Josep Lluís Piñol

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.

Metabolic Syndrome as a Cardiovascular Disease Risk Factor: Patients Evaluated in Primary Care

To estimate the prevalence of metabolic syndrome (MS) in a population receiving attention in primary care centers (PCC) we selected a random cohort of ostensibly normal subjects from the registers of 5 basic-health area (BHA) PCC. Diagnosis of MS was with the WHO, NCEP and IDF criteria. Variables recorded were: socio-demographic data, CVD risk factors including lipids, obesity, diabetes, blood pressure and smoking habit and a glucose tolerance test outcome. Of the 720 individuals selected (age 60.3 ± 11.5 years), 431 were female, 352 hypertensive, 142 diabetic, 233 pre-diabetic, 285 obese, 209 dyslipemic and 106 smokers. CVD risk according to the Framingham and REGICOR calculation was 13.8 ± 10% and 8.8 ± 9.8%, respectively. Using the WHO, NCEP and IDF criteria, MS was diagnosed in 166, 210 and 252 subjects, respectively and the relative risk of CVD complications in MS subjects was 2.56. Logistic regression analysis indicated that the MS components (WHO set), the MS components (IDF set) and the female gender had an increased odds ratio for CVD of 3.48 (95CI%: 2.26–5.37), 2.28 (95%CI: 1.84–4.90) and 2.26 (95%CI: 1.48–3.47), respectively. We conclude that MS and concomitant CVD risk is high in ostensibly normal population attending primary care clinics, and this would necessarily impinge on resource allocation in primary care.

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.

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

Rationale and design of the PREDICE project: cost-effectiveness of type 2 diabetes prevention among high-risk Spanish individuals following lifestyle intervention in real-life primary care setting

BackgroundType 2 diabetes is an important preventable disease and a growing public health problem. Based on information provided by clinical trials, we know that Type 2 diabetes can be prevented or delayed by lifestyle intervention. In view of translating the findings of diabetes prevention research into real-life it is necessary to carry out community-based evaluations so as to learn about the feasibility and effectiveness of locally designed and implemented programmes. The aim of this project was to assess the effectiveness of an active real-life primary care strategy in high-risk individuals for developing diabetes, and then evaluate its efficiency.Methods/DesignCost-Effectiveness analysis of the DE-PLAN (Diabetes in Europe - Prevention using Lifestyle, physical Activity and Nutritional intervention) project when applied to a Mediterranean population in Catalonia (DE-PLAN-CAT). Multicenter, longitudinal cohort assessment (4 years) conducted in 18 primary health-care centres (Catalan Health Institute). Individuals without diabetes aged 45-75 years were screened using the Finnish Diabetes Risk Score - FINDRISC - questionnaire and a 2-h oral glucose tolerance test. All high risk tested individuals were invited to participate in either a usual care intervention (information on diet and cardiovascular health without individualized programme), or the intensive DE-PLAN educational program (individualized or group) periodically reinforced. Oral glucose tolerance test was repeated yearly to determine diabetes incidence. Besides measuring the accumulated incidence of diabetes, information was collected on economic impact of the interventions in both cohorts (using direct and indirect cost questionnaires) and information on utility measures (Quality Adjusted Life Years). A cost-utility and a cost-effectiveness analysis will be performed and data will be modelled to predict long-term cost-effectiveness.DiscussionThe project was intended to evidence that a substantial reduction in Type 2 diabetes incidence can be obtained at a reasonable cost-effectiveness ratio in real-life primary health care setting by an intensive lifestyle intervention. As far as we know, the DE-PLAN-CAT/PREDICE project represents the first assessment of long-term effectiveness and cost-effectiveness of a public healthcare strategy to prevent diabetes within a European primary care setting.

La escala de Framingham sobrevalora el riesgo cerebrovascular de la diabetes y el síndrome metabólico en la población española

Objetivo Estimar el riesgo de accidente cerebrovascular (ACV) de la diabetes, en el contexto del sindrome metabolico (SM) o fuera de el, segun los criterios de la Organizacion Mundial de la Salud (OMS) y del National Cholesterol Education Program (NCEP). Diseno Estudio multicentrico y prospective de cohortes. Emplazamiento Atencion primaria de salud. Participantes Sujetos de 55-85 anos libres de ACV incluidos desde 1998 en una muestra poblacional aleatoria y representativa para el seguimiento del SM en Reus (Tarragona). Mediciones principales El riesgo de ACV se estimo con la escala de Framingham aplicando un algoritmo informatico de calculo automatico y un diseno factorial por diagnosticos (diabetes y/o SM). Se comparo el riesgo teorico con la incidencia real de acontecimientos cerebrovasculares (1998-2003). Resultados Entre 728 sujetos (412 mujeres; edad media de 66 anos; indice de masa corporal = 29), 457 (62,8%) no tenian diabetes ni SM, 93 (12,8%) con SM no tenian diabetes, 72 (9,9%) con diabetes no tenian SM y 106 (14,5%) presentaban ambas enfermedades (segun criterios de la OMS). Segun el NCEP, estas proporciones fueron del 60,7; el 14,8; el 7,8 y el 16,7%. El riesgo de ACV medio a 10 anos para los 4 grupos (OMS/NCEP) fue: 8,4/9,1; 10,8/10,5; 18/17,3 y 18,8/19,1%, respectivamente. La incidencia acumulada de acontecimientos cerebrovasculares fue del 2,8; 1,4; 5,4 y 3,8% (OMS) y 2,5; 2,8; 3,5 y 5,8% (NCEP). Conclusiones El riesgo de ACV calculado mediante la formula de Framingham es muy elevado en sujetos con diabetes, con independencia de su integracion en el SM. Es muy probable que la escala tambien sobredimensione este riesgo en la poblacion espanola.

Comorbilidad de la depresión mayor con otros trastornos mentales comunes en pacientes de atención primaria

INTRODUCTION Psychiatric comorbidity affects the impact, the prognosis and the management of depression. AIMS To determine the prevalence of other common mental disorders in patients with major depression and to analyse their associated comorbidities. DESIGN Two-stage cross-sectional study: a) screening (Zungs Self-Rating Depression Scale); b) a standardised psychiatric interview. SETTINGS Ten health centres in the province of Tarragona. PATIENTS A total of 906 consecutive patients were screened. In the second stage, the 209 patients who gave a positive result and 97 patients who gave a negative result (1/7 at random) were evaluated. ANALYSIS The statistical analysis used weights that took into account the two-stage sampling. The frequency with which dysthymia, generalised anxiety disorder, panic disorder and somatisation disorder presented concomitantly with major depression was determined. The characteristics of the depressed patients were compared for different degrees of comorbidity. RESULTS In 45.7% (95% CI, 32.8-59.2) of patients with major depression there was one other coexisting mental disorder, in 19.9% (95% CI, 13.7-27.9) two more mental disorders and in 8.3% (95% CI, 4.5-14.8) three more mental disorders. Generalised anxiety disorder was present in 55.2% of depressed patients (95% CI, 41.6-68), panic disorder in 33.8% (95% CI, 21.1-47.1), dysthymia in 15.7% (95% CI, 10.3-23.4) and somatisation disorder in 6.6% (95% CI, 3.3-12.8). In the groups of patients with comorbidity, the depression was more severe and had a greater functional impact. There were no differences in the clinical management variables. CONCLUSIONS Psychiatric comorbidity of depression is common in primary care. Most depressed patients suffer from other disorders, often anxiety.

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.