Antonia Caballero

Assessment of an enhanced program for depression management in primary care: a cluster randomized controlled trial. The INDI project (Interventions for Depression Improvement)

AbstractBackgroundMost depressed patients are attended at primary care. However, there are significant shortcomings in the diagnosis, management and outcomes of these patients. The aim of this study is to determine whether the implementation of a structured programme for managing depression will provide better health outcomes than usual management.Methods/DesignDesign: A cluster-randomized controlled trial involving two groups, one of which is the control group consisting of patients who are treated for depression in the usual way and the other is the intervention group consisting of patients on a structured programme for treating depression. Setting: 20 primary care centres in the province of Tarragona (Spain) Sample: 400 patients over 18 years of age who have experienced an episode of major depression (DSM-IV) and who need to initiate antidepressant treatment Intervention: A multi-component programme with clinical, educational and organisational procedures that includes training for the health care provider and evidence-based clinical guidelines. It also includes primary care nurses working as care-managers who provide educational and emotional support for the patients and who are responsible for active and systematic clinical monitoring. The programme aims to improve the primary care/specialized level interface. Measurements: The patients will be monitored by telephone interviews. The interviewer will not know which group the patient belongs to (blind trial). These interviews will be given at 0, 3, 6 and 12 months. Main variables: Severity of the depressive symptoms, response rate and remission rate. Analysis: Outcomes will be analyzed on an intent-to-treat basis and the unit of analysis will be the individual patient. This analysis will take into account the effect of study design on potential lack of independence between observations within the same cluster.DiscussionThe effectiveness of caring for depression in primary care can be improved by various strategies. The most effective models involve organisational changes and a greater role of nurses. However, these models are almost exclusively from the USA, and this randomized clinical trial will determine if this approach could be effective to improve the outcomes of depression in primary care in the Spanish health care system.Trial registrationISRCTN16384353

Effectiveness of a multi-component programme for managing depression in primary care: A cluster randomized trial. The INDI project

BACKGROUND There are significant shortcomings in the management and clinical outcomes of depressed patients. The objective is to assess the effectiveness of a multi-component programme to improve the management of depression in primary care. METHODS This is a cluster-randomized controlled trial, conducted between June 2007 and June 2010. Twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a multi-component programme with clinical, educational and organizational procedures including primary care nurses working as case-managers. Outcomes were monitored by a blinded interviewer at 0, 3, 6 and 12 months. TRIAL REGISTRATION ISRCTN16384353, at http://isrctn.org. RESULTS In total, 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 12 months, 302 patients were assessed, 172 in the intervention group and 130 in the control group. The severity of depression (mean Patient Health Questionnaire-9 score) was 1.76 points lower in the intervention group [7.15 vs. 8.78, 95% CI=-3.53 to 0.02, p=0.053]. The treatment response rate was 15.4% higher in the intervention group than in the controls [66.9% vs. 51.5%, odds ratio 1.9, 95% CI=1.2 to 3.1, p=0.011)], and the remission rate was 13.4% higher [48.8% vs. 35.4%, odds ratio 1.8, 95% CI=1.1 to 2.9, p=0.026)]. LIMITATIONS Unblinded physicians diagnosed depression in their patients and decided whether to include them in the study, so we cannot discount a hidden selection bias. CONCLUSIONS The programme for managing depression leads to better clinical outcomes in patients with major depression in primary care settings.

Improving the Role of Nursing in the Treatment of Depression in Primary Care in Spain

PURPOSE We describe a multicomponent program for the systematic evaluation and treatment of depression in primary care. CONCLUSION Primary-care nurses trained in clinical and therapeutic aspects of depression play a central role in care management, patient education, treatment adherence, and clinical monitoring. PRACTICE IMPLICATIONS Diverse interventions, including organizational changes and the enhancement of the role of nurses, have been effective in improving depression outcomes in primary-care settings.

Prevalencia del déficit de atención e hiperactividad en personas adultas según el registro de las historias clínicas informatizadas de atención primaria

Fundamento:El TDAH en adultos no es infrecuente y, segun datos epidemiologicos recientes, tiene una prevalencia poblacional del 3-4%. Sin embargo, existe un gran desconocimiento sobre este trastorno entre los medicos, particularmente en atencion primaria. El objetivo de este trabajo es determinar la prevalencia del diagnostico registrado de TDAH en adultos y la proporcion de pacientes con prescripcion farmacologica para este trastorno en atencion primaria. Metodos:Se trata de un estudio transversal sobre las bases de datos de las historias clinicas electronicas de atencion primaria. La poblacion diana son los adultos (18-44 anos) adscritos a centros de salud del Instituto Catalan de la Salud (n=2.452.107). Hemos obtenido la proporcion de pacientes con diagnostico de TDAH (codigo F90/CIE-10) en la lista de problemas activos, y la proporcion de pacientes con prescripcion activa de un farmaco especifico para el TDAH en adultos: metilfenidato, metilfenidato de liberacion prolongada o atomoxetina. Resultados:La prevalencia de TDAH registrado es del 0,04% (0,07% en hombres; 0,02% en mujeres). Los pacientes con prescripcion para TDAH son el 0,07% (0,08% en hombres; 0,05% en mujeres). El 32,05% de los TDAH tenian prescripcion especifica. Conclusion:El diagnostico en adultos de TDAH y el tratamiento especifico son extremadamente bajos en atencion primaria. Estos resultados contrastan con los datos poblacionales: el TDAH registrado es 1/85 de la prevalencia poblacional.

Cost-effectiveness analysis of a collaborative care programme for depression in primary care.

BACKGROUND Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care. METHODS A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007-2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs). RESULTS Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane. LIMITATIONS The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression. CONCLUSIONS The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.

Persistence in the long term of the effects of a collaborative care programme for depression in primary care

BACKGROUND A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring. METHODS Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life. TRIAL REGISTRATION ISRCTN16384353. RESULTS A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance. LIMITATIONS The number of patients lost (31%) before follow-up may have introduced a bias. CONCLUSIONS Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables.

Actitudes y opiniones de los médicos de familia frente a la depresión: una aproximación con el Depression Attitudes Questionnaire (DAQ)

AIM To describe the attitudes of General Practitioners (GPs) towards depression in Primary Health Care Centres. DESIGN Cross-sectional study based on the application of a standard questionnaire. SETTING AND PARTICIPANTS A total of 112 GPs from all of the 20 Primary Health Care Centres in the Tarragona-Reus Primary Care Area (Catalan Health Institute). MEASUREMENTS A Spanish adaptation of Depression Attitudes Questionnaire was used. RESULTS A total of 88.4% of doctors agreed there was an increase in the number of depressive patients in recent years. Around half of the GPs thought that depression in Primary Health Care Centres are due to the adversities of life, but 72.3% considers that there is a biological root in severe depressions. A large majority (81.2%) of doctors believed that antidepressants used in Primary Care are efficient and the majority values psychotherapy as a useful therapeutic option. There is an agreement in the role of nursing staff when attending depressed patients. The role of psychiatric referral when a satisfactory result is not obtained in Primary Care is recognised. Although 64.3% of doctors consider that dealing with depressed patients is hard work, but 57.1% feel comfortable and only 19.7% think it is an unpleasant job. CONCLUSIONS In general, there is a favourable predisposition to deal with depression in Primary Care where training and organisational initiatives can be introduced to improve clinical outcomes of depression in Primary Care.

Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI·i project)

AbstractBackgroundPrimary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice.MethodsObjective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care. Design: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system. Participants: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia). Intervention: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework. Measures: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact.DiscussionThis project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society.Trial registrationClinicalTrials.gov identifier: NCT03285659; Registered 12th September, 2017.