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CONTiNUiNg PROfEssiONAL dEVELOPMENT 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 62 VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE
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 of Auckland, PB 92019, Auckland, New Zealand pam.bennett@auckland.ac.nz Pounamu CONTiNUiNg PROfEssiONAL dEVELOPMENT 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) VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE 63
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