BACKGROUND: Research is needed into ways of reducing patients' dependence on benzodiazepine. So far, dose reduction has never been compared with reduction without intervention. Furthermore, the added value of combining treatment with psychotherapy has never been evaluated in a randomised controlled study. AIM: To evaluate the efficacy and feasibility of controlled dose reduction with and without the help of group cognitive behavioural therapy (CBT) in primary care. METHOD: One hundred and eighty chronic users of benzodiazepine unable to stop taking the drug on their own accord participated in a randomised controlled trial. They were assigned to 3 groups: a controlled dose-reduction group; a controlled dose-reduction group receiving group-CBT; and a group receiving usual care. RESULTS: Of the patients subjected to controlled reduction 62% stopped taking benzodiazepine entirely, which significantly differed from the control group (21%). Adding group-CBT did not increase the success rate in the controlled dose-reduction group. The intention to participate in the controlled reduction programme motivated 1 in 5 patients to stop taking benzodiazepine on their own accord. Neither discontinuation nor the type of intervention had any influence on patients' psychological functioning. Both intervention programmes could be performed successfully by family doctors although only 17% of the 1036 eligible benzodiazepine users agreed to participate in this study. CONCLUSION: In primary care controlled dose reduction is an effective way of helping motivated long-term users of benzodiazepine to stop taking the drug. The addition of group-CBT, however, provides no added value. No definitive conclusions can be drawn until long-term follow-up data recording relapse rates become available.
Our aim was to examine the relationship between gout on the one hand and cardiovascular diseases and cardiovascular risk indicators on the other.A case-control study was carried out in an aggregate primary care population of approximately 12 000 patients from four Dutch general practices, with follow-up of the cases free of cardiovascular diseases at the time of the first registered episode of gout. The subjects comprised 261 patients with a first episode of gout, 170 of whom were without prevalent cardiovascular diseases, and two control patients for each case matched for age, sex and practice. In the case-control study, the main outcome measures were the prevalence of cardiovascular morbidity (angina pectoris, myocardial infarction, heart failure, cerebrovascular accident, transient ischaemic attack, peripheral vascular disease), hypertension, diabetes mellitus, obesity and hypercholesterolaemia; in the follow-up study, the main outcome measure was the incidence of cardiovascular morbidity.Thirty-five percent of 261 gout patients and 26% of 522 controls had one or more prevalent cardiovascular diseases. Compared with controls, patients had a higher prevalence of hypertension (43% versus 18%), hypercholesterolaemia (14% versus 6%) and obesity (56% versus 30%). A total of 170 gout patients without prevalent cardiovascular diseases (compared with 340 controls) had a higher prevalence of hypertension (39% versus 14%), hypercholesterolaemia (8% versus 4%), diabetes mellitus (5% versus 1%) and obesity (52% versus 27%). The first occurrence of a cardiovascular disease (real end-point) was seen in 26% of the patients free of cardiovascular morbidity and in 21% of the controls. This difference was not significant. In a Cox proportional hazard model, controlling for the cardiovascular risk indicators, gout did not prove to be an independent determinant for the development of cardiovascular disease.Gout was found to be associated with cardiovascular diseases and with cardiovascular risk indicators, without evidence of it being an independent risk indicator itself. A gout attack should be an incentive to assess the cardiovascular risk profile, when a patient seeks medical help.
Reliable longitudinal data of patients with functional somatic symptoms in general practice are lacking.To identify distinctive features in patients with chronic functional somatic symptoms, and to determine whether these symptoms support the hypothesis of the existence of specific somatic syndromes.Observational study, with a comparison control group.Four primary care practices affiliated with the University of Nijmegen in the Netherlands.One hundred and eighty-two patients diagnosed between 1998 and 2002 as having chronic functional somatic symptoms and 182 controls matched by age, sex, socioeconomic status, and practice were included. Data on comorbidity, referrals, diagnostic tests, and hospital admissions over a period of 10 years prior to the diagnosis were collected. Medication use and number of visits to the general practitioner (GP) were extracted from the moment computerised registration was started.In the 10 years before the diagnosis of chronic functional somatic symptoms, significantly more patients than controls presented functional somatic symptoms in at least two body systems, and used more somatic and psychotropic drugs. They visited the GP twice as much, statistically had significantly more psychiatric morbidity, and were referred more often to mental health workers and somatic specialists. The number of patients undergoing diagnostic tests was higher for patients with chronic functional somatic symptoms than for controls, but hospital admissions rates were equal.Patients with chronic functional somatic symptoms have a great diversity of functional somatic symptoms. They use more somatic and psychotropic drugs than controls in the years before diagnosis. Moreover, they show high rates of referrals and psychiatric morbidity. The diversity of symptoms of patients with chronic functional somatic symptoms supports the concept that symptoms do not cluster in well defined distinct syndromes. Therefore, patients with chronic functional somatic symptoms should preferably not be classified into medical subspecialty syndromes.
Control group characteristics as comorbidity and chronic psychosocial problems may play an important part in study outcomes. A primary care data base was used to quantify the effects of varying the case mix of participants.Historical cohort study.Data were collected from 1967-1996 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen.All newly diagnosed type 2 diabetic patients in the period 1967-1989 fulfilling the WHO criteria (n = 265); for each type 2 diabetic patient a control was matched for practice, sex, age, and social class; from these controls subgroups were selected based on the absence of different types of morbidity; these subgroups were also matched for practice, sex, age, and social class.The relative risk of mortality in type 2 diabetic patients in comparison with various subsets of controls ranged from 1.33 (95% CI 0.97, 1.81) to 2.16 (95% CI 1.46, 3.20).Control group characteristics as comorbidity and chronic psychosocial problems turned out to influence the risk estimation in a cohort study. General practice data enhance the study of these aspects.
