Literature Collection

This article seeks to summarize the clinical presentation and management of generalized anxiety disorder in the primary care setting with a focus on primary care-based interventions.

PURPOSE OF REVIEW: Attention-deficit and hyperactivity disorder (ADHD) often presents with comorbid substance use disorders (SUD). Due to similarities in key symptoms of both disorders and suboptimal efficacy of the available treatments, clinicians are faced with difficulties in the diagnosis and treatment of these patients with both disorders. This review addresses recent publications between 2017 and 2019 on the etiology, prevalence, diagnosis and treatment of co-occurring ADHD and SUD. RECENT FINDINGS: ADHD is diagnosed in 15-20% of SUD patients, mostly as ADHD with combined (hyperactive/inattentive) presentation. Even during active substance use, screening with the Adult ADHD Self-Report Scale (ASRS) is useful to address whether further diagnostic evaluation is needed. After SUD treatment, the diagnosis of ADHD generally remains stable, but ADHD subtype presentations are not. Some evidence supports pharmacological treatment with long-acting stimulants in higher than usual dosages. Studies on psychological treatment remain scarce, but there are some promising findings on integrated cognitive behaviour therapy. SUMMARY: Diagnosis and treatment of patients with comorbid ADHD and SUD remain challenging. As ADHD presentations can change during active treatment, an active follow-up is warranted to provide treatment to the individuals' personal strengths and weaknesses.

INTRODUCTION: The general practitioners' (GP) approach to diagnosing depression has not yet been included in depression questionnaires. Therefore, the 'Questionnaire for the assessment of DEpression SYmptoms in Primary Care' (DESY-PC) has been developed. The DESY-PC consists of two parts, comprising the patient's perspective and psychiatric diagnostic criteria (DESY-PAT), and additionally the GP's heuristics and knowledge of patients (DESY-GP). The aim was to investigate the diagnostic accuracy and factor structure of the DESY-PC. METHODS: A multicentre diagnostic accuracy study was conducted in ten practices. Patients completed the DESY-PAT and PHQ-9 (Patient Health Questionnaire-9), while their GPs completed the DESY-GP. The Structured Clinical Interview for DSM-V disorders (SCID-V-CV) was used as reference standard. Sensitivity, specificity, receiver operating characteristic curves (ROC) and area under the curve (AUC) values were calculated to determine the diagnostic accuracy of the DESY-PC and PHQ-9. Factorial validity was assessed. RESULTS: 435 patients (mean age 47.6 years, 60.1% female, prevalence of depression 15.9%) were analysed. The diagnostic accuracy of the DESY-PAT (AUC=0.862, 95% Confidence Interval 0.815-0.908) was significantly higher (p<0.001) than that of PHQ-9 (AUC=0.821, 0.764-0.878). The diagnostic accuracy increased further when DESY-PAT was combined with DESY-GP for the overall questionnaire DESY-PC (AUC=0.874, 0.834-0.914). Goodness of fit indices indicated a plausible fit for the DESY-PC. CONCLUSIONS: Incorporating the GP's heuristics, judgement and knowledge of the patient contributes to a more accurate diagnosis. The DESY-PC integrates the GP's perspective, patient-specific factors, and psychiatric criteria into the diagnostic assessment, which might contribute to improved diagnostic decision-making in primary care.