Pasquale Roberge

Cognitive-Behavioral Treatment for Panic Disorder With Agoraphobia A Randomized, Controlled Trial and Cost-Effectiveness Analysis

A randomized, controlled trial was conducted to examine the cost-effectiveness of cognitive-behavioral treatment (CBT) for panic disorder with agoraphobia. A total of 100 participants were randomly assigned to standard (n = 33), group (n = 35), and brief (n = 32) treatment conditions. Results show significant clinical and statistical improvement on standard symptom measures and quality of life from baseline to posttreatment and 3-month follow-up, with no significant differences between treatment conditions. Compared with standard CBT, brief and group CBT incurred lower treatment costs and had a superior cost-effectiveness ratio, suggesting the potential of these alternative treatment conditions in increasing access to effective treatment.

Determinants of Service Use Among Young Canadians With Mental Disorders

Objective: To identify the determinants of service use by young Canadians with mental health problems. Methods: Data were drawn from a recent large Canadian mental health survey. The analyses were conducted on a subsample of 1092 Canadians aged 15 to 24 years and identified as presenting a mood disorder, an anxiety disorder, or a substance-related disorder in the 12 months preceding the survey. We classified variables potentially associated with any type of service use for a mental health problem over a 12-month period according to predisposing, enabling, and need factors. We conducted weighted multivariate logistic regressions to determine the association of each factor with service use. Results: In the final model, being female and living alone were the predisposing factors associated with service use. None of the enabling factors predicted help seeking. In regard to the perceived need factors, those who had difficulties with social situations were more likely to use services. Having a mood disorder and (or) having a diagnosed chronic illness were the evaluated need factors associated with service use. Conclusion: Certain groups of young Canadians are less likely to seek help for mental health problems and could be the target of interventions aimed at increasing service use.

Quality of care for major depression and its determinants: a multilevel analysis

BackgroundNumerous studies highlight an important gap in the quality of care for depression in primary care. However, basic indicators were often used. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The purpose of this study was to estimate the proportion of primary care patients with a major depressive episode (MDE) who receive adequate treatment and to examine the individual and organizational (i.e., clinic-level) characteristics associated with the receipt of at least one minimally adequate treatment for depression.MethodsThe sample used for this study included 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for MDE during the 12 months preceding the survey (T1), and nested within 65 primary care clinics. Data reported in this study were obtained from the “Dialogue” project. Adherence rates for 27 quality indicators selected to cover the most important components of depression treatment were estimated. Multilevel analyses were conducted.ResultsAdherence to guidelines was high (>75%) for one third of the quality indicators that were measured but was low (<60%) for nearly half of the measures. Just over half of the sample (52.2%) received at least one minimally adequate treatment for depression. At the individual level, determinants of receipt of minimally adequate care included age, having a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and the severity of depression. At the clinic level, determinants included the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration.ConclusionsOur findings suggest that interventions are needed to increase the extent to which primary mental health care conforms to evidence-based recommendations. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration.

Mental health effects from urban bed bug infestation (Cimex lectularius L.): a cross-sectional study

Objective To assess whether bed bug infestation was linked to sleep disturbances and symptoms of anxiety and depression. Design Exploratory cross-sectional study. Setting Convenience sample of tenants recruited in apartment complexes from Montreal, Canada. Participants 39 bed bug-exposed tenants were compared with 52 unexposed tenants. Main outcome measures The effect of bed bug-exposed tenants on sleep disturbances, anxiety and depression symptoms measured using the Pittsburgh Sleep Quality Index, 5th subscale, Generalised Anxiety Disorder 7-item scale and Patient Health Questionnaire, 9-item, respectively. Results In adjusted models, bed bug infestation was strongly associated with measured anxiety symptoms (OR (95% CI)=4.8 (1.5 to 14.7)) and sleep disturbance (OR (95% CI)=5.0 (1.3–18.8)). There was a trend to report more symptoms of depression in the bed bug-infested group, although this finding was not statistically significant ((OR (95% CI)=2.5(0.8 to 7.3)). Conclusions These results suggest that individuals exposed to bed bug infestations are at risk of experiencing sleep disturbance and of developing symptoms of anxiety and possibly depression. Greater clinical awareness of this problem is needed in order for patients to receive appropriate mental healthcare. These findings highlight the need for undertaking of deeper inquiry, as well as greater collaboration between medical professionals, public health and community stakeholders.

Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial

BackgroundChronic diseases represent a major challenge for health care and social services. A number of people with chronic diseases require more services due to characteristics that increase their vulnerability. Given the burden of increasingly vulnerable patients on primary care, a pragmatic intervention in four Family Medicine Groups (primary care practices in Quebec, Canada) has been proposed for individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain) who are frequent users of hospital services. The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program. The goals of this study are to: (1) analyze the implementation of the intervention in the participating practices in order to determine how the various contexts have influenced the implementation and the observed effects; (2) evaluate the proximal (self-efficacy, self-management, health habits, activation and psychological distress) and intermediate (empowerment, quality of life and health care use) effects of the intervention on patients; (3) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention.Methods/DesignThe analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders (Family Medicine Group and health centre management, Family Medicine Group practitioners, patients and their families, health centre or community partners). The data will be obtained through individual and group interviews, project documentation reviews and by documenting the intervention. Evaluation of the effects on patients will be based on a pragmatic randomized before-after experimental design with a delayed intervention control group (six months). Economic analysis will include cost-effectiveness and cost-benefit analysis.DiscussionThe integration of a case management intervention delivered by nurses and self-management group support into primary care practices has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care. Decision-makers, managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practices in the region and elsewhere.Trial RegistrationNCT01719991

Correlates of Depressive and Anxiety Disorders Among Young Canadians

Objective: The current study presents data on the prevalence of depressive and anxiety disorders in the Canadian population aged between 15 and 24 years and examines their potential correlates. Methods: The study is based on the 2002 Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). This survey was administered to a representative sample of 36 984 Canadians. A subsample of 5673 Canadians aged between 15 and 24 years was available for the analyses. We used descriptive analyses to calculate lifetime and 12-month prevalence of depressive and anxiety disorders, and we used logistic regressions to measure odds ratios. Results: Among Canadian youths, 10.2% had suffered from depressive disorders during their lifetime, whereas 12.1% had suffered from anxiety disorders. For 12-month prevalence, the rates were 6.4% and 6.5% for depressive and anxiety disorders, respectively. Depressive disorders were more frequent among youth aged 20 to 24 years and among those no longer in school. Both disorders were more common among women and people under extreme stress. Conclusions: The prevalence rates found are comparable with other studies, and most of the correlates are concordant with the literature. Results indicate that there is a turning point for depression between late adolescence and adulthood that could be crucial for intervention planning.

Healthcare utilization following cognitive-behavioral treatment for panic disorder with agoraphobia.

The aim of this study was to examine the overall changes in healthcare services utilization after providing an empirically supported cognitive‐behavioral treatment for panic disorder with agoraphobia. Data on healthcare utilization were collected for a total of 84 adults meeting DSM‐IV criteria. Participants were completers of a cognitive‐behavioral treatment for panic disorder with agoraphobia. Data on utilization of healthcare services and medication were obtained from semi‐structured interviews from baseline to 1‐year after treatment. Results of the Friedman non‐parametric analysis reveal a significant decrease in overall and mental health‐related costs following treatment. This study shows a significant reduction in healthcare costs following cognitive behavior therapy for panic disorder with agoraphobia. More studies are needed to examine the potential long‐term cost‐offset effect of empirically supported treatments for panic disorder.

Comparative effectiveness and safety of antipsychotic drugs in schizophrenia treatment: a real-world observational study

The objective was to compare, in a real‐world setting, the risk of mental and physical health events associated with different antipsychotic drugs (clozapine, olanzapine, risperidone, quetiapine and first‐generation antipsychotics) in patients with SZ.

Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions

OBJECTIVE This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions. METHOD Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions. RESULTS Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46). CONCLUSIONS Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts.

What is the association between quality of treatment for depression and patient outcomes? A cohort study of adults consulting in primary care

BACKGROUND The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The main objective of this study was to examine the association between receiving at least one minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6- and 12-months. Associations with receiving pharmacotherapy and/or psychotherapy and the role of severity of depression were examined. METHODS This cohort study included 908 adults meeting criteria for previous-year MDE and consulting at one of 65 primary care clinics in Quebec, Canada. Multilevel analyses were performed. RESULTS Results show that (i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; (ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and (iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months. LIMITATIONS Measures are self-reported. Participants were recruited at different stages over the course of their MDE. CONCLUSIONS This study shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions, but that those with more severe depressive symptoms are more likely to receive adequate treatment and improve across time.