Clinical practice guidelines

Detecting depression

Concerns that depression may be underdiagnosed and undertreated led researchers to test whether better education would result in family physicians making more use of clinical practice guidelines (CPGs) to provide better detection and management. Between July and December 1997, they randomly assigned 42 Newfoundland family physicians to 1 of 2 groups. Physicians in both groups received CPGs on depression, but those in the first group also received a 3-hour, case-based educational session on the CPGs and access to a psychiatrist for consultation. The authors report that while family doctors in the group that received extra education did not diagnose significantly more patients with depression (4.1 v. 2.8), considerably more of their patients were still taking their medication at the six-month follow-up (56% v. 39.3%). Similarly, family physicians from the first group referred considerably more patients to psychiatrists (15.4% v. 3.5%) than physicians from the other group.

The authors concluded that while the educational strategy had some positive effects on the outcomes for patients with depression, considerable concern remains about the low rates of drug treatment and referral to mental health professionals by family physicians. [CMAJ 1999;161(1):37-40]

Guidelines for referral to nephrology

Evidence indicates that late referral to nephrology is a problem in Canada. A serum creatinine level of 120 µmol/L represents a loss of filtration function of more than 50%, but in one study 84% of physicians surveyed said they would not refer a patient with this level to a nephrologist. A subcommittee of the Canadian Society of Nephrology conducted a systematic review of the literature relating to referral. Clinical practice guidelines, endorsed by the College of Family Physicians of Canada and the Canadian Society of Nephrology, outline referral criteria for four classes of patients: those who have an elevated creatinine level, those who have newly discovered renal insufficiency, those with chronic creatinine increases and those who need dialysis. [CMAJ 1999;161(4):413-7]

New dementia guidelines

Dementia affects 8% of Canadians over age 65, but as the population ages the growing number of people with the condition will pose an increasing burden for patients, their caregivers and the health care system. In response, the Canadian Consensus Conference on Dementia was created in 1998. Thirty-four experts developed a series of consensus statements to serve as a basis for clinical practice guidelines for recognizing, assessing and managing dementing disorders.

The results were revealed June 15, 1999 in a special CMAJ supplement. The goal is to help primary care physicians better recognize the many forms of dementing disorders. The 48 recommendations represent the best available evidence.

An accompanying article explains why doctors should read the guidelines closely. By 2031 the number of Canadians experiencing dementia will surpass 750,000 - that's roughly the population of Calgary, and three times the current number. [CMAJ 1999;160(12):1738-42]