Disentangling the value equation: a step forward in value-based healthcare.

BACKGROUND: The value equation of value-based healthcare (VBHC) as a single figure remains ambiguous, closer to a theoretical framework than a useful tool for decision making. The challenge lies in the way patient-centred outcomes (PCOs) might be combined to produce a single value of the numerator. This paper aims to estimate the weights of PCOs to provide a single figure in the numerator, which ultimately will allow a VBHC figure to be reached. METHODS: A cohort of patients diagnosed with breast cancer (n = 690) with a 6-month follow-up recruited in 2019-20 across six European hospitals was used. Patient-reported outcomes (PROs), clinical-related outcomes (CROs), and clinical and socio-demographic variables were collected. The numerator was defined as a composite indicator of the PCOs (CI-PCO), and regression analysis was applied to estimate their weights and consequently arrive at a single figure. RESULTS: Pain showed as the highest weight followed by physical functioning, emotional functioning, and ability to work, and then by a symptom, either arm or breast. PCOs weights were robust to sensitivity analysis. The CI-PCO value was found to be more informative than the health-related quality of life (HRQoL) value. CONCLUSIONS: To the best of our knowledge, this is the first research to combine the PCOs proposed by ICHOM to provide a single figure in the numerator of the value equation. This figure shows a step forward in VBHC to reach a holistic benchmarking across healthcare centres and a value-based payment. This research might also be applied in other medical conditions as a methodological pathway.

European value-based healthcare benchmarking: moving from theory to practice.

BACKGROUND: Value-based healthcare (VBHC) is a conceptual framework to improve the value of healthcare by health, care-process and economic outcomes. Benchmarking should provide useful information to identify best practices and therefore a good instrument to improve quality across healthcare organizations. This paper aims to provide a proof-of-concept of the feasibility of an international VBHC benchmarking in breast cancer, with the ultimate aim of being used to share best practices with a data-driven approach among healthcare organizations from different health systems. METHODS: In the VOICE community-a European healthcare centre cluster intending to address VBHC from theory to practice-information on patient-reported, clinical-related, care-process-related and economic-related outcomes were collected. Patient archetypes were identified using clustering techniques and an indicator set following a modified Delphi was defined. Benchmarking was performed using regression models controlling for patient archetypes and socio-demographic characteristics. RESULTS: Six hundred and ninety patients from six healthcare centres were included. A set of 50 health, care-process and economic indicators was distilled for benchmarking. Statistically significant differences across sites have been found in most health outcomes, half of the care-process indicators, and all economic indicators, allowing for identifying the best and worst performers. CONCLUSIONS: To the best of our knowledge, this is the first international experience providing evidence to be used with VBHC benchmarking intention. Differences in indicators across healthcare centres should be used to identify best practices and improve healthcare quality following further research. Applied methods might help to move forward with VBHC benchmarking in other medical conditions.

Mental well-being of the general population: direct and indirect effects of socioeconomic, relational and health factors.

PURPOSE: The aim of this study was to analyse the association between individual mental well-being and social, economic, lifestyle and health factors. METHODS: Cross-sectional study on a representative sample of 13,632 participants (> 15y/o) from the Catalan Health Interview Survey 2013-2016 editions. Mental well-being was assessed with the Warwick-Edinburg Mental Well-being Scale (WEMWBS). Linear regressions were fitted to associate well-being and sociodemographic, relational, lifestyle and health variables according to minimally sufficient adjustment sets identified using directed acyclic graphs. Predictors entered the model in blocks of variable types and analysed individually. Direct and total effects were estimated. RESULTS: Health factors significantly contributed to mental well-being variance. Presence of a mental disorder and self-reported health had the largest effect size (eta2 = 13.4% and 16.3%). The higher individual impact from a variable came from social support (ß = - 12.8, SE = 0.48, eta2 = 6.3%). A noticeable effect gradient (eta2 = 4.2%) from low to high mental well-being emerged according to economic difficulties (from ß = 1.59, SE = 0.33 for moderate difficulties to ß = 6.02 SE = 0.55 for no difficulties). Younger age (ß = 5.21, SE = 0.26, eta2 = 3.4%) and being men (ß = 1.32, SE = 0.15, eta2 = 0.6%) were associated with better mental well-being. Direct gender effects were negligible. CONCLUSIONS: This study highlights health and social support as the most associated factors with individual mental well-being over socioeconomic factors. Interventions and policies aimed to these factors for health promotion would improve population mental well-being.

Gender commonalities and differences in risk and protective factors of suicidal thoughts and behaviors: A cross-sectional study of Spanish university students.

AIM: To assess gender differences in the association between risk/protective factors and suicidal thoughts and behaviors (STB); and whether there is any gender-interaction with those factors and STB; among Spanish university students. METHODS: Data from baseline online survey of UNIVERSAL project, a multicenter, observational study of first-year Spanish university students (18-24 years). We assessed STB; lifetime and 12-month negative life-events and family adversities; mental disorders; personal and community factors. Gender-specific regression models and gender-interactions were also analyzed. RESULTS: We included 2,105 students, 55.4% women. Twelve-month prevalence of suicidal ideation (SI) was 10%, plans 5.7%, attempts 0.6%. Statistically significant gender-interactions were found for lifetime anxiety disorder, hopelessness, violence between parents, chronic health conditions and family support. Lifetime mood disorder was a common risk factor of SI for both genders (Females: OR= 5.5; 95%CI 3.3-9.3; Males: OR= 4.4; 95%CI 2.0-9.7). For females, exposure to violence between parents (OR= 3.5; 95%CI 1.7-7.2), anxiety disorder (OR= 2.7; 95%CI 1.6-4.6), and alcohol/substance disorder (OR= 2.1; 95%CI 1.1-4.3); and for males, physical childhood maltreatment (OR= 3.6; 95%CI 1.4-9.2), deceased parents (OR= 4.6; 95%CI 1.2-17.7), and hopelessness (OR= 7.7; 95%CI 2.8-21.2), increased SI risk. Family support (OR= 0.5; 95%CI 0.2-0.9) and peers/others support (OR= 0.4; 95%CI 0.2-0.8) were associated to a lower SI risk only among females. CONCLUSIONS: Only mood disorder was a common risk factor of SI for both genders, whereas important gender-differences were observed regarding the other factors assessed. The protective effect from family and peers/others support was observed only among females. Further research assessing underlying mechanisms and pathways of gender-differences is needed.

Suicidal ideation risk among LGB Spanish university students: The role of childhood and adolescence adversities and mental disorders.

BACKGROUND: Childhood/adolescence adversities and mental disorders are higher among LGB youths. AIMS: To evaluate the role of childhood maltreatment, bullying, and mental disorders on the association between sexual orientation and suicidal ideation (SI); and the role of mental disorders on the association between sexual orientation discrimination and SI. METHODS: Baseline and 12-month follow-up online surveys of Spanish first-year university students (18-24-year-olds). Multivariable logistic regression models assessed the effects of childhood/adolescence adversities and mental disorders in the relationship between sexual orientation, discrimination and SI. RESULTS: A total of 1224 students were included (16.4 % LGBs). Risk factors of lifetime SI were sexual orientation (OR 2.4), any bullying (OR 2.4), any childhood maltreatment (OR 4.0), and any mental disorders (OR 3.8). Final model Area Under the Curve (AUC) 0.78. Among homosexual and bisexual students, discrimination showed increased risk of 12-month SI (OR 2.2), but this effect was no longer statistically significant when any 12-month mental disorder was added (OR 7.8). Final model AUC 0.72. LIMITATIONS: Sample of interest was relatively small. But it was similar to comparable studies and statistical adjustments have been performed. Assessment of mental disorders and SI was not based on clinical assessment. However, validated scales showing good diagnostic agreement with clinical judgement were used. CONCLUSIONS: Childhood/adolescence adversities and mental disorders interact in the association between sexual orientation and SI. Mental disorders may mediate the association between sexual orientation discrimination and SI. Further research using larger samples and causal modelling approach assessing the mediators of SI risk among LGBs is needed.

Factors associated with high and low mental well-being in Spanish university students.

BACKGROUND: Previous studies conducted in various nationally representative samples of the general population show that positive mental health is related to social prosperity. However, specific studies in university populations are scarce. In this study, we set out to explore factors associated with mental well-being (MWB) in a representative sample of first-year university students in Spain. METHODS: MWB was assessed with the short version of the Warwick-Edinburgh Mental Well-Being Scale. Multinomial logistic regressions were performed to explore the association between different blocks of factors, including relational, adversity, stress, lifestyle, spiritual, health, and self-perceived health variables with high and low MWB, controlling for sociodemographic and university-related variables. RESULTS: Data from 2082 students (18.6 ± 1.2 years; 56.6 % females) were analysed. Being male, being born in a foreign country, "high" self-perceived support, and "high" self-perceived mental health increased the odds of high MWB. Growing up in the suburbs, stressful experiences, and anxiety disorders reduced the odds of high MWB. Mood and anxiety disorders increased the odds of low MWB. "Middle" self-perceived support, sleeping ≥8 h per day, and "high" self-perceived mental health reduced the odds of low MWB. LIMITATIONS: The cross-sectional design precludes establishing causal relationships. Data were collected in the 2014-15 academic year using self-reported online surveys. CONCLUSION: The factors associated with high and low MWB do not always mirror each other, so specific plans are needed to successfully address each of the two poles. Interventions and policies targeting these factors for health promotion and disease prevention would improve the MWB of university students.

Premature Death, Suicide, and Nonlethal Intentional Self-Harm After Psychiatric Discharge.

Importance: There is a need for representative research on serious adverse outcomes following discharge from psychiatric hospitalization. Objective: To compare rates of premature death, suicide, and nonlethal intentional self-harm after psychiatric discharge with rates in the general population and investigate associations of these outcomes with relevant variables associated with the index psychiatric hospitalization. Design, Setting, and Participants: This retrospective cohort study included all residents from Catalonia, Spain (7.6 million population), who had psychiatric hospitalizations between January 1, 2014, and December 31, 2018, and were older than 10 years at the index (first) hospitalization. Follow-up was until December 31, 2019. Statistical analysis was performed from December 1, 2022, through April 11, 2024. Exposures: Socioeconomic status, psychiatric diagnoses, duration of index hospitalization, and number of previous psychiatric hospitalizations. Main Outcomes and Measures: Postdischarge premature death (ie, all-cause death before age 70 years) and suicide (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code range X60-X84), identified using mortality data, and postdischarge nonlethal intentional self-harm, identified using electronic health record and self-harm case register data. Standardized mortality ratios (SMRs) compared rates of premature death and suicide between the cohort and the general population. Fully adjusted, multivariable, cause-specific Cox proportional hazards regression models for the 3 outcomes were fitted. Results: A total of 49 108 patients discharged from psychiatric hospitalization were included (25 833 males [52.6%]; mean [SD] age at discharge, 44.2 [18.2] years). During follow-up, 2260 patients (4.6%) died prematurely, 437 (0.9%) died by suicide, and 4752 (9.7%) had an episode of nonlethal intentional self-harm. The overall SMR for premature death was 7.5 (95% CI, 7.2-7.9). For suicide, SMR was 32.9 (95% CI, 29.9-36.0) overall and was especially high among females (47.6 [95% CI, 40.2-54.9]). In fully adjusted sex-stratified hazard models, postdischarge premature death was associated with cognitive disorders (adjusted hazard ratio [AHR], 2.89 [95% CI, 2.24-3.74] for females; 2.59 [95% CI, 2.17-3.08] for males) and alcohol-related disorders (AHR, 1.41 [95% CI, 1.18-1.70] for females; 1.22 [95% CI, 1.09-1.37] for males). Postdischarge suicide was associated with postdischarge intentional self-harm (AHR, 2.83 [95% CI, 1.97-4.05] for females; 3.29 [95% CI, 2.47-4.40] for males), with depressive disorders (AHR, 2.13 [95% CI, 1.52-2.97]) and adjustment disorders (AHR, 1.94 [95% CI, 1.32-2.83]) among males, and with bipolar disorder among females (AHR, 1.94 [95% CI, 1.21-3.09]). Postdischarge intentional self-harm was associated with index admissions for intentional self-harm (AHR, 1.95 [95% CI, 1.73-2.21] for females; 2.62 [95% CI, 2.20-3.13] for males) as well as for adjustment disorders (AHR, 1.48 [95% CI, 1.33-1.65] for females; 1.99 [95% CI, 1.74-2.27] for males), anxiety disorders (AHR, 1.24 [95% CI, 1.10-1.39] for females; 1.36 [95% CI, 1.18-1.58] for males), depressive disorders (AHR, 1.54 [95% CI, 1.40-1.69] for females; 1.80 [95% CI, 1.58-2.04] for males), and personality disorders (AHR, 1.59 [95% CI, 1.46-1.73] for females; 1.43 [95% CI, 1.28-1.60] for males). Conclusions and Relevance: In this cohort study of patients discharged from psychiatric hospitalization, risk for premature death and suicide was significantly higher compared with the general population, suggesting individuals discharged from psychiatric inpatient care are a vulnerable population for premature death and suicidal behavior.

Health service and psychotropic medication use for mental health conditions among healthcare workers active during the Spain Covid-19 Pandemic - A prospective cohort study using web-based surveys.

Little is known about healthcare workers' (HCW) use of healthcare services for mental disorders. This study presents data from a 16-month prospective cohort study of Spanish HCW (n = 4,809), recruited shortly after the COVID-19 pandemic onset, and assessed at four timepoints using web-based surveys. Use of health services among HCW with mental health conditions (i.e., those having a positive screen for mental disorders and/or suicidal thoughts and behaviours [STB]) was initially low (i.e., 18.2 %) but increased to 29.6 % at 16-month follow-up. Service use was positively associated with pre-pandemic mental health treatment (OR=1.99), a positive screen for major depressive disorder (OR=1.50), panic attacks (OR=1.74), suicidal thoughts and behaviours (OR=1.22), and experiencing severe role impairment (OR=1.33), and negatively associated with being female (OR = 0.69) and a higher daily number of work hours (OR=0.95). Around 30 % of HCW with mental health conditions used anxiolytics (benzodiazepines), especially medical doctors. Four out of ten HCW (39.0 %) with mental health conditions indicated a need for (additional) help, with most important barriers for service use being too ashamed, long waiting lists, and professional treatment not being available. Our findings delineate a clear mental health treatment gap among Spanish HCW.

Experience sampling methods for the personalised prediction of mental health problems in Spanish university students: protocol for a survey-based observational study within the PROMES-U project.

INTRODUCTION: There is a high prevalence of mental health problems among university students. Better prediction and treatment access for this population is needed. In recent years, short-term dynamic factors, which can be assessed using experience sampling methods (ESM), have presented promising results for predicting mental health problems. METHODS AND ANALYSIS: Undergraduate students from five public universities in Spain are recruited to participate in two web-based surveys (at baseline and at 12-month follow-up). A subgroup of baseline participants is recruited through quota sampling to participate in a 15-day ESM study. The baseline survey collects information regarding distal risk factors, while the ESM study collects short-term dynamic factors such as affect, company or environment. Risk factors will be identified at an individual and population level using logistic regressions and population attributable risk proportions, respectively. Machine learning techniques will be used to develop predictive models for mental health problems. Dynamic structural equation modelling and multilevel mixed-effects models will be considered to develop a series of explanatory models for the occurrence of mental health problems. ETHICS AND DISSEMINATION: The project complies with national and international regulations, including the Declaration of Helsinki and the Code of Ethics, and has been approved by the IRB Parc de Salut Mar (2020/9198/I) and corresponding IRBs of all participating universities. All respondents are given information regarding access mental health services within their university and region. Individuals with positive responses on suicide items receive a specific alert with indications for consulting with a health professional. Participants are asked to provide informed consent separately for the web-based surveys and for the ESM study. Dissemination of results will include peer-reviewed scientific articles and participation in scientific congresses, reports with recommendations for universities' mental health policy makers, as well as a well-balanced communication strategy to the general public. STUDY REGISTRATION: osf.io/p7csq.

Traumatic stress symptoms among Spanish healthcare workers during the COVID-19 pandemic: a prospective study.

AIM: To investigate the occurrence of traumatic stress symptoms (TSS) among healthcare workers active during the COVID-19 pandemic and to obtain insight as to which pandemic-related stressful experiences are associated with onset and persistence of traumatic stress. METHODS: This is a multicenter prospective cohort study. Spanish healthcare workers (N = 4,809) participated at an initial assessment (i.e., just after the first wave of the Spain COVID-19 pandemic) and at a 4-month follow-up assessment using web-based surveys. Logistic regression investigated associations of 19 pandemic-related stressful experiences across four domains (infection-related, work-related, health-related and financial) with TSS prevalence, incidence and persistence, including simulations of population attributable risk proportions (PARP). RESULTS: Thirty-day TSS prevalence at T1 was 22.1%. Four-month incidence and persistence were 11.6% and 54.2%, respectively. Auxiliary nurses had highest rates of TSS prevalence (35.1%) and incidence (16.1%). All 19 pandemic-related stressful experiences under study were associated with TSS prevalence or incidence, especially experiences from the domains of health-related (PARP range 88.4-95.6%) and work-related stressful experiences (PARP range 76.8-86.5%). Nine stressful experiences were also associated with TSS persistence, of which having patient(s) in care who died from COVID-19 had the strongest association. This association remained significant after adjusting for co-occurring depression and anxiety. CONCLUSIONS: TSSs among Spanish healthcare workers active during the COVID-19 pandemic are common and associated with various pandemic-related stressful experiences. Future research should investigate if these stressful experiences represent truly traumatic experiences and carry risk for the development of post-traumatic stress disorder.

Psychological impact of the COVID-19 pandemic on primary care workers: a cross-sectional study.

BACKGROUND: The COVID-19 pandemic has had a major impact on the mental health of healthcare workers, yet studies in primary care workers are scarce. AIM: To investigate the prevalence of and associated factors for psychological distress in primary care workers during the first COVID-19 outbreak. DESIGN AND SETTING: This was a multicentre, cross-sectional, web-based survey conducted in primary healthcare workers in Spain, between May and September 2020. METHOD: Healthcare workers were invited to complete a survey to evaluate sociodemographic and work-related characteristics, COVID-19 infection status, exposure to patients with COVID-19, and resilience (using the Connor-Davidson Resilience Scale), in addition to being screened for common mental disorders (depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder). Positive screening for any of these disorders was analysed globally using the term 'any current mental disorder'. RESULTS: A total of 2928 primary care professionals participated in the survey. Of them, 43.7% (95% confidence interval [CI] = 41.9 to 45.4) tested positive for a current mental disorder. Female sex (odds ratio [OR] 1.61, 95% CI = 1.25 to 2.06), having previous mental disorders (OR 2.58, 95% CI = 2.15 to 3.10), greater occupational exposure to patients with COVID-19 (OR 2.63, 95% CI = 1.98 to 3.51), having children or dependents (OR 1.35, 95% CI = 1.04 to 1.76 and OR 1.59, 95% CI = 1.20 to 2.11, respectively), or having an administrative job (OR 2.24, 95% CI = 1.66 to 3.03) were associated with a higher risk of any current mental disorder. Personal resilience was shown to be a protective factor. CONCLUSION: Almost half of primary care workers showed significant psychological distress. Strategies to support the mental health of primary care workers are necessary, including designing psychological support and resilience-building interventions based on risk factors identified.

Predictive models for first-onset and persistence of depression and anxiety among university students.

BACKGROUND: Depression and anxiety are both prevalent among university students. They frequently co-occur and share risk factors. Yet few studies have focused on identifying students at highest risk of first-onset and persistence of either of these conditions. METHODS: Multicenter cohort study among Spanish first-year university students. At baseline, students were assessed for lifetime and 12-month Major Depressive Episode and/or Generalized Anxiety Disorder (MDE-GAD), other mental disorders, childhood-adolescent adversities, stressful life events, social support, socio-demographics, and psychological factors using web-based surveys; 12-month MDE-GAD was again assessed at 12-month follow-up. RESULTS: A total of 1253 students participated in both surveys (59.2% of baseline respondents; mean age = 18.7 (SD = 1.3); 56.0% female). First-onset of MDE-GAD at follow-up was 13.3%. Also 46.7% of those with baseline MDE-GAD showed persistence at follow-up. Childhood/Adolescence emotional abuse or neglect (OR= 4.33), prior bipolar spectrum disorder (OR= 4.34), prior suicidal ideation (OR=4.85) and prior lifetime symptoms of MDE (ORs=2.33-3.63) and GAD (ORs=2.15-3.75) were strongest predictors of first-onset MDE-GAD. Prior suicidal ideation (OR=3.17) and prior lifetime GAD symptoms (ORs=2.38-4.02) were strongest predictors of MDE-GAD persistence. Multivariable predictions from baseline showed AUCs of 0.76 for first-onset and 0.81 for persistence. 74.9% of first-onset MDE-GAD cases occurred among 30% students with highest predicted risk at baseline. LIMITATIONS: Self-report data were used; external validation of the multivariable prediction models is needed. CONCLUSION: MDE-GAD among university students is frequent, suggesting the need to implement web-based screening at university entrance that identify those students with highest risk.

Validation of an Online Version of the Alcohol Use Disorders Identification Test (AUDIT) for Alcohol Screening in Spanish University Students.

Online alcohol screening may be helpful in preventing alcohol use disorders. We assessed psychometric properties of an online version of the Alcohol Use Disorders Identification Test (AUDIT) among Spanish university students. We used a longitudinal online survey (the UNIVERSAL project) of first-year students (18-24 years old) in five universities, including the AUDIT, as part of the WHO World Mental Health International College Student (WMH-ICS) initiative. A reappraisal interview was carried out with the Timeline Followback (TLFB) for alcohol consumption categories and the Mini International Neuropsychiatric Interview (MINI) for alcohol use disorder. Reliability, construct validity and diagnostic accuracy were assessed. Results: 287 students (75% women) completed the MINI, of whom 242 also completed the TLFB. AUDIT's Cronbach's alpha was 0.82. The confirmatory factor analysis for the one-factor solution of the AUDIT showed a good fit to the data. Significant AUDIT score differences were observed by TLFB categories and by MINI disorders. Areas under the curve (AUC) were very large for dependence (AUC = 0.96) and adequate for consumption categories (AUC > 0.7). AUDIT cut-off points of 6/8 (women/men) for moderate-risk drinking and 13 for alcohol dependence showed sensitivity/specificity of 76.2%/78.9% and 56%/97.5%, respectively. The online version of the AUDIT is useful for detecting alcohol consumption categories and alcohol dependence in Spanish university students.

Mental health impact of the first wave of COVID-19 pandemic on Spanish healthcare workers: A large cross-sectional survey.

INTRODUCTION: Healthcare workers are vulnerable to adverse mental health impacts of the COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during the first wave of the pandemic among healthcare professionals in Spain. METHODS: All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental health status (May 5 - September 7, 2020). We report: probable current mental disorders (Major Depressive Disorder-MDD- [PHQ-8≥10], Generalized Anxiety Disorder-GAD- [GAD-7≥10], Panic attacks, Posttraumatic Stress Disorder -PTSD- [PCL-5≥7]; and Substance Use Disorder -SUD-[CAGE-AID≥2]. Severe disability assessed by the Sheehan Disability Scale was used to identify probable "disabling" current mental disorders. RESULTS: 9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53-13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18-29 years (OR=1.36; 95%CI:1.02-1.82), caring "all of the time" for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95). CONCLUSIONS: One in seven Spanish healthcare workers screened positive for a disabling mental disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quarantined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support.

Mental health impact of the first wave of COVID-19 pandemic on Spanish healthcare workers: A large cross-sectional survey.

INTRODUCTION: Healthcare workers are vulnerable to adverse mental health impacts of the COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during the first wave of the pandemic among healthcare professionals in Spain. METHODS: All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental health status (May 5 - September 7, 2020). We report: probable current mental disorders (Major Depressive Disorder-MDD- [PHQ-8≥10], Generalized Anxiety Disorder-GAD- [GAD-7≥10], Panic attacks, Posttraumatic Stress Disorder -PTSD- [PCL-5≥7]; and Substance Use Disorder -SUD-[CAGE-AID≥2]. Severe disability assessed by the Sheehan Disability Scale was used to identify probable "disabling" current mental disorders. RESULTS: 9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53-13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18-29 years (OR=1.36; 95%CI:1.02-1.82), caring "all of the time" for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95). CONCLUSIONS: One in seven Spanish healthcare workers screened positive for a disabling mental disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quarantined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support.

Mental disorders in Spanish university students: Prevalence, age-of-onset, severe role impairment and mental health treatment.

BACKGROUND: The university period carries risk for onset of common mental disorders. Epidemiological knowledge on mental disorders among Spanish university students is limited. AIMS: To estimate lifetime and 12-month prevalence, persistence and age-of-onset of mental disorders among Spanish first-year university students, as well as associated role impairment and mental health treatment use. METHODS: First-year university students (N=2,118; 55.4% female; mean age=18.8 years) from five Spanish universities completed a web-based survey, screening possible DSM-IV mental disorders (major depressive episode(MDE), mania/hypomania, generalized anxiety disorder(GAD), panic disorder(PD), alcohol abuse/dependence(AUD), drug abuse/dependence(DUD), and adult attention-deficit/hyperactivity disorder(ADHD)). Role impairment and treatment associated with mental disorders were assessed. RESULTS: Lifetime and 12-month prevalence of any possible mental disorder was 41.3%(SE=1.08) and 35.7%(SE=1.05), respectively. Persistence (i.e., ratio of 12-month to lifetime prevalence) was 86.4%(SE=1.58). Median age-of-onset was 14 for adult ADHD, 15 for mood disorders and AUD, and 16 for anxiety disorders and DUD. One third (29.2%) of 12-month disorders were associated with role impairment. Twelve-month PD (OR=4.0;95%CI=1.9-8.5) had the highest odds for role impairment. Only 12.6% of students with 12-month disorder received any mental health treatment. Twelve-month treatment was the highest among those students with 12-month GAD (OR=7.4;95%CI=3.7-14.8). LIMITATIONS: The assessment of mental disorders was based on self-reports. Cross-sectional nature of the data prevents causal associations. CONCLUSION: One third of Spanish university students report a common mental disorder in the past year, and one third of those report severe role impairment. Only one out of eight students with 12-month mental disorders receives mental health treatment.

Accuracy of online survey assessment of mental disorders and suicidal thoughts and behaviors in Spanish university students. Results of the WHO World Mental Health- International College Student initiative.

OBJECTIVE: To assess the accuracy of WMH-ICS online screening scales for evaluating four common mental disorders (Major Depressive Episode[MDE], Mania/Hypomania[M/H], Panic Disorder[PD], Generalized Anxiety Disorder[GAD]) and suicidal thoughts and behaviors[STB] used in the UNIVERSAL project. METHODS: Clinical diagnostic reappraisal was carried out on a subsample of the UNIVERSAL project, a longitudinal online survey of first year Spanish students (18-24 years old), part of the WHO World Mental Health-International College Student (WMH-ICS) initiative. Lifetime and 12-month prevalence of MDE, M/H, PD, GAD and STB were assessed with the Composite International Diagnostic Interview-Screening Scales [CIDI-SC], the Self-Injurious Thoughts and Behaviors Interview [SITBI] and the Columbia-Suicide Severity Rating Scale [C-SSRS]. Trained clinical psychologists, blinded to responses in the initial survey, administered via telephone the Mini-International Neuropsychiatric Interview [MINI]. Measures of diagnostic accuracy and McNemar χ2 test were calculated. Sensitivity analyses were conducted to maximize diagnostic capacity. RESULTS: A total of 287 students were included in the clinical reappraisal study. For 12-month and lifetime mood disorders, sensitivity/specificity were 67%/88.6% and 65%/73.3%, respectively. For 12-month and lifetime anxiety disorders, these were 76.8%/86.5% and 59.6%/71.1%, and for 12-month and lifetime STB, 75.9%/94.8% and 87.2%/86.3%. For 12-month and lifetime mood disorders, anxiety disorders and STB, positive predictive values were in the range of 18.1-55.1% and negative predictive values 90.2-99.0%; likelihood ratios positive were in the range of 2.1-14.6 and likelihood ratios negative 0.1-0.6. All outcomes showed adequate areas under the curve [AUCs] (AUC>0.7), except M/H and PD (AUC = 0.6). Post hoc analyses to select optimal diagnostic thresholds led to improved concordance for all diagnoses (AUCs>0.8). CONCLUSION: The WMS-ICS survey showed reasonable concordance with the MINI telephone interviews performed by mental health professionals, when utilizing optimized cut-off scores. The current study provides initial evidence that the WMS-ICS survey might be useful for screening purposes.

Suicidal Thoughts and Behaviors: Prevalence and Association with Distal and Proximal Factors in Spanish University Students.

OBJECTIVE: We report on the prevalence of suicidal thoughts and behaviors in Spanish university students and their risk and protective factors (distal/proximal; individual/environmental). METHODS: First-year university students completed an online survey including Self-Injurious Thoughts and Behaviors Interview (SITBI) items, the screening version of the Columbia-Suicide Severity Rating Scale (C-SSRS) along with adversities and positive relationships during childhood/adolescence, recent stressful experiences, and lifetime mental disorders. Nested logistic regression models were estimated and areas under the curve (AUC) compared. RESULTS: A total of 2,118 students completed the survey (mean age = 18.8 [SD = 1.4] years; 55.4% female). Twelve-month prevalence of suicide ideation (SI) was 9.9%, plans, 5.6%, and attempts, 0.6%. Risk factors of 12-month SI were as follows: parental psychopathology (OR = 1.7, 95% CI 1.2-2.5); sexual assault (OR = 5.6, 95% CI 1.4-22.1); lifetime mood disorder (OR = 5.2, 95% CI 3.5-7.7); and lifetime anxiety disorder (OR = 1.7, 95% CI: 1.1-2.5). Childhood positive relationships protected from SI were as follows: peers/others (OR = 0.6, 95% CI 0.4-0.9 for the second highest tertile) and family (OR = 0.4, 95% CI 0.3-0.7 for the highest tertile). AUC of the final model was 0.82 (SE = 0.015). CONCLUSION: Our results indicate a high prevalence of SI among Spanish university students and identify protective and risk factors from a comprehensive conceptual model.

Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies.

OBJECTIVES: To assess the association between gender and suicide attempt/death and identify gender-specific risk/protective factors in adolescents/young adults. METHODS: Systematic review (5 databases until January 2017). Population-based longitudinal studies considering non-clinical populations, aged 12-26 years, assessing associations between gender and suicide attempts/death, or evaluating their gender risk/protective factors, were included. Random effect meta-analyses were performed. RESULTS: Sixty-seven studies were included. Females presented higher risk of suicide attempt (OR 1.96, 95% CI 1.54-2.50), and males for suicide death (HR 2.50, 95% CI 1.8-3.6). Common risk factors of suicidal behaviors for both genders are previous mental or substance abuse disorder and exposure to interpersonal violence. Female-specific risk factors for suicide attempts are eating disorder, posttraumatic stress disorder, bipolar disorder, being victim of dating violence, depressive symptoms, interpersonal problems and previous abortion. Male-specific risk factors for suicide attempt are disruptive behavior/conduct problems, hopelessness, parental separation/divorce, friend's suicidal behavior, and access to means. Male-specific risk factors for suicide death are drug abuse, externalizing disorders, and access to means. For females, no risk factors for suicide death were studied. CONCLUSIONS: More evidence about female-specific risk/protective factors of suicide death, for adolescent/young adults, is needed.

First-onset and persistence of suicidal ideation in university students: A one-year follow-up study.

BACKGROUND: Longitudinal evidence about risk and protective factors for suicidal ideation among university students is limited. METHODS: 12-month first-onset and persistence of suicidal ideation (SI) among Spanish first-year university students were estimated using baseline (T1) and 12-month follow-up (T2) online surveys. Information about STBs, childhood/adolescence adversities, positive relationships, mental disorders, recent stressful experiences, and university sense of membership was assessed. Logistic regression analysis was used to study risk/protective factors of first-onset and persistence of suicidal ideation (SI). RESULTS: A total of 1,248 respondents (58.9% response) were included. Mean age at baseline was 18.7 (SD = 1.3) and 56.0% were female. 7.3% reported 12-month SI at T2. Incidence of new SI cases was 3.4% and, among students with SI at T1, 21.2% also reported SI at T2 (persistence). Risk factors of T2 SI included 12-month mood disorder at T2 both without (aOR = 12.08 95% CI 5.45-26.80) or with (aOR = 7.2 95% CI 2.91-17.80) lifetime mood at T1, past lifetime suicide attempt (aOR = 8.79 95% CI 2.37-32.64) and plan without attempt (aOR = 4.72 95% CI 2.32-9.61), and 12-month physical or sexual assault (aOR = 3.28 95% CI 1.13-9.46). Twelve-month mood at T2 withoutT1 lifetime mood (aOR = 11.27 95% CI 3.02-42.14) and childhood/adolescence emotional abuse or neglect (aOR = 3.41 95% CI 1.10-10.57) or having been bullied (aOR = 3.2 95% CI 1.08-9.53) were associated with first-onset of SI. Twelve-month mood at T2 either without (aOR = 13.92 95% CI 3.76-51.59) or with (aOR = 8.03 95% CI 2.13-30.29) were associated to T2 SI persistence. University sense of membership was protective for overall 12-month SI at T2 (aOR = 0.25 95% CI 0.12-0.53 for middle tertile), first-onset SI (aOR = 0.1 95% 0.02-0.55 for middle tertile) and persistence (aOR = 0.3 95% CI 0.11-0.81 for middle tertile). LIMITATIONS: Analysis was based on self-report data focusing on SI only, and conclusions about the direction of the associations are limited. CONCLUSIONS: High proportion of SI suggests the need of suicide prevention strategies. The potential role of university sense of membership in reducing suicidal behaviour among university students deserves further investigation.