon R, Franklin N. Reducing diagnostic 

errors in medicine: what’s the goal? Acad 

Med 2002; 77(10):981–92. 

5. Gorovitz S, MacIntyre A. Toward a theory of medical 

fallibility. Hastings Cent Rep 1975; 5(6):13–23. 

6. Montgomery K. How doctors think: Clinical 

judgment and the practice of medicine. New York: 

Oxford University Press; 2006. 

7. Elstein AS. Clinical reasoning in medicine. In: 

Higgs J, Jones MA, editors. Clinical Reasoning 

in the Health Professions. Woburn, Mass: 

Butterworth-Heinemann; 1995. p 49–59. 

8. Berner ES, Graber ML. Overconfidence as a cause 

of diagnostic error in medicine. Am J Med 2008; 

121(5 Suppl):S2–23. 

9. Paget M. The Unity of Mistakes: a phenomenological 

interpretation of medical work. Philadelphia: 

Temple University Press; 1988. 

10. Elstein AS. Heuristics and biases: selected errors 

in clinical reasoning. Acad Med 1999;74(7):791–4. 

11. Reason J. Human Error: Cambridge University 

Press; 1990. 

12. Dowrick C, Frith L, editors. General practice and 

ethics: Uncertainty and responsibility. London: 

Routledge; 1999. 

13. Mele AR. Real self-deception. Behav Brain Sci 

1997; 20(1):91–102; discussion 3–36. 

14. Katz J. Why doctors don’t disclose uncertainty. 

Hastings Cent Rep 1984;14(1):35–44. 

15. Henry MS. Uncertainty, responsibility, and the 

evolution of the physician/patient relationship. J 

Med Ethics 2006;32(6):321–3. 

16. Katz J. The silent world of doctor and patient. New 

York: The Free Press; 1984. 

17. Lantos J. Do we still need doctors? New York: 

Routledge; 1997. 

18. Johnson CG, Levenkron JC, Suchman AL, 

Manchester R. Does physician uncertainty affect 

patient satisfaction? J Gen Intern Med 1988; 

3(2):144–9. 

19. Scully B. Make room for Lisa: The Simpsons. 

Episode 219; 1999. 


EssAYs 

sub-threshold mental health syndromes: 

Finding an alternative to the medication of unhappiness 

Fiona Mathieson MA(Applied), DipTchg; sunny collings MBChB, MRCPsych, FRANZCP, DPH, PhD; Anthony Dowell MBChB, FRNZCGP 

ABstRACt 

Sub-threshold anxiety and depression 

are common presentations in primary 

care. They carry a significant disability 

burden along with the risk of developing 

a frank disorder. Intervention 

options are limited, although there is 

some evidence that ultra brief interventions 

may be effective with this 

patient group. We argue that there is 

a need for a systematic but ultra brief, 

minimal contact intervention, that can 

be delivered by GPs or practice nurses. 

Such an intervention would be a form of 

facilitated self-management, a step up 

from self-help, from which people could 

be referred on to more intensive treatment 

or medication if required. 

MesH keywords: Primary health 

care, mental health, psychotherapy, 

mental disorders 

CORREsPONDENCE tO: 

sunny Collings 

Director Social Psychiatry 

& Population Mental 

Health Research Unit, 

Otago University 

Wellington, New Zealand 

sunny.collings@ 

otago.ac.nz 

introduction 

Just over one quarter (26.5%) of primary 

care patients in NZ and overseas 1,2 are 

considered by GPs to have sub-threshold 

mental health syndromes. These are 

combinations of signs and symptoms 

that do not meet the threshold for 

disorder in standard diagnostic systems 

such as DSM-IV. 3 Unlike secondary 

mental health service populations, the 

primary care mental health population 

includes people with a broad spectrum 

of undifferentiated syndromes ranging 

from few, mild or transient symptoms to 

symptom combinations and severity that 

meet diagnostic criteria. Often these 

arise in the context of social problems 

such as family or economic stress. In 

a NZ primary care sample, functional 

impairment was found not to differ 

significantly between diagnosed disorder 

and sub-threshold syndromes. 7 Furthermore, 

a subset of those with sub-threshold 

syndromes are at increased risk for 

development of clinical depression 4 or 

eventual suicide. 5 Sub-threshold mental 

health syndromes therefore represent 

an important morbidity and disability 

burden to the community, 6 in terms of 

work and role impairment as well as 

distress. 7,8 It has been suggested that 

intervention may be warranted for up to 

80% of those affected. 9,10 

Despite the extent of morbidity burden, 

in New Zealand only 22% of these people 

receive an intervention of any kind, 

most commonly supportive discussion 

and non-specific counselling. 10 Access to 

interventions for sub-threshold syndromes 

is likely to be even less equitably 

distributed than access to treatment 

for diagnosed disorders. The evaluation 

of Ministry of Health–funded NZ 

demonstration projects for primary care 

services for common mental disorders 

and sub-threshold syndromes shows a 

high degree of perceived unmet need 

for treatment and substantial variability 

in what is offered for sub-threshold 

syndromes. 11 

Given this information, the key questions 

are, firstly, should people with 

such syndromes receive an intervention 

and, secondly, if so, what should the 

intervention be? These questions can be 

answered by considering the nature of 

contemporary primary care practice, the 

availability of interventions, the existing 

evidence about interventions, the policy 

context, and primary care sector workforce 

development. 

Nature of primary care practice 

GPs face a number of challenges in the 

management of sub-threshold syndromes: 

The primary care environment 

is complex and chaotic, with dynamic 

treatment plans that change to meet the 

changing need of the patient, competing 

illness priorities and difficult socioeconomic 

problems. The current classification 

of psychiatric illness does not apply 

well to undifferentiated psychosocial 

problems in primary care. Sub-threshold 

syndromes do not always conform to the 

boundaries of less severe forms of DSM- 

IV defined entities. 7,12–15 In practice, GPs 

tend to make pragmatic management 

decisions based as much on functioning 


as on whether or not syndromes exceed a 

diagnostic threshold. 16,17 In this context, 

management of sub-threshold syndromes 

is inevitable, as GPs are balancing a 

focused and pragmatic response to competing 

presenting problems. 18 Common 

non-specific GP management strategies 

include giving advice and/or reassurance, 

sometimes in extended consultations. 19 

Availability of interventions 

Other options for sub-threshold mental 

health syndromes are limited. Secondary 

care services are not appropriate for 

this group, even if they were available 

and patients wished to use them. GPs 

can refer patients for generic counselling 

or specific psychotherapies but, 

despite recent policy initiatives, 20 cost 

may still be an important barrier. The 

need for referral out of the practice is a 

barrier for both patients (due to waiting 

and uncertainty about eligibility for 

treatment) and some practitioners (due 

to administration and supply of trusted 

providers to refer to). 11,17,20 Furthermore, 

the notion of on-referral to a ‘specialist’ 

or ‘expert’ is a secondary care model 

which may not be appropriate for the 

majority of these problems. The Internet 

offers the possibility of direct patient 

access to self-management information. 

The HRC has funded a clinical trial of 

Internet treatment for clinical depression 

(RID, i PI Dr S Nada-Raja, University of 

Otago), which is also available to those 

with sub-threshold syndromes. 

Evidence for interventions 

Treatments used in primary care RCTs 

are commonly described generically 

using terms such as ‘counselling’, 21 and 

they are being conducted with varied 

clinical groups (e.g. sub-threshold 

depression, 22 major depression, or sub- 

i http://www.otago.ac.nz/rid/ 

threshold syndromes, 23 meaning trials 

cannot be readily compared or replicated. 

There is some limited evidence supporting 

the use of ultra brief interventions 

for sub-threshold depression in primary 

care, using cognitive behavioural and 

interpersonal–dynamic principles 24 and 

interpersonal psychotherapy. 25 A smaller 

evidence base is developing in relation to 

self-help for sub-threshold syndromes. 8 

The evidence to date indicates that the 

treatments best supported by evidence 

include exercise and relaxation training, 

bibliotherapy based on CBT 26,27 and webbased 

psycho-education. 26 

Many brief treatments, including selfhelp, 

appear to be condensed versions of 

interventions developed to treat discrete 

disorders over many months. 28 Some of 

these interventions may be too densely 

packed with therapeutic elements to 

actually be feasible over a short period. 

The Primary Care Initiatives Evaluation 

therapist survey revealed that counsellors 

and therapists generally considered 

that six sessions were too few. 20 

While severity of the conditions being 

treated may explain some of this, several 

therapists also described difficulties in 

choosing the ‘right’ approach in such 

a short space of time. The underlying 

assumption that the nature of the 

psychopathology is the same as for full 

(especially severe) disorders may be 

flawed, 29,30 and this may partly explain 

the smaller effect sizes commonly seen 

for more established treatments such as 

CBT in primary care settings, although 

lower distress at baseline and the effectiveness 

of ‘usual GP care’ may also 

contribute. 21 In their seminal review 

of psychotherapy research, leading UK 

psychotherapists Roth and Fonagy called 

for further development work on the 

management of sub-threshold syndromes 

in primary care. 28 

Policy context 

EssAYs 

The Primary Health Care Strategy 31 

prompted a new direction for NZ 

primary health care, within an overarching 

public health framework. The 

vehicle for achieving the changes was 

Primary Health Organisations (PHOs), 

which have evolved from a range of 

other provider entities, resulting in 

diversity in philosophical approaches, 

capacities and rates of development, and 

different expectations with respect to 

infrastructure and workforce. 20 These 

structures and the revision of funding 

mechanisms made it possible for mental 

health services to be developed as an 

integral part of PHOs and these are 

now embedded as a core part of funded 

primary care activity. The expectation 

is that primary care will manage 

mental disorders of ‘mild’ to ‘moderate’ 

severity and also be proactive in mental 

health promotion (with a possible hope 

that this will reduce incident cases of 

frank disorder). Clearly in this policy 

context there is an intention to address 

sub-threshold syndromes given their 

position in this spectrum. 

Primary care sector 

workforce development 

The evaluation of the Primary Mental 

Health Initiatives showed that there 

was great diversity among clinicians 

providing psychological interventions, 

in terms of professional and theoretical 

backgrounds. There will need to be 

considerable primary mental health 

workforce expansion and skill enhancement 

in order to meet the extent of 

unmet need. Existing staff working in 

this area have particularly emphasised 

the need for skill development in brief 

interventions. 20 Substantial work will 

be required in relation to this, as most 


EssAYs 

training for psychological treatments is 

time-consuming, whether it is delivered 

intensively or intermittently. 

should people with subthreshold 

mental health 

syndromes receive 

intervention and, if so, what? 

We suggest that the evidence supports 

intervention on the grounds of relief 

of suffering and the restoration of 

functioning. However, the over-riding 

argument is that the nature of primary 

care practice means that people with 

these syndromes are already receiving 

interventions of various kinds. On the 

whole these are likely to be pragmatic 

approaches to common and complex 

presentations, of the kind that GPs 

have been delivering for many decades, 

variably infused with evidence as it 

comes to hand. In light of this, and the 

need to be thoughtful about the use of 

scarce health resources, the focus needs 

to be on the most effective way of 

delivering this care. 

A useful framework for considering 

the problem of provision of treatment 

for mental health problems in the face 

of scarce resources is that proposed by 

Jorm. 26 The model suggests that a range 

of responses is available for subpopulations 

with varying levels of symptoms 

and impairment. As symptoms and 

impairment increase from a low base 

due to stresses in everyday life, 32,33 so 

the interventions called into play move 

from the first ‘wave’ of self-help using 

everyday strategies such as exercise 

and talking to family or friends, 

through a second ‘wave’ of facilitated 

self-help. The next ‘wave’ is professional 

help-seeking, with, finally, 

provision of specific treatments once 

severity is at the disorder threshold. 

This approach is consistent with the 

‘stepped care’ model now commonly 

accepted as a structure for funding 

mental health services. 

In this framework, presentation or 

detection in primary care represents 

part of the first wave of professional 

help-seeking. Primary care practitioners 

need a range of management options 

to call on at this level, and there have 

been calls for investment in research to 

establish whether the use of ‘minimal’ 

interventions are an efficient method of 

delivering psychological treatments. 34 

We have been fortunate to receive 

Health Research Council funding to 

develop an ultra-brief intervention that 

can be delivered by a trained but nonmental 

health–specialist primary care 

practitioner (e.g. practice nurse or GP). 

This will involve a pragmatic two–three 

contact intervention to reduce the disability 

associated with sub-threshold 

mental health syndromes, as a step up 

from self help in the ‘wave’ framework. 

The intervention will require minimal 

additional training; and we hope it will 

reduce the need for referral on, thus 

maintaining patient links with the 

primary care team; and will reinforce 

the patient’s existing self-help strategies, 

consistent with the strengths-based 

approaches now being emphasised in NZ 

mental health practice. Following development 

we hope to take the intervention 

to pragmatic clinical trial in the NZ 

primary care setting. 

Novel intervention research such as this 

is central to meeting demand in primary 

care mental health in NZ and it will 

contribute to the national and international 

evidence base for the management 

of this common and burdensome 

problem. We acknowledge that secondary 

care mental health clinicians may be 

doubtful about the idea of an ultra brief 

intervention that can be used by people 

with a minimum of training: ‘Where are 

the formulations? The risk assessments? 

The highly trained mental health clinicians?’ 

However, current mental health 

funding policy in New Zealand provides 

access to sophisticated, expensive treatment, 

which is in relatively short supply, 

and is aimed at diagnosable disorders. 

Most primary care patients cannot 

jump this high threshold for access to 

services, and this is probably appropriate. 

However, below this threshold there a 

large group of people with, at best, (and 

only recently) partly-met need. We aim 

to help meet this need. 

References 

1. The MaGPIe research group. The nature and 

prevalence of psychological problems in New 

Zealand primary health care: a report on Mental 

Health and General Practice Investigation. NZMJ 

2003;116(1171):1–15. 

2. Ustun T, Sartorius N. Mental illness in general 

health care. England: Wiley, 1995. 

3. American Psychiatric Association A. DSM IV. 

Washington DC: American Psychiatric Association; 

1995. 

4. Kessler R, Zhao S, Blazer D, Swartz M. Prevalence, 

correlates, and course of minor depression in 

the national comorbidity survey. J Affect Disord 

1997;45(1–2):19–30. 

5. Sadek N, Bona J. Subsyndromal symptomatic 

depression: a new concept. Depress Anxiety 

2000;12:30–39. 

6. Judd L, Schettler P, Akiskal H. The prevalence, 

clinical relevance and public health significance 

of subthreshold depressions. Psychiatr Clin North 

Am 2002;25:685–698. 

7. Hickie I. Primary care psychiatry is not specialist 

psychiatry in general practice. Med J Aust 

1999;170:171–173. 

8. Jorm AF, Griffiths KM. Population promotion of 

informal self help strategies for early intervention 

against depression and anxiety. Psychol Med 

2006;36(3–6). 

9. Wagner H, Burns B, Broadhead W, Yarnall K, 

Sigmon A, Gaynes B. Minor depresssion in family 

practice: functional morbidity, co-morbidity, 

service utilisation and outcomes. Psychol Med 

2000;30:1377–1390. 

10. The MaGPIe Research Group. The treatment of 

common mental health problems in general practice. 

Fam Pract 2006;23:53–59. 

11. Dowell A, Garrett S, Collings S, McBain L, McKinlay 

E, Stanley J. Primary Mental Health Initiatives: 

Interim Report. Wellington: School of Medicine & 

Health Sciences, University of Otago, Wellington, 

2007;242. 

12. The MaGPIe Research Group. General 

practitioner recognition of mental ilness in the 

absence of a ‘gold standard’. Aust NZ J Psychiatry 

2004;38:789–794. 

13. Goldberg D. Plato versus Aristotle: categorical and 

dimensional models for common mental disorders. 

Compr Psychiatry 2000;41:8–13. 

14. Backenstrass M, Frank A, Joest K, Hingman S, 

Mundt C, Kronmuller K. A comparative study 

of nonspecific depressive symptoms and minor 

depression regarding functional impairment and 

associated characteristics in primary care. Compr 

Psychiatry 2006;47:35–41. 


15. Collings S. Clinical practice is as important as 

diagnosis. BMJ 2001;322(13 Jan):80–81. 

16. Collings S, MaGPie Research Group. Disability and 

the detection of mental disorder in primary care. Soc 

Psychiatry Psychiatr Epidemiol 2005;40:994–1002. 

17. Dew K, Dowell A, McLeod D, Collings S, Bushnell 

J. ‘This glorious twilight zone of uncertainty’: mental 

health consultations in general practice in New 

Zealand. Soc Sci Med 2005;61(6):1189–1200. 

18. Klinkman MS. Competing demands in psychosocial 

care: A model for the identification and 

treatment of depressive disorders in primary care. 

Gen Hosp Psychiatry 1997;19:98–111. 

19. Hemmings A. A systematic review of the effectiveness 

of brief psychological therapies in primary 

health care. Fam Syst Health 2000;18(3):279–313. 

20. Dowell A, Garrett S, Collings S, McBain L, McKinlay 

E, Stanley J. Evaluation of the Primary Mental 

Health Initiatives: summary report 2008. Wellington: 

Otago University Wellington and Ministry 

of Health; 2008. 

21. Bower P. The clinical effectiveness of couselling in 

primary care: a systematic review and meta-analysis. 

Psychol Med 2003;33:203–215. 

22. Willemse G, Smit F, Cuijpers P, Tiemens B. Minimal 

contact psychotherapy for sub-threshold depression 

in primary care: a randomised controlled trial. 


23. Mead N, MacDonald W, Bower P, Lovell K, Richards 

D, Roberts C, et al. The clinical effectiveness of guided 

self-help versus waiting-list control in the management 

of anxiety and depression: a randomised 

controlled trial. Psychol Med 2005;35:1633–1643. 

24. Barkham M, Shapiro DA, Hardy GE, Rees A. Psychotherapy 

in two-plus-one sessions: Outcomes of 

a randomized controlled trial of cognitive-behavioral 

and psychodynamic-interpersonal therapy for 

subsyndromal depression. J Consult Clin Psychol 

1999;67(2):201–211. 

25. Klerman GL, Budman S, Berwick D, Weissman 

MM, Damico-White J, Demby A, et al. Efficacy of 

a brief psychosocial intervention for symptoms of 

stress and distress among patients in primary care. 

Med Care 1987;25(11):1078–88. 

26. Jorm A, Griffiths K, Christensen H, Parslow R. 

Actions taken to cope with depression at different 

levels of severity: a community survey. Psychol 

Med 2004;34:293–299. 

27. den Boer P, Wiersma D, van den Bosch R. Why is 

self-help neglected in the treatment of emotional 

disorders? Psychol Med 2004;34:959–971. 

28. Roth A, Fonagy P. What works for whom? A critical 

review of psychotherapy research. 2nd ed. New 

York: Guilford Press; 2005. 

29. Parker G. Evaluating treatments for the mood 

disorders: time for the evidence to get real. Aust 

NZ J Psychiatry 2004;38(6):408–414. 

30. Parker G, Parker I, Brotchie H, Stuart S. Interpersonal 

psychotherapy for depression? The need 

to define its ecological niche. J Affect Disord 

2006;95(1–3):1–11. 

31. Ministry of Health. The Primary Health Care 

Strategy. Wellington: Ministry of Health; 2001. 

32. Mulder R. An epidemic of depression or the medicalisation 

of unhappiness? NZ Family Physician 

2005;32(3):161–163. 

33. Mulder R. Psychiatric illness in primary care: 

whom should we treat? NZMJ 2003;116(1171). 

34. Bower P, Gilbody S. Stepped care in psychological 

therapies: access, effectiveness and efficiency: 

Narrative literature review. Br J Psychiatry 

20 05;186(1):11–17. 

Mind over matter—implications for general practice 

Andrew corin MBChB, FRNZCGP 

For centuries, it has been recognised 

that the mind has power over the 

body, and experience of external 

stimuli is subjective and variable. This 

paper will explore some of the evidence 

for this, and seek to apply the phenomenon 

to a health care setting. 

In the New Zealand (NZ) primary care 

environment where patients are increasingly 

critical of the service they receive, 

where retention of capitation base is 

important, and recruitment of appropriate 

new patients is desirable and, most importantly, 

where efficient delivery of quality 

health care is paramount, a good under- 

CORREsPONDENCE tO: 

Andrew P Corin 

CentralMed, 434 Devonport Rd, 

Tauranga, New Zealand 

andrewc@centralmed.co.nz 

standing of the relationship between 

expectations and experience is vital. 1 

Patients in primary care are increasingly 

mobile, and many will seek provision of 

their health care from various sources, 

depending on the specific problem. This 

may be due to a desire for confidentiality, 

an opportunity to seek specialised 

care, or merely a geographical or temporal 

convenience. The fourth reason for 

patient movement is dissatisfaction with 

care provision, from phone to reception 

to nursing and doctor involvement. The 

advent of fully capitated general practice 

funding in NZ is encouraging patients 

to seek all their primary care needs from 

the one provider, as subsidy is enrolment-specific 

to one practice. 

If general practitioners and primary care 

business owners are able to understand 

and cooperate with patient expectations, 

EssAYs 

they will have better opportunity to manage 

patient movement and financial risk, as 

well as provide improved health outcomes. 

Many studies have been undertaken to 

demonstrate the psychological relationship 

between the brain’s expectation of 

a sensory input, and the actual report 

of that experience. 2–7 Most famous are 

the experiments involving wine tasting 

and pain stimulation. In these various 

blinded experiments, different subjects 

reported variable experiences despite 

identical sensory challenges. Being told 

that you are drinking an expensive 

wine, or about to receive a reduced pain 

impulse, results in tasting a fine wine 

or feeling less pain, despite the wine 

being poor or pain level unchanged, 

respectively. The conclusions are that the 

pre-frontal cortex modulates the actual 

sensory assessment to fit with a pre-determined 

expectation. Indeed, Magnetic 


EssAYs 

Resonance Imaging (MRI) analysis 

demonstrates complex cerebral processes 

involved in the association of expectation 

and subjective pain experience. 6 In 

this study subjects with a positive (more 

optimistic) expectation of the pain experience 

reported reduced pain levels. MRI 

has also been used to demonstrate that 

altering a subject’s expectation of a specific 

taste will modify brain activity in 

that related region of the cortex, and so 

subjectively alter the taste experience. 7 

The relevance to primary care is that if 

GPs able to understand the expectations 

of their patients and over time create an 

expectation set that is one of satisfaction 

and wellness, the level of health, 

compliance with treatment and patient 

retention will be maximised. 8 

More specifically, the following example 

may help: 

Ms D is a 46-year-old woman. She is 

eight weeks post-laparoscopic cholecystectomy, 

and suffering severe right subscapula 

pain, with nausea, weight loss 

and insomnia. She has been thoroughly 

assessed in recent weeks by her surgeon 

as an outpatient and then an inpatient 

for six days, with no cause for her pain 

found. She was treated with strong analgesia, 

without improvement. 

Her sister, who is a patient of mine, 

suggested that a second opinion from me 

would help her. Examination of Ms D 

was normal, apart from her anxious and 

exhausted appearance. 

My suspicion was that there was a complex 

neuralgia process here, heightened 

by her anxiety, and I recommended cessation 

of her tramadol, and started a low 

dose of gabapentin. Reassurance was an 

important part of the consultation. 

At review one week later Ms D reported 

almost full resolution of her pain, 

insomnia and nausea after taking one 

gabapentin dose! At that consult she also 

confessed to having significant preoperative 

anxiety regarding the outcome 

of the surgery. 

I believe that the dramatic resolution of 

her pain syndrome was largely mediated 

by her state of mind, and the expectation 

created at the consultation of 

improvement. In addition, I suspect that 

her atypical pain behaviour following 

surgery may well have been due to her 

anxious expectation of a poor outcome 

from the operation. 

There are two issues which should be 

considered and addressed by a GP concerned 

about the realities of maintaining 

a successful medical practice. Firstly, 

and waiting environment, being given 

opportunity to talk and be listened to by 

the doctor, having clear communication 

and a management plan from the doctor, 

a focus on preventative medicine, and 

having confidence in the professionalism 

and skill of the doctor. 9 Patients gave 

higher priority than GPs to availability 

and accessibility of the practice and seeing 

the same GP. 10 

A review of the literature on patient priorities 

found that the most common priorities 

were informative-ness, ‘humane-ness’, 

and competence/accuracy. 11 Other aspects 

included involving patients in decisions, 

time for care, availability/accessibility, 

exploring patients’ needs, good communication 

and availability of special services. 

Part of an effective clinical and consultation relationship 

involves assessing expectations and agendas, and 

educating the patient where those expectations and 

agendas are inappropriate 

they should seek to have an understanding 

of the expectations of their patients. 

This will often not be immediately obvious 

or volunteered, and a relationship 

of trust may be necessary before honest 

expectations are volunteered. Secondly, 

they should aim to create a set of expectations 

that are associated with patient 

satisfaction, and thus achieve business 

growth, patient health and staff gratification. 

The expectation of the patient 

can reasonably be influenced by their 

understanding of the dynamics of the 

medical practice they attend. If the staff 

consistently provides prompt, informative 

and professional health care, this 

will become the expectation and, indeed, 

the experience, even when occasionally 

the quality of care is substandard. 

Issues to consider here are acceptable 

access and cost, acceptable waiting times 

Webb and Lloyd identified two strong 

factors which influenced the management 

behaviour of GPs in two North 

London practices. 12 The first was the 

patient’s level of anxiety. If a given 

patient presented with a problem about 

which they were particularly anxious, 

they were more likely to receive either 

a prescription or hospital referral. The 

second was patient expectation. This 

suggests that the patient also communicated 

the expectation of either prescription 

or referral. 

A medical practitioner needs to balance 

patient expectations with the realities 

of clinically appropriate and responsible 

practice. It is obviously not appropriate 

to prescribe antibiotics at every patient 

request, nor order every test a patient demands, 

nor refer without restraint. Part of 

an effective clinical and consultation re- 


lationship involves assessing expectations 

and agendas, and educating the patient 

where those expectations and agendas 

are inappropriate. The GP and their team 

are well placed and generally respected 

opinion-holders, such that in the space of 

a consultation unreasonable expectations 

can be identified and modified. 

Newsomel and Wright present an excellent 

summary with exhaustive references 

relating to the theories of satisfaction. 13 

In particular, the ‘zone of tolerance’ 

seems to fit the medical model. Here 

patients have a zone of expectation from 

the health care contact. If the actual 

service delivery falls within this zone, 

or above it, then satisfaction is experienced. 

The more important the health 

experience, the more narrow the zone of 

tolerance. If the expectation levels are 

too high, the patient is more likely to 

be dissatisfied more often. However, the 

theory propounded to under promise to 

achieve higher levels of satisfaction is 

not well supported. 

Clearly, it is important to understand 

what the zone of expectation is for a patient, 

reinforce this when it is appropriate, 

and seek to adjust it when inappropriate. 

GPs, by virtue of their training 

and experience, are generally adept at 

adapting style and structure in the consultation 

to suit the needs of the patient 

and doctor. Thus, it should present no 

significant challenge to suggest that 

the GP assesses the expectations of the 

patient on a regular basis, and adjusts 

the interaction accordingly. Two patients 

who receive identical care may evaluate 

the consultation differently, according to 

their expectations. 14,15 

A recent US survey of physician attitudes 

to prescribing ‘placebos’ revealed a 

reasonably widespread acceptance of the 

role of exploiting the patient’s expectation 

of a treatment by using a pharmacologically 

neutral substance to achieve a 

therapeutic outcome. 16 

The opening gambit of a consultation 

such as ‘What can I do for you?’ or ‘how 

can I help today?’ provides opportunity 

for the patient to verbalise and GP to 

assess the agenda and expectation set for 

the interaction. In addition, during and 

at the end of the consultation there can 

be opportunity to reinforce the management 

message. This can take the form of 

simple repetition, or may include positive 

suggestion such as ‘I am sure you will 

improve with this medication’. Whilst 

this is not medico-legally binding promise-making, 

it can be a very powerful tool 

to turn the pre-frontal cortex activity 

into one that supports the optimal health 

goals of the doctor and patient. 

In summary then, understanding 

patients and their expectations from the 

health care experience is important in 

targeting intervention and management. 

Such an understanding will provide opportunity 

for maximising the success of 

health care, from building location and 

design, to staffing and training, to education 

strategies and models of chronic 

care delivery, as well as to the nuances 

of the individual consultation. 

References 

1. Gabbott M, Hogg G. Competing for Patients: 

Understanding Consumer Evaluation of Primary 

Care. J Manag Med 1994;8(1):12–18. 

2. Koyama T, McHaffie J, Laurienti P, Coghill 

RC. The subjective experience of pain: where 

expectation becomes reality. Proc Natl Acad Sci 

2005;102(36):12950–12955. 

3. d’Hauteville F, Fornerino M, Perrouty J. Disconfirmation 

of taste as a measure of region of origin 

equity: An experimental study on five French wine 

regions. Intl J Wine Bus Res 2007;19(1):33–48. 

4. Coggins A, Beardsmore A. Blind Faith. The Strad 

(Newsquest Specialist Media Limited). Feb 2007. 

5. Taber G, Mondavi R. Judgement of Paris: California 

vs. France and the Historic 1976 Paris Tasting 

That Revolutionized Wine. Simon and Schuster 

Adult Publishing Group; Nov 2006.352. 

6. Berk L. Beta-endorphins and HGH increase are associated 

with both the anticipation and experience 

of mirthful laughter. Paper presented at: American 

Physiological Society session at Experimental Biology; 

2006 March 31; SanFrancisco, CA. 

7. Sarinopoulos I, Dixon GE, Short SJ, Davidson RJ, 

Nitschke JB.Brain mechanisms of expectation 

associated with insula and amygdala response 

EssAYs 

to aversive taste: Implications for placebo. Brain 

Behav and Immun 2006;20:120–132. 

8. Kumar R, Kirking D, Hass S, et al. The association 

of consumer expectation, experiences and satisfaction 

with newly prescribed medicines. Qual Life 

Res 2007;16(7):1127–1136. 

9. Rahman MM, Rahman S, Begum N, Asaduzzaman 

AM, Shahjahan M, Firoz A, Metul MS. Client 

expectation from doctors: Expectation—reality 

gap. KUMJ 2007;5 (4):566–573. 

10. Vedsted P, Mainz J, Lauritzen T, Olesen F. Patient 

and GP agreement on aspects of general practice 

care. Fam Pract 2002;19:339–343. 

11. Wensing M, Jung H, Mainz J, Olesen F, Grol R. 

A systematic review of the literature on patient 

priorities for general practice care. Soc Sci Med 

1998;47(10):1573–1588. 

12. Webb S, Lloyd M. Prescribing and referral 

in general practice: a study of patients’ 

expectations and doctors’ actions. Br J Gen 

Pract.1994;44(381):165–169. 

13. Newsomel P, Wright G. A review of patient 

satisfaction: 1. Concepts of satisfaction. Br Den J 

1999;186(4):161–165. 

14. Lilford RJ, Brown CA. Using outcomes to monitor 

the quality of clinical practice—handle with care. 

BMJ 2007;335:648–650. 

15. Conway T, Willcocks S. The role of expectations in 

the perception of health care quality: developing 

a conceptual model. Intl J Health Care Qual Assur 

Inc Leadersh Health Serv 1997;10(2-3):131–40. 

16. Tilburt J, Emanuel E, Kaptchuk T, Curlin F, Miller 

FG. Prescribing ‘placebo treatments’: results of 

national survey of US internists and rheumatologists. 

BMJ 2008;337:a1938. 


LETTERS TO THE EDITOR 

Vignette from the ‘olden days’ 

Many years ago, when I was a Southland country GP, I 

was called to visit an elderly lady living alone. The front 

‘fence’ was an indication of what was to come. The neglected 

bushes had grown to tall trees, shading the house. The decaying 

farmhouse had not seen paint or maintenance in many 

years. 

Entering through the billiard room of this erstwhile mansion, 

I noticed the large arched skylight leaking at the corners, 

with green mould growing down the walls. In the dim and 

dusty bedroom I found an emaciated 80-year-old lady thin as a 

Belsen concentration camp victim. The low point of the clinical 

examination was finding wriggling maggots under each 

shrunken breast. 

Transferred to hospital, she died in a few days. The frail old 

soul would have had little resistance to the basal pneumonia 

that ended her days. On enquiry, it transpired that she had 

lived alone for many years, the last of the family, after caring 

for her father until he died of old age. 

She had been living without heating (in Southland winters!) 

and severely restricting her diet, all to save money to 

bequeath to Scottish cousins she had never met. How strange 

are the ways of the human race! I trust the inheritors of such 

hardly come by money were duly appreciative. 

Lance Austin 

Concern about the name change 

read ePulse 16 September with much interest noting the sug- 

I gestion that the journal invites nurses and community pharmacists 

to be a part of the journal and that there be a move to 

focus on primary health care with a name change to that of 

the Journal of Primary Health Care. Nurses and pharmacists 

already have their journals. 

The journal as I understand its role is to focus on medical 

issues and the family physician. The cornerstone of primary 

care is about the credentials of the practising family physician. 

What I hope your role as the new editor is, firstly, to 

attract more enthusiasm from colleagues to submit articles for 

publication. Letters to the Editor might occupy one section of 

the journal. 

If ever a change in name is contemplated then might I suggest 

that the college become, The Royal New Zealand College 

of Family Physicians, then we achieve equity with our Physician 

colleagues in other branches of medicine. The medical 

specialty of primary care therefore is a focus on the interaction 

between the patient as a family member and the attending 

family physician. 

It is an unwise move to dilute this role of the GP for which 

the primary care strategy appears to be achieving. 

Henare Broughton 

Homeopathy and acupuncture reviews are not CME 

am concerned to find the Journal Review Service continuing 

I to publish reviews of homeopathy and acupuncture under the 

guise of ‘continuing medical education’. 1 I am, however, heartened 

by Dr Tony Hanne’s trenchant criticism of homeopathy. 

This absurd belief system has no place in any medical journal. 

Acupuncture can be similarly criticised. Many of the 

reviews are unintentionally funny. Could there be anything 

more absurd than the statement2 ‘One could also argue that a 

major acuppoint, e.g. LR-3, from the Liver meridian for detoxification 

should have been included in the prescription used.’? 

Such foolishness reminded me of a spoof of a British Medical 

Journal article entitled ‘Delayed ketoalkalotic effects of 

aldosterone-producing adenoma in a man with a pig’s head’. 

Although I still have a copy of this I am unsure as its provenance. 

The new Editor has promised to improve the journal even 

further. Please let us drop the alternative medical nonsense 

and have more useful material from people like Professor 

Bruce Arroll and others. 

Dr John Welch MBChB FRNZCGP DipAvMed 

Competing Interests: I am a reformed acupuncturist, member of the 

New Zealand Skeptic’s Society for whom I write a column (Hokum Locum) 

on alternative medicine. 

References 

1. NZFP 2008; 35:74–75. 

2. NZFP 2008; 35:137. 

Letters may respond to published papers, briefly report original research or case reports, or raise matters of interest relevant to 

primary health care. The best letters are succinct and stimulating. Letters of no more than 400 words may be emailed to: 

editor@rnzcgp.org.nz. All letters are subject to editing and may be shortened. 


Intravenous Vitamin C 

Enjoyed seeing the Vitamin C article in the recent NZMJ 

[sic]. Was interesting and informative. I enjoy incorporating 

some nutritional work into my own general practice. Would 

enjoy seeing more nutritional medicine type articles over time. 

Dr Helen Smith, GP 

How disappointing that the NZFP saw fit to publish a 

summary of personal opinion and anecdote as an ‘original 

scientific paper’ (Vitamin C: Evidence, application and commentary. 

Melissa Ge et al. NZFP 2008;35:312–318). 

After a careful read of the claims that megadoses of vitamin 

C can cure a wide range of terminal illnesses as well as 

infectious diseases I was quite intrigued and sceptical. When 

looking further however, I noticed the references used to 

authenticate this paper do not provide the evidence to support 

the claims. 

Here is a single example: ‘Over the past 10-year period I have 

treated over 9550 patients with large doses of vitamin C’. 1 The 

author of this paper, Cathcart, does not discuss these patients— 

he only refers to single episodes and individual results. He also 

mentions that when treating bacterial infections ‘Ascorbic Acid 

should be used with the appropriate antibiotic.’ He reports that 

this broadens the spectrum for the antibiotic but the evidence is 

lacking any specific information—it is just noted in passing. 

The authors of this paper claim that Cathcart ‘was giving 

megadoses of vitamin C to patients with polio, diphtheria, 

herpes, chicken pox, influenza, measles, mumps, pneumonia, 

viral encephalitis and Shiga toxin poisoning.’ This scientific 

paper was written before the availability of the polio vaccine 

in the 1940s. The patients treated with the IV Vitamin C were 

‘considered infected’ during an epidemic, which is different 

than a confirmed case of polio. 1 Surely the authors of this 

paper aren’t suggesting that vitamin C is a treatment for polio 

based on one article. 

The authors advocated ‘Several case studies, small clinical 

trials and in vitro experiments have been published suggesting 

that vitamin C at the correct dosage has anti-cancer effects.’ 

This might lead one to believe that vitamin C can hinder 

cancer cells from metastasising when really the authors are 

offering ‘palliative’ care for terminal patients. 

There is no disclosure of the possible adverse effects. Extreme 

doses of ascorbic acid are not as harmless as suggested in 

this paper—when ingested in large amounts ‘may cause renal 

failure’. 2 Vitamin C deficiency may cause scurvy but the effects 

of an overdose of vitamin C are not necessarily innocuous. 

‘The role of vitamin C in disease intervention at doses 

higher than previously considered relevant should be thor- 

LETTERS TO THE EDITOR 

oughly investigated in a clinical setting.’ I totally agree with 

this statement as many of the referenced articles lacked the 

evidence to support the claims made, specifically using vitamin 

C to treat infectious diseases. 

Erin Hanlon-Wake, Registered midwife 

References 

1. Cathcart RF. Vitamin C, titrating to bowel tolerance, anascorbemia, and 

acute induced scurvy. Med Hypothesis 1981;7:1359–1376. 

2. Material Safety Data Sheet: Ascorbic Acid MSDS. ScienceLab. http:// 

www.sciencelab.com/xMSDS-Ascorbic_acid-9922972. Published 9 

October 2005. Accessed 5 May 2008. 

was appalled to see the opinion piece in NZFP masquerad- 

I ing as an original scientific paper ‘Vitamin C: Evidence, 

application and commentary’ but will resist the temptation to 

perform an autopsy and critique on the authors’ interpretation 

of the literature. 

It appears that all of the authors have a vested interest in 

plying desperate patients with intravenous vitamin C, presumably 

at a reasonable profit, and to be fair this is declared. 

However, it is deceitful to misrepresent the literature and 

evidence. A quick glance at the list of references is enough to 

raise immediate scepticism as they generally consist of hypotheses, 

laboratory studies or case studies; some are 30 and even 

60 years old. This is about as low level as evidence gets and is 

certainly not sufficient to inform practice. 

One part that is so dubious that it is actually funny is the 

table that shows Vitamin C synthesis in the rat, dog and goat 

and then extrapolates this to humans. Humans are not rats, 

dogs or goats and I think we have had enough lessons from 

animal models to know this. If humans behaved like their distant 

rodent cousins according to laboratory studies we would 

have cures for a lot more diseases than we do now. This is not 

something that belongs under the name science as it does not 

employ any. 

Helen Petousis-Harris, Senior Lecturer, General Practice and 

Primary Health Care 

REpLy: JPHC will publish the nature and quality of evidence 

around efficacy and safety of herbal medicines in our column 

Charms and Harms. We also welcome systematic reviews and 

meta-analyses on complementary and alternative medicines 

(CAM) and nutritional supplements that critique the available 

evidence on efficacy and harm, produce evidence tables and 

offer recommendations based on the graded evidence in the 

accepted scientific fashion (see http://www.rnzcgp.org.nz/ 

journal-of-primary-health-care/systematic reviews). – Editor 


BOOK REVIEWS 

The Baby Business: 

What’s happened to maternity care in New Zealand 

By Lynda Exton 

Review by William Fergusson, GP 

The Baby Business is a modern history 

book that had to be written. 

Its author, Christchurch General 

Practitioner Lynda Exton, needed a 

more than usual amount of courage and 

determination to surmount this task. 

All participants in the tortuous saga of 

New Zealand’s maternity services over 

the last 18 years should be interested, 

if not required, to read this detailed 

and extensively referenced account of 

events. The book manages piece by 

piece to explain how it is that a medical 

sub-speciality, that of the general 

practitioner obstetrician, that was both 

revered by its practitioners and in ceaseless 

demand from its patients, could be 

simply erased. 

What ideologically driven unholy alliance 

of ministry bureaucrats, politicians and 

midwifery interests expended so much 

effort over so long to ensure the absolute 

demise of GP Obstetrics? The cast of characters 

is fairly well detailed in the book. It 

stops short however of attempting to properly 

explain the rationale of this shadowy 

force. What were they really thinking? 

Perhaps more time needs to elapse for clarity 

around this to emerge. Generally, the 

perpetrators have continued to imagine 

themselves sunned by some reflected 

glory in achieving choice for women, or 

the de-medicalisation of childbirth, or 

some such thing. The evidence the book 

presents suggests they are doing so somewhere 

in a parallel universe that does not 

relate to mothers and babies in NZ. 

The beginning chapters are dedicated 

to some of the landmarks in the history 

of our maternity service, and reference 

several brave and dedicated early NZ 

doctors. The author documents many of 

the national controversies of the time, 

such as the use of ‘twilight sleep’, infant 

feedings and the culture change towards 

the hospitalisation of childbirth. There 

are vividly conjured images of some of 

the hair-raising and skilful exploits of 

our early GPOs and midwives. This sets 

the stage for the inexplicable, calculated 

and ruthless path that was pursued, it 

seems, from the anti medical politics 

of the late 1980s, to eliminate choice 

of maternity care provider and create 

a midwifery-only service in NZ. The 

author has painstakingly gathered the 

meagre existing scraps of data by which 

this momentous juggling of vulnerable 

lives was ‘monitored’ or evaluated, and 

there emerges the sketchy outline of a 

deteriorating maternity service relative 

to our past performance, and the services 

within comparable countries. 

Perhaps it is only now these policies have 

fully achieved their goals that the wider 

public will be able to read this book and 

gasp in horror at what has been taken 

from them. I am reminded of a quote 

from Doris Gordon’s autobiography Back 

Blocks Baby Doctor in which she recounts 

the formation of the NZ Obstetric and 

Gynaecological Society, in February 

1927. The O & G Society, as it came to 

be known, was formed in response to a 

drive from the Ministry of Health of the 

time to remove doctors from maternity 

care. Newspaper headlines of the day 

exclaimed ‘women advised not to have 

doctors at confinements’. The society 

went on to be a bastion of CME provision 

throughout the country for GPOs, 

specialists and midwives for many 

decades, until it was severely holed by 

the infamous July 1996 Section 88 Maternity 

Notice, and sank without trace 

soon afterwards as GPs pulled out of 

maternity care. Doris Gordon recounts: 

‘fed up with ever increasing “shalts” 

and “shalt nots” 180 doctors signed as 

foundation members. A few doctors 

who had no prospects of begetting or 

delivering babies gave us the backing of 

their membership, saying, “you do well 

to found your society, for what threatens 

maternity care today will threaten all 

branches of medicine tomorrow”.’ 

Review by Joan Carll, midwife 

The Baby Business records the 

changes to the NZ maternity service 

over the past 20 years and, in 

particular, the changes for general practitioners 

which led to their move away from 

active involvement in maternity care. 

The book outlines the journey of change 

beginning with a history of birthing 

from the 1880s. The history gives 

insight into the players who determined 

the early formation of the service and an 

explanation for the difficulties to change 

a service that became deeply entrenched. 

The ensuing changes to NZ’s maternity 

service (well passed its use-by-date in 

1988) lacked the necessary processes to 

prevent the political and collegial fallout 

exposed in this recount. 

Dr Exton details the changing NZ maternity 

service from 1988. However, go 

back 10 years to the end of the training 

of midwives at the St Helens Hospitals 


and the talk of change at the Midwives 

section. A time when women suffered 

the indignity of enemas, pubic shaves, 

episiotomies and limited choice for place 

to deliver. Women were even required to 

write a letter to have their husband present 

in the delivery room! A service that 

would encourage any newly graduated 

midwife to walk away and say—if that is 

midwifery and if that is what having a 

baby is about then why would you want 

a bar of either? Change was inevitable, 

supported by professionals within the 

service, and women and families for 

whom the service is all about. 

As a midwife I have found the record 

of events interesting reading and a 

forum for reflection and insight into the 

turnaround of what was certainly a very 

The New Zealand pregnancy Book: 

A guide to pregnancy, birth and a baby’s first three months 

3RD EDITION 

By Sue Pullon and Cheryl Benn 

Review by Jon Wilcox, GP 

At first glance the latest edition 

of this venerable 20-year-old 

matter-of-fact guide for new 

parents looks very different from 

earlier versions. It immediately seems 

more user friendly and the layout is 

now more upmarket—there is an 

abundance of colour photography and 

excellent illustrations. Wellington GP 

Sue Pullon has changed the approach 

a little to perhaps steer away from the 

perceptually ‘medicalised’ editions we 

might have been more familiar with 

during the infamous years of what 

some might call the de-commissioning 

of general practice obstetrics. The 

market is now unashamedly—and 

probably in order of preference—midwives 

and mothers. 

unfriendly maternity service to one with 

new achievements and challenges. 

The author captures the feeling of grief 

felt by GP obstetricians who are no 

longer part of the maternity service; 

however she misses the opportunity to 

provide positive steps forward. Hands up 

those who have been to their GP needing 

attention only to be left in the waiting 

room while they dash off to deliver a 

baby? Perhaps there was also a need for 

general practice to change, and find new 

ways to rebuild the relationships with 

their patients in a different manner, to 

maintain that holistic approach to family 

medicine and create the important links 

with the new maternity service. I believe 

Dr Exton has inadvertently exposed a 

missed opportunity for primary care. 

Overall the new edition is excellent and 

I feel it is good value for new parents. 

There is accurate information on a huge 

range of important issues relating to 

preparing for pregnancy and childbirth, 

including parental leave, benefits, new 

maternal serum screening initiatives and 

so forth. Generally the information is of 

high quality and, even though the book 

now could give the impression of being 

just another ‘touchy feely’ publication 

to peruse during the last four weeks of 

pregnancy, it still has the excellent practical 

content relating to real life issues 

such as common problems in pregnancy, 

labour and childbirth. Having been 

written from the standpoint of a clinician 

with a lot of experience in obstetrics 

and neonatal paediatric care, the 

advice is generally extremely sensible 

and very comprehensive. 

BOOK REVIEWS 

A good read for health professionals who 

would like to recall the events of NZ’s 

changing maternity services. A rather 

negative read for consumers who are the 

beneficiaries of the change and remain unable 

to assess the current system through 

lack of data. A reminder to midwives the 

challenges have been and continue to be 

extreme. And to GPs, who are critically 

placed to ensure primary care is seamless, 

efficient and continuous, this book 

provides reason to look at new ways. 

Publisher: Craig Potton Publishing 

Publication Date: Oct 2008 

No. of pages: 260 

RRP: $29.99 

The Baby Business can be ordered 

through www.craigpotton.co.nz 

Furthermore, Pullon does not give the 

reader the misleading impression that 

almost all pregnancies and labour are normal 

(which can tend to give many mothers 

feelings of inadequacy or failure) and, as 

many of us who are still actively involved 

in intra-partum care know, each and every 

labour has its own idiosyncrasies. 

Pullon has joined with midwife Cheryl 

Benn to produce the new format and by 

and large it has been an excellent team 

effort. I have for 20 years recommended 

this book to all my own maternity 

patients, and for those with limited 

resources we have even had a cache of 

secondhand editions to loan for the 

duration of pregnancy. I would certainly 

continue to endorse the latest edition as 

first choice for NZ GPs to recommend to 

their expecting client couples. 


BOOK REVIEWS 

Review by Ms Helen Ride, midwife 

This is the third edition of Pullon 

and Benn’s New Zealand Pregnancy 

Book. Since it was first 

published in 1991 there have been 

many changes within the delivery of 

maternity care in New Zealand with 

the introduction of the Lead Maternity 

Care system. This third edition has been 

written for New Zealand parents and 

parents-to-be and includes information 

specific to the New Zealand maternity 

system, and all New Zealanders. The 

aim of the authors is to present a book 

which prepares the reader, her partner 

and family for the pregnancy, birth and 

the first three months of the baby’s life. 

This book is written chronologically 

from planning for a pregnancy through 

to the first three months with your 

baby, and provides vast amounts of information 

which appears to cover everything 

the reader would wish to know. 

It includes the physical and emotional 

changes occurring within the pregnant 

woman, common health problems, 

potential problems and the birth. The 

format of the book is very appealing to 

the reader. The photographs are beautiful, 

the diagrams are excellent and the 

personal stories complete the experience. 

The reader can dip in and out of the 

book choosing specific topics or stages 

within the pregnancy to read, and crossreferencing 

is made throughout the book 

for further information. 

This is a very informative book. However, 

there is very little reference to homeopathy 

throughout the text but there 

is a reference within the appendix to the 

homeopathy website. I am aware that 

quite a few midwives use homeopathy 

and many women are interested in this 

during their pregnancies yet there was 

very little information within the book. 

As a former Bereavement Support 

Midwife I have a particular interest in 

the care and support of bereaved parents. 

One error that I found within this book 

is the information that a baby born dead 

Ideological Debates in Family Medicine 

By Stephen Buetow and Tim Kenealy 

Review by Professor Marjan Kljakovic, 

School of General Practice, Rural, & 

Indigenous Health, Australian National 

University Medical School, Canberra, 

Australia 

This is a book written for the academic 

who likes to ponder ideological 

debates that occur within the 

field of family medicine. The book would 

also appeal to people who want a comprehensive 

way of looking at the world of 

general practice and primary health care. 

The book presents a collection of ideas 

about family medicine around 13 

debates, each of which was written in 

two chapters posing the affirmative 

and negative position on a theme. Each 

theme began with the words ‘Family 

Medicine should…’ and then continued 

with the following words: ‘Refine its 

essential attributes; Rediscover a focus 

of family care; Emphasise population on 

health care; Focus on the sick; Encourage 

its clinicians to sub-specialise; Tolerate 

uncertainty to manage clinical risk; Use 

more Evidence Based Medicine than at 

present; Shift attention from rationality 

to emotions; Encourage the development 

of Luxury Practices; Promote the 

delivery of care through group practice; 

Emphasise the Provision of Health Care 

as a social good; Promote the optimal au- 

before 28 weeks gestation does not need 

a funeral. However the Births, Deaths 

and Marriages Registrations Act 1995 

redefined what constituted a still birth 

and changed it to a foetus born after 20 

weeks gestation or weighing over 400 

grams. Babies in this category are legally 

required to have a funeral. 

I found this book to be informative and 

great to read. Many first-time parents 

will enjoy reading it from cover to cover. 

The beautiful photographs add to the 

pleasurable experience. 

Publisher: Bridget Williams Books 

Publication date: Nov 2008 


Bridget Williams Books 

Phone: 04 473 8128 

Email: info@bwb.co.nz 

Web: www.bwb.co.nz 

The New Zealand Pregnancy Book is 

available to health professionals at 20% 

discount off the recommended retail price 

($44 rather than $54.99). 

tonomy of patients in decision making; 

And finally, Self-regulate to best protect 

patient and professional autonomy’. 

The aim of giving ideological perspectives 

is to offer change in the field of 

family medicine through a normative 

thought process. An ideology is a system 

of abstract thought applied to public 

matters, and thus makes this concept 

central to family medicine. The book 

has 36 authors who came from different 

parts of the Western world and therefore 

gave very different perspectives 

on particular ideological themes. For 

example the debate on ‘Family Medicine 

should encourage its specialists to 


sub-specialise’ had Leese arguing for 

the affirmative having come from the 

UK where the concept of the generalist 

is most developed, and the GP acts 

as gatekeepers for specialist services. 

Starfield argued for the negative having 

come from the USA where the concept 

of the generalist is least developed and 

there is a huge negative impact of subspecialisation 

in primary care. 

Some of the debates reminded me about 

themes I had been taking for granted. For 

example, Svab and van Weels’ negative position 

on ‘Family Medicine should refine 

its essential attributes’ reminded me that 

family medicine is an emancipated field of 

medicine and no longer needed to debate 

this position (been there, done that). 

Furthermore, family medicine should get 

on with improving its image and be rid of 

‘the harmful benefits of extreme complexity, 

uniqueness, exclusivity, and threat’. 

Other debates taught me a lot. For 

example, Bohan and Donohoe argued for 

and against the theme: ‘Family Medicine 

should encourage the development of 

Luxury Practices’. Their debate revealed 

how much luxury Practices have flourished 

in the USA in the last few years 

and how malignant such a growth was 

for patient care and provider greed. 

A few of the debates annoyed me. For 

example Upshur and Tracey’s negative 

position that ‘Family Medicine should 

use more Evidence Based Medicine 

than at present’. They argued that EBM 

cannot meet its own standards, is no 

Integrating mental health into primary care: 

A global perspective 

This report on integrating mental 

health into primary care, developed 

jointly by the World Health 

Organization (WHO) and the World Organization 

of Family Doctors (Wonca), 

presents the justification and advantages 

of providing mental health services in 

primary care. It provides advice on how 

to implement and scale-up primary care 

for mental health, and describes how a 

range of health systems have successfully 

undertaken this transformation. 

Key messages 

1. Mental disorders affect hundreds 

of millions of people and, if left 

untreated, create an enormous toll of 

suffering, disability and economic loss. 

2. Despite the potential to successfully 

treat mental disorders, only a small 

minority of those in need receive 

even the most basic treatment. 

3. Integrating mental health services 

into primary care is the most viable 

4. 

5. 

6. 

7. 

way of closing the treatment gap and 

ensuring that people get the mental 

health care they need. 

Primary care for mental health is 

affordable, and investments can bring 

important benefits. 

Certain skills and competencies 

are required to effectively assess, 

diagnose, treat, support and refer 

people with mental disorders; it is 

essential that primary care workers are 

adequately prepared and supported in 

their mental health work. 

There is no single best practice model 

that can be followed by all countries. 

Rather, successes have been achieved 

through sensible local application of 

broad principles. 

Integration is most successful 

when mental health is incorporated 

into health policy and legislative 

frameworks and supported by senior 

leadership, adequate resources, and 

ongoing governance. 

BOOK REVIEWS 

superior to other modes of obtaining 

evidence, and lacks legitimacy. Their 

solution was for family medicine ‘to be 

descriptive, careful in observation, and 

explicitly recognise and integrate the 

interpretive grammar of medicine’. A 

solution I find is easily accepted by an 

arcane social scientist of family medicine, 

rather than a pragmatic GP whose 

patient wants evidence from outside the 

consultation to answer a health question. 

The virtue of this book is that it does 

generate feelings such as annoyance, 

disagreement, and surprise. It stimulates 

the reader and for that reason alone I 

recommend buying this book. 

Publisher: Nova Science 

Date of Publication: Dec 2007 


8. To be fully effective and efficient, 

primary care for mental health must 

be coordinated with a network of 

services at different levels of care 

and complemented by broader health 

system development. 

9. Numerous low- and middle-income 

countries have successfully made the 

transition to integrated primary care 

for mental health. 

10. Mental health is central to the values 

and principles of the Alma Ata 

Declaration; holistic care will never 

be achieved until mental health is 

integrated into primary care. 

The full report can be accessed at http:// 

www.globalfamilydoctor.com/index. 

asp?PageID=9063 

Publisher: World Health Organization and 

World Organization of Family Doctors 

(Wonca) 

Date of publication: 2008 



RESEARCH GEMS 

GemS Of NeW ZeAlAND 

primary Health Care Research 

Access to CME an issue for 

overseas-trained rural Gps 

Difficulty in accessing CME has been 

identified as a negative aspect of rural 

practice in a study investigating retention 

of overseas-trained doctors in 

rural NZ. The study included thematic 

analysis of nine in-depth interviews 

of overseas-trained doctors working 

in rural settings. Other factors noted 

by interviewees as detracting from the 

rural practice environment were reduced 

options for employment of their spouse 

and for secondary schooling, and limited 

cultural and entertainment activities. 

On the positive side, doctors valued 

the scope of the practice work and the 

sense of community loyalty. The rural 

lifestyle offered also featured as a key 

attraction. 

Kearns RA, Myers JM, Adair V, Coster H, Coster 

G. What makes ‘place’ attractive to overseas- 

trained doctors in rural New Zealand? Health & 

Social Care in the Community 2006;14:532-40. 

Corresponding author: R. Kearns. Email: 

r.kearns@auckland.ac.nz 

Antibiotics not first-line treatment 

for acute purulent rhinitis 

A meta-analysis of data from seven 

RCTs of antibiotics versus placebo 

for acute purulent rhinitis concludes 

that antibiotics are probably effective. 

However, as no serious adverse events 

occurred in the placebo group, antibiotics 

are not indicated as first line treat- 

ment. This conclusion is in keeping 

with most guidelines which recommend 

against using antibiotics on the basis 

of one earlier study. Harms attributed 

to antibiotics in the RCTs were mainly 

vomiting, diarrhoea, and abdominal pain 

but also included rashes and hyperactivity 

(in children). A treatment approach 

of ‘watchful waiting’ is suggested, with 

antibiotics used only when symptoms 

have persisted for long enough to concern 

parents or patients. 

Arroll B, Kenealy T. Are antibiotics effective for 

acute purulent rhinitis? Systematic review and 

meta-analysis of placebo controlled randomised 

trials. BMJ 2006;333:279. Corresponding au- 

thor: B. Arroll. Email: b.arroll@auckland.ac.nz 

problem gamblers often 

have other problems 

Primary care screening for problem 

gambling highlights common lifestyle 

and mental health co-morbidities. The 

cross-sectional study conducted in 51 

urban and rural primary care practices 

in NZ found that people identified with 

concerns about their gambling behaviour 

were significantly more likely to have 

concerns about alcohol use, recreational 

drug use, and smoking. Problems with 

depression, anxiety and anger control 

were also more likely to be reported by 

these individuals. Problem gambling 

was readily identified using a brief 

multi-item screening tool containing a 

validated gambling question: ‘Sometimes 

I’ve felt depressed or anxious after a session 

of gambling—yes or no’. The study 

signals the potential of screening for 

problem gambling in the primary care 

setting. 

Goodyear-Smith F, Arroll B, Kerse N, et al. 

Primary care patients reporting concerns about 

their gambling frequently have other co-occur- 

ring lifestyle and mental health issues. BMC 

Fam Pract 2006;7:25. Corresponding author: 

Felicity Goodyear-Smith Email:f.goodyear- 

smith@auckland.ac.nz 

No geographic disparity for NZ 

women with breast cancer 

Studies in Australia, Canada and the 

USA have shown that people living in 

regional and remote areas have higher 

mortality rates from cancer than people 

living in urban and suburban areas. A 

recent study of NZ with breast cancer 

showed no such geographic disparity, 

however. The study drew on the NZ 

Cancer Registry Data from a four-year 

period, involving 11 340 women. Just 

under a third lived within 10km of a cancer 

centre, another third lived 11–50km 

away, and the remaining third lived more 

than 50km away. Reasons put forward 

to explain the equity seen in stage at 

diagnosis include BreastScreen Aotearoa 

which has mobile/outreach services, high 

community awareness, and the natural 

history of the disease. Regional coordination 

of cancer services was seen as 

contributing to equity of survival, with 

GEMS are short précis of original papers published by NZ researchers. FOR A COpy of a full paper please 

email the corresponding author. Researchers, TO HAVE yOUR WORK INCLUDED please send your 

references and pdfs of your papers to: editor@rnzcgp.org.nz 


service configuration attempting to balance 

centralisation and local access. 

Bennett H, Marshall R, Campbell I, Lawrenson 

R. The effect of urban versus rural residence 

on stage at diagnosis and survival for women 

with breast cancer in Aotearoa-New Zealand. 

NZ Med J 2007;120(1266). Corresponding 

author: H. Bennett. Email: hayleyandcam@ 

clear.net.nz 

Dairy calves are a potential 

source for Giardia infection 

A recent Otago study characterising 

Giardia genotypes present in calves and 

humans has found a substantial overlap 

of identical genotypes for assemblages 

A and B, the only assemblages capable 

of causing human infection, in the two 

hosts. The finding implies zoonotic 

transmission may have occurred and 

demonstrates the possibility of the dairy 

herd as a reservoir for human infection. 

It is of particular note given recent intensification 

of dairying in NZ and the 

potential for transmission via waterways 

contaminated by runoff. 

Winkworth CL, Learmonth JL, Matthaei CD, 

Townsend CR. Molecular characterization of 

Giardia isolates from calves and humans in a 

region in which dairy farming has recently inten- 

sified. Appl Environ Microbiol 2008;74:5100- 

5105. Corresponding author: C. Winkworth. 

Email: Cynthia.winkworth@zoology.otago.ac.nz 

Fast acting agents essential 

to breakthrough pain 

management in cancer 

Most breakthrough analgesia for cancer 

pain fails to be effective in the time 

required. No useful analgesia is therefore 

provided but drug adverse effects 

increase. This paper addresses this problem, 

outlining a systematic, evidencebased 

approach to breakthrough pain 

management, whether due to end-ofdose 

failure, incident or idiopathic pain. 

The paper details non-pharmacological 

as well as pharmacological approaches, 

while highlighting the value of fast 

acting fentanyl formulations (such as the 

oral transmucosal fentanyl citrate lozenge 

and the fentanyl buccal tablet), and 

analogues (such as intranasal alfentanil), 

specifically developed for breakthrough 

pain treatment. 

William L, MacLeod R. Management of break- 

through pain in patients with cancer. Drugs 

2008;68:913–924. Corresponding author: 

L. William. Email: leeroy.william@waitemat- 

adhb.govt.nz 

Thiazide diuretics ‘justifiable’ 

for hypertension in patients 

with pre-diabetes 

This article, part of a series exploring 

uncertainties in clinical practice, considers 

whether diuretics are appropriate 

antihypertensive agents for patients 

with pre-diabetes. The ALLHAT 2002 

trial provides the basis for this clinical 

uncertainty, having reported an increase 

in cardiac risk factors, including 

development of diabetes, as a result of 

treatment with the thiazide-like diuretic 

chlortalidone. A Japanese clinical trial 

(diuretics in the management of essential 

hypertension study; http://clinicaltrials.gov/show/NCT00131846) 

currently 

underway should provide the definitive 

answer when it concludes in a few 

years. In the interim, existing evidence 

suggests that use of thiazide diuretics 

as first-line agents for hypertension in 

pre-diabetic patients is ‘justifiable’, especially 

in resource-poor settings. 

Arroll B, Kenealy T, CR Elley. Should we pre- 

scribe diuretics for patients with prediabetes 

and hypertension? BMJ 2008;337:a679. Cor- 

responding author: B. Arroll. Email: b.arroll@ 


Mobile phone cameras have potential 

for triage in rural practice 

A study designed to assess population 

access and clinical usefulness of mobile 

phone cameras has shown the potential 

of such technology for triaging afterhours 

care. The study was conducted 

among 480 patients in two rural primary 

care practices in NZ. Mobile phone cameras 

were found to be widely available, 

with most patients open to the idea of 

their use for medical triaging. Clinical 

utility was tested by quizzing 30 health 

professionals using photographs of 10 

primary care cases. The photographs 

used were taken on a standard mobile 

phone (Motorola v 360 with an integrated 

camera and 4 x zoom). Picture resolution 

was 176 x 220 pixels. Images were 

found to increase diagnostic confidence 

for all but one case. 

Jayaraman C, Kennedy P, Dutu G, Lawrenson 

R. Use of mobile phone cameras for after-hours 

triage in primary care. J Telemed Telecare 

2008;14:271–274. Corresponding author: 

R. Lawrenson. Email: LawrensR@waikatodhb. 


govt.nz 

RESEARCH GEMS 

Tenosynovitis due to text messaging 

This brief case report draws reader attention 

to a new overuse condition, ‘texting 

tenosynovitis’. The case in question presented 

with tenderness over the tendons 

of extensor pollicis brevis and abductor 

pollicis longus at the wrist and distally, 

consistent with de Quervain’s tenosynovitis. 

This had developed over a 3-month 

period during which the right-handed 

student had sent about 2500 texts every 

month, each of about 150 characters. 

Two international case reports of this 

condition are cited by the authors and 

the question is raised as to whether more 

cases are likely, given growing ownership 

and use of mobile phones. 

Storr EF, de Vere Beavis FO, Stringer MD. 

Texting tenosynovitis. NZ Med J 2007;1267. 

Corresponding author: M. Stringer Email: 

mark.stringer@anatomy.otago.ac.nz

JOURNAL OF pRIMARy HEALTH CARE 

The Journal of Primary Health Care (JPHC) is a peer-reviewed journal 

which has replaced the New Zealand Family Physician. It is a multidisciplinary 

publication aimed at moving research into primary health 

care practice and practice into research. This includes the fields of 

family practice, primary health care nursing and community pharmacy 

as well as areas such as health care delivery, health promotion, epidemiology, 

public health and medical sociology of interest to a primary 

health care provider audience. 

The journal publishes peer-reviewed quantitative and qualitative original 

research, systematic reviews, papers on improving performance 

and short reports that are relevant to its primary health care practitioners. 

For the aim, scope, instructions to authors and templates for 

publications see www.rnzcgp.org.nz/journal-of-primary-health-care/. 

JPHC acts as a knowledge refinery to provide busy practitioners with 

up-to-date knowledge about the latest evidence and best practice. 

Continuing professional development includes pithy summaries of the 

latest evidence such as Cochrane Corner, POEMS (Patient Oriented 

Evidence that Matters), brief synopses of guidelines and bulletins, a 

String of PEARLS (Practical Evidence About Real Life Situations) and 

Charms and Harms (evidence of effectiveness and safety of complementary 

and alternative medicines). JPHC includes Poumanu (treasures 

of Maori wisdom) and Gems of NZ Primary Health Care Research 

published at home and internationally. 

Evidence can help inform best practice. However sometimes there is no 

evidence available or applicable for a specific patient with his or her own 

set of conditions, capabilities, beliefs, expectations and social circumstances. 

Evidence needs to be placed in context. General practice is an 

art as well as a science. Quality of care lies also with the nature of the 

clinical relationship, with communication and with truly informed decision-making. 

JPHC publishes viewpoints, commentaries and reflections 

that explore areas of uncertainty on aspects of care for which there is 

no one right answer. Debate is stimulated by the Back to Back section 

where two professionals present their opposing views on a topic. There 

is a regular Ethics column. Letters to the Editor are welcomed. 

While published in New Zealand by the Royal New Zealand College of 

General Practitioners, much of this research has generic implications. 

Our Editorial Board comprises renowned and active primary care clinicians, 

clinical and scientific academics and health policy experts with 

both New Zealand and international representation. 

Editor 

Dr Felicity Goodyear-Smith, Associate Professor, Department of 

General Practice & Primary Health Care, University of Auckland, 

Auckland, New Zealand; editor@rnzcgp.org.nz 

Editorial Board 

Prof Bruce Arroll: Professor and Head of the Department of General 

Practice & Primary Health Care, University of Auckland, NZ 

Dr Jo Barnes: Associate Professor of Pharmacy, School of Pharmacy, 

University of Auckland, NZ 

Prof Peter Crampton: Dean and Head of Campus, Wellington School 

of Medicine & Health Sciences, University of Otago, NZ 

Prof Tony Dowell: Professor and Head of the Department of Primary 

Health Care & General Practice, Wellington School of Medicine, 

University of Otago, NZ 

Dr Pat Farry: Director of Te Waipounamu Rural Health Unit, University 

of Otago, NZ 

Dr Ron Janes: Associate Professor of Rural Health, Department of 

General Practice and Primary Health Care, University of Auckland, NZ 

Dr Derelie Mangin: Associate Professor, Department of Public Health 

& General Practice, University of Otago, Christchurch, NZ 

Dr Barry Parsonson: Psychologist for NZ Ministry of Education and 

International Consultant, UNICEF (Georgia) Training Project for Institutional 

Staff working with disabled children 

Dr Shane Reti: Assistant Professor, International Program Director 

Clinical Informatics and CEO of Clinical Informatics Industrial 

Research, Harvard Medical School, USA 

Prof Kurt Stange: Professor of Family Medicine, Case Western Reserve 

University, Cleveland, OH, USA and Editor, Annals of Family Medicine 

Dr Colin Tukuitonga: Associate Professor and CEO of the Ministry of 

Pacific Island Affairs, Wellington, NZ 

Editorial assistant 

Please send all submissions to the Editor: editor@rnzcgp.org.nz or to 

the Editorial Assistant Pam Berry: editorialassistant@rnzcgp.org.nz 

accompanied by a covering letter as outlined at http://www.rnzcgp. 

org.nz/journal-of-primary-health-care/#cover 

Subscription or advertising queries 

Cherylyn Borlase, Publications Coordinator 

RNZCGP, PO Box 10440, Wellington 6143 

jphcnz@rnzcgp.org.nz 

The Journal of Primary Health Care is the official journal of the RNZCGP. However, views expressed are not necessarily those of the College, the Edi- 

tor, or the Editorial Board. ©The Royal New Zealand College of General Practitioners 2009. All Rights Reserved.

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