Diego Palao

Burden of chronic physical conditions and mental disorders in primary care

BACKGROUND The World Health Organization (WHO) has stated that the three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depression and ischaemic heart disease. AIMS To estimate health-related quality of life (HRQoL) and quality-adjusted life-year (QALY) losses associated with mental disorders and chronic physical conditions in primary healthcare using data from the diagnosis and treatment of mental disorders in primary care (DASMAP) study, an epidemiological survey carried out with primary care patients in Catalonia (Spain). METHOD A cross-sectional survey of a representative sample of 3815 primary care patients. A preference-based measure of health was derived from the 12-item Short Form Health Survey (SF-12): the Short Form-6D (SF-6D) multi-attribute health-status classification. Each profile generated by this questionnaire has a utility (or weight) assigned. We used non-parametric quantile regressions to model the association between both mental disorders and chronic physical condition and SF-6D scores. RESULTS Conditions associated with SF-6D were: mood disorders, beta = -0.20 (95% CI -0.18 to -0.21); pain, beta = -0.08 (95%CI -0.06 to -0.09) and anxiety, beta = -0.04 (95% CI -0.03 to -0.06). The top three causes of QALY losses annually per 100 000 participants were pain (5064), mood disorders (2634) and anxiety (805). CONCLUSIONS Estimation of QALY losses showed that mood disorders ranked second behind pain-related chronic medical conditions.

Factor structure, internal consistency and construct validity of the Sheehan Disability Scale in a Spanish primary care sample

RATIONALE, AIMS AND OBJECTIVES The Sheehan Disability Scale (SDS) is a three-item instrument that measures disability in three inter-related domains: work, family life/home responsibilities and social/leisure activities. The main objective of the present study was to examine the factor structure, reliability and construct validity of the SDS in a wide Spanish sample of primary care (PC) patients. METHODS One phase cross-sectional survey. A total of 3815 patients, aged 18 years or older attending PC for a medical visit, were interviewed between October 2005 and March 2006. The interviews included the Structured Clinical Interview for DSM-IV Axis I Disorders for depressive and anxiety disorders, the Mini-International Neuropsychiatric Interview for the rest of mental disorders, a medical conditions checklist, the 2.0 version of the 12-item Short-Form Health Survey (SF-12) for measuring quality of life and the SDS. RESULTS The principal component analysis and the subsequent confirmatory factor analysis indicated that the SDS is one-dimensional (normed fit index = 0.990, non-normed fit index = 0.987, comparative fit index = 0.991, goodness-of-fit index = 0.993, standardized root mean-square residual = 0.037, root mean-square error of approximation = 0.053). The internal consistency of the scale was good (α = 0.83) and it was significantly associated with the physical and mental component of the SF-12. Concerning discriminative validity, patients with major depression or panic disorder scored higher on the SDS than patients with chronic medical conditions or with no chronic pathology. We also found that a cut-off point of 8 in the SDS adequately discriminated between patients with and without depression (area under the curve = 0.814, sensitivity = 81.60%, specificity = 70.60%). CONCLUSIONS The SDS seems a reliable, valid and useful clinical tool for measuring disability in Spanish PC patients.

Haloperidol: Therapeutic Window in Schizophrenia

Twenty-two schizophrenic inpatients were treated for 3 weeks with three randomly fixed oral doses of haloperidol (10, 20, or 30 mg). Analysis of the results by a nonlinear regression model revealed a curvilinear relationship between haloperidol levels in plasma and clinical response, as assessed on the Brief Psychiatric Rating Scale (pseudo-R2 = 0.85, F = 17.7, p < 0.001, correlation between coefficients ranged from 0.99 to -0.52). This curve defines roughly three drug level ranges (low, < 5.5 ng/ml; optimal, 5.5 to 14.4 ng/ml; and high or toxic, > 14.4 ng/ml), which are significant for clinical practice. Patients with high levels improve to a lesser extent or even worsen in negative symptoms, showing a nonstatistically significant trend to present more extrapyramidal symptoms. Our data thus support the existence of a therapeutic window for haloperidol. Schizophrenic patients with acute exacerbation and drug levels in this range would have a greater probability of global clinical improvement.

Effectiveness of a telephone management programme for patients discharged from an emergency department after a suicide attempt: controlled study in a Spanish population.

OBJECTIVE To determine the effectiveness over one year of a specific telephone management programme on patients discharged from an emergency department (ED) after a suicide attempt. We hypothesized that the programme will reduce the percentage of patients re-attempting suicide and delay the time between attempts. DESIGN A multicentre, case-control, population-based study. The effect of the 1-year intervention on the main outcome measures was evaluated with respect to a 1-year baseline period and a control group. SETTING Two hospitals with distinct catchment areas in Catalonia (Spain). PARTICIPANTS A total of 991 patients discharged from the ED of either hospital after a suicide attempt during the baseline year and the intervention year. INTERVENTION The intervention was carried out on patients discharged from the ED for attempted suicide (Sabadell). It consisted of a systematic, one-year telephone follow-up programme: after 1 week, thereafter at 1, 3, 6, 9 and 12-month intervals, to assess the risk of suicide and increasing adherence to treatment. The population in the control group (Terrassa) received treatment as usual after discharge, without additional telephone management. MAIN OUTCOME MEASURES Time elapsed between initial suicide attempt and subsequent one, and changes in the annual rate of patients who reattempted suicide in the year of the intervention and the preceding one. RESULTS The telephone management programme delayed suicide reattempts in the intervention group compared to the baseline year (mean time in days to first reattempt, year 2008=346.47, sd=4.65; mean time in days to first reattempt, year 2007=316.46, sd=7.18; P<0.0005; χ²=12.1, df=1) and compared to the control population during the same period (mean time in days to first reattempt, treatment period=346.47, sd=4.65; mean time in days to first reattempt, pre-treatment period=300.36, sd=10.67; P<0.0005; χ²=16.8, df=1). The intervention reduced the rate of patients who reattempted suicide in the experimental population compared to the previous year (Intervention 6% (16/296) v Baseline 14% (39/285) difference 8%, 95% confidence interval 2% to 12%) and to the control population (Intervention 6% (16/296) v Control 14% (31/218) difference 8%, -13% to -2%) LIMITATIONS One of the main obstacles was the difficulty to contact all patients within the established deadlines. Another limitation of our study was that patients under the age of 18 underwent an intensive intervention in the day hospital, although their number was very small (13/319 in 2008) and did not significantly influence the results. But the main limitation of our study was that it was performed within the EAAD project. This project includes a comprehensive multilevel intervention practically in the same experimental area and aimed at an early diagnosis and treatment of depression, which is the main psychiatric disorder associated with suicide. Moreover, longer-term studies should be encouraged to determine whether such interventions really reduce suicide CONCLUSION A telephone management programme for patients discharged from an ED after a suicide attempted would be a useful strategy in delaying further suicide attempts and in reducing the rate of reattempts, which is known as the highest risk factor for suicide completion.

Impact of mental disorders and chronic physical conditions in health-related quality of life among primary care patients: results from an epidemiological study

PurposeTo estimate the comorbidity of mental disorders with chronic physical conditions and to assess their independent and combined effects on health-related quality of life (HRQOL).MethodsFace-to-face cross-sectional survey of adult attendants to public primary care (PC) centres from Catalonia (Spain). A total of 3,815 out of 5,402 selected patients provided data for this study. We report frequency of chronic physical conditions among participants with mental disorders and the contribution of each mental disorder and chronic physical condition to HRQOL.ResultsChronic pain is the most frequent condition among those with mental disorders (74.54%). The effect of chronic physical conditions on HRQOL is rather minor when compared to the effect of mental disorders (especially mood disorders). However, chronic pain plays an important role in HRQOL loss.ConclusionsMood disorders and chronic pain negatively affect HRQOL of PC patients. Especial efforts should be made to detect and treat mental disorders and chronic pain at this level.

Psychotropic prescribing in Catalonia: results from an epidemiological study

BACKGROUND Mental disorders (MDs) are mainly treated in primary care (PC), where psychotropic drug (PSD) prescribing is highly prevalent. Prescription of PSD is associated with clinical and non-clinical factors. PURPOSE To describe the patterns of PSD prescribing over a 12-month period and to determine the factors associated with this in a PC population. METHODS Cross-sectional study. Data were collected on 3815 patients, via patient interview, on sociodemographics and MDs [Diagnostic and Statistical Manual of Mental Disorders (DSM-IV criteria)]. Computerized records provided data on PSD prescribing. Multilevel logistic regressions assessed the factors that influence prescribing. RESULTS Thirty-four per cent of PC patients were prescribed PSDs >12 months, with anxiolytics being the most commonly prescribed (22%). Fifty-three per cent of patients with any MD in this 12-month period were prescribed PSDs; however, 25% of patients without any of these disorders were also prescribed these medications. Higher rates of prescribing were associated with female gender, older age, presence of MD, being a househusband/housewife, consulting about psychological problems, increasing number of consultations and higher self-perceived disability. PSDs were less likely to be prescribed to patients born outside Spain and those consulting about physical conditions. PSD prescribing was higher in patients previously married and antipsychotic prescribing was higher in patients never married. No statistically significant associations were found between PSD prescription and education. CONCLUSIONS PSD prescribing rates are high in Catalonia and are associated with a number of clinical and non-clinical factors. A significant proportion of patients are receiving these drugs in the absence of MD. These findings need to be considered when prescribing in PC.

Protocolo breve de evaluación del suicidio, fiabilidad interexaminadores

INTRODUCTION Inter-rater agreement is a crucial aspect in the planning and performance of a clinical trial in which the main assessment tool is the clinical interview. The main objectives of this study are to study the inter-rater agreement of a tool for the assessment of suicidal behavior (Brief Suicide Questionnaire) and to examine whether the inter-examiner agreement when multiple ratings are made on a single subject is an efficient method to assess the reliability of an instrument. METHOD In the context of designing a multicenter clinical trial, 32 psychiatrists assessed a videotaped clinical interview of a patient with suicidal behavior. In order to identify those items in which a greater level of discordance existed and detect the examiners whose ratings differed significantly from the average ratings, we used the DOMENIC method (Detecion of Multiple Examiners Not in Consensus). RESULTS Inter-rater agreement was between poor (<70%) to excelent (90-100%. Inter-rater agreement in Brughas list of threatening experiences ranged from 75.5 and 100%; in the Global Assessment of Functioning (GAF) Scale was 82.58%; in the Becks Suicidal Intent Scale, ranged from 67.5 and 97%; in the Becks Scale for Suicide Ideation, ranged from 63.5 and 100%; and in the Lethality Rating Scale was 88.39%. On the whole, the level of agreement among raters, both in general scores and in particular items, was appropriate. CONCLUSION The proposed design allows the assessment of the inter-rater agreement in an efficient way (only in one session). In addition, regarding the Brief Suicide Questionnaire, inter-raters agreement was appropriate.

Positive versus negative symptoms in schizophrenia: Response to haloperidol

1. Clinical response to treatment with haloperidol was studied in 20 schizophrenic inpatients with acute exacerbation (DSM-IIIR). 2. Patients were assigned to fixed doses of haloperidol (10, 20 or 30 mg/day) for three weeks. Clinical assessment was made using scales SAPS, SANS, BPRS and Simpson-Angus Scale for rating of extrapyramidal side effects. 3. Sixteen patients showed forty per cent or more decrease in positive symptoms assessed by SAPS, being considered the group of responders. Six out of the twenty patients showed improvement in negative symptoms assessed by SANS (improvement above 30%). 4. Clinical predictors of response were only identified for SAPS. The group of responders showed higher basal scores in total scale and formal thought disorder. 5. Negative symptoms responsive to treatment were affective flattening and alogia. Improvement in negative symptoms was independent from that in positive ones. 6. Socio-demographic predictors of clinical response were not found. No differences in clinical response were found in relation to the dose administered. 7. The results of our study suggest that negative symptomatology improves in a scheduled treatment with haloperidol. Assessment of negative symptoms may be useful in the evaluation of treatment of acute schizophrenia.

A new computerized cognitive and social cognition training specifically designed for patients with schizophrenia/schizoaffective disorder in early stages of illness: A pilot study

People with schizophrenia/schizoaffective disorders at early stages of the illness present cognitive and social cognition deficits that have a great impact in functional outcomes. Cognitive Remediation Therapy (CRT) has demonstrated consistent effect in cognitive performance, symptoms and psychosocial functioning. However, any CRT intervention or social cognition training have been specifically designed for patients in the early stages of psychosis. The aim of this pilot study is to assess the efficacy of a new computerized cognitive and social cognition program for patients with schizophrenia/schizoaffective disorder with recent diagnosis. A comprehensive assessment of clinical, social and non-social cognitive and functional measures was carried out in 53 randomized participants before and after the 4-months treatment. Significant results were observed in Spatial Span Forwards, Immediate Logical Memory and Pictures of Facial Affect (POFA) total score. None of these results were explained by medication, premorbid social functioning or psychopathological symptoms. No impact of the intervention was observed in other cognitive and social cognition outcome neither in clinical and functional outcomes. This new computerized intervention may result effective ameliorating visual attention, logical memory and emotional processing in patients in the early stages of schizophrenia/schizoaffective disorder.

Selective effect of neurocognition on different theory of mind domains in first-episode psychosis.

Abstract The aim of this study was to investigate the influence of neurocognition on affective and cognitive theory of mind (ToM) tasks in early phases of psychosis. In a cross-sectional study of 60 first-episode schizophrenia/schizoaffective disorder patients, the implication of neurocognition in first- and second-order ToM stories, Hinting Task, and Reading the Mind in the Eyes Test (RMET) was analyzed. Regression models were used, controlling for clinical symptoms and antipsychotic dose. Spatial span backward (odds ratio [OR], 0.34; p = 0.01) and intrusions in the Rey Auditory Verbal Learning Test (OR, 4.86; p = 0.04) were the best factors to predict second-order ToM failure. Trail Making Test B (B = 0.01; p = 0.04) and negative symptoms (B = 0.09; p = 0.01) predicted Hinting task performance while Block design (B = 0.1; p = 0.04) was related to RMET outcome. Executive functions and clinical symptoms were related to ToM performance in first-episode schizophrenia patients, although different patterns of relationship were observed in each ToM task.