Enric Aragonès

Prevalence and determinants of depressive disorders in primary care practice in Spain

Objective: Depressive disorders are considered to be a public health problem. Primary health care plays an important role in the treatment of such disorders. Our aim is to determine the prevalence and determinant factors of major depression and dysthymia in consecutive primary care attenders. Method: The study took place in medical consultations in 10 Primary Care Centers in Tarragona (Spain). It was designed as a two-phase cross-sectional study. In the first phase we screened 906 consecutive patients according to Zungs Self-Rating Depression Scale. In the second phase the 209 patients whose results were positive and 97 patients whose results were negative (1/7 chosen at random) were given the Structured Clinical Interview for DSM-IV Axis I Disorders, plus a series of questionnaires. We evaluated the link between major depression and dysthymia and several sociodemographic and clinical variables using non-conditional logistic regression. Results: Weighted prevalence was 14.3% (CI 95%: 11.2–17.4) for major depression and 4.8% (CI 95%: 2.8–6.8) for dysthymia. Independently linked to the presence of major depression were female sex, panic disorder, generalized anxiety disorder, frequency of primary care visits, and clinical presentation in the form of explicitly psychosocial symptoms as opposed to exclusively somatic symptoms. Independently linked to the presence of dysthymia were age, generalized anxiety disorder and psychosocial symptoms. Conclusion: In our area, depressive disorders in primary care attenders are very common. General practitioners should be aware of this fact so that these disorders can be detected and treated correctly.

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

Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care

BACKGROUND Benzodiazepines are extensively used in primary care, but their long-term use is associated with adverse health outcomes and dependence. AIMS To analyse the efficacy of two structured interventions in primary care to enable patients to discontinue long-term benzodiazepine use. METHOD A multicentre three-arm cluster randomised controlled trial was conducted, with randomisation at general practitioner level (trial registration ISRCTN13024375). A total of 532 patients taking benzodiazepines for at least 6 months participated. After all patients were included, general practitioners were randomly allocated (1:1:1) to usual care, a structured intervention with follow-up visits (SIF) or a structured intervention with written instructions (SIW). The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription claims at 12 months. RESULTS At 12 months, 76 of 168 (45%) patients in the SIW group and 86 of 191 (45%) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 (15%) in the control group. After adjusting by cluster, the relative risks for benzodiazepine discontinuation were 3.01 (95% CI 2.03-4.46, P<0.0001) in the SIW and 3.00 (95% CI 2.04-4.40, P<0.0001) in the SIF group. The most frequently reported withdrawal symptoms were insomnia, anxiety and irritability. CONCLUSIONS Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity. A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits.

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.

Comparative efficacy of two primary care interventions to assist withdrawal from long term benzodiazepine use: a protocol for a clustered, randomized clinical trial.

BackgroundAlthough benzodiazepines are effective, long-term use is not recommended because of potential adverse effects; the risks of tolerance and dependence; and an increased risk of hip fractures, motor vehicle accidents, and memory impairment. The estimated prevalence of long-term benzodiazepine use in the general population is about 2,2 to 2,6%, is higher in women and increases steadily with age. Interventions performed by General Practitioners may help patients to discontinue long-term benzodiazepine use. We have designed a trial to evaluate the effectiveness and safety of two brief general practitioner-provided interventions, based on gradual dose reduction, and will compare the effectiveness of these interventions with that of routine clinical practice.Methods/DesignIn a three-arm cluster randomized controlled trial, general practitioners will be randomly allocated to: a) a group in which the first patient visit will feature a structured interview, followed by visits every 2-3 weeks to the end of dose reduction; b) a group in which the first patient visit will feature a structured interview plus delivery of written instructions to self-reduce benzodiazepine dose, or c) routine care. Using a computerized pharmaceutical prescription database, 495 patients, aged 18-80 years, taking benzodiazepine for at least 6 months, will be recruited in primary care health districts of three regions of Spain (the Balearic Islands, Catalonia, and Valencia). The primary outcome will be benzodiazepine use at 12 months. The secondary outcomes will include measurements of anxiety and depression symptoms, benzodiazepine dependence, quality of sleep, and alcohol consumption.DiscussionAlthough some interventions have been shown to be effective in reducing benzodiazepine consumption by long-term users, the clinical relevance of such interventions is limited by their complexity. This randomized trial will compare the effectiveness and safety of two complex stepped care interventions with that of routine care in a study with sufficient statistical power to detect clinically relevant differences.Trial RegistrationCurrent Controlled Trials: ISRCTN13024375

Reinforcing Stigmatization: Coverage of Mental Illness in Spanish Newspapers

Because the media influences societys perceptions of reality, the treatment of mental illness in the news can have an effect on the societal stigma related to it. This study aimed to analyze the content and form of news items related to mental illness in Spanish newspapers in order to understand their role in propagating or attenuating stereotypes, prejudices, and stigma. The authors conducted a cross-sectional descriptive study on the basis of a review of news items related to mental illness appearing in the Spanish print media. A sample was taken from articles published on the subject in the 20 Spanish newspapers with the widest circulations over the course of the year 2010. Formal elements and content were analyzed by means of a structured evaluation system. The authors analyzed 695 news items. The content of 47.9% (n = 333) of the articles was not strictly related to mental illness, but rather clinical or psychiatric terms were used metaphorically, and frequently in a pejorative sense. The remaining 52.1% (n = 362) consisted of news items related specifically to mental illness. Of these, news items linking mental illness to danger were the most common (178 texts, 49.2%), specifically those associating mental illness with violent crime (130 texts, 35.9%) or a danger to others (126 texts, 34.8%). The results confirm the hypothesis that the press treats mental illness in a manner that encourages stigmatization. The authors appeal to the presss responsibility to society and advocate an active role in reducing the stigma towards mental illness.

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.

Registered prevalence of borderline personality disorder in primary care databases

OBJECTIVE Borderline personality disorder (BPD) is a common personality disorder, with a population prevalence of 1.4-5.9%, although the epidemiology of this disorder in primary care is insufficiently known. Our objective was to determine the registered prevalence of BPD in primary care databases and to study the demographic and clinical characteristics of these patients. METHODS We performed a cross-sectional study of the computerized databases of primary care clinical records. The target population consisted of all adults (≥ 16 years old) registered in the Catalan Health Institute (n = 4,764,729). RESULTS The prevalence of recorded BPD was 0.017%, and was higher in patients with other mental disorders, particularly substance-abuse disorders (0.161%). These patients had twice as many appointments with the general practitioner as the general population (8.1 vs. 4.4). CONCLUSION The number of diagnoses of BPD recorded in primary care is extremely low, which contrasts with the available population-based data.