Effectiveness of a universal personalized intervention for the prevention of anxiety disorders: Protocol of a randomized controlled trial (the prevANS project).

Background: To date, all preventive anxiety disorders interventions are one-fit-all and none of them are based on individual level and risk profile. The aim of this project is to design, develop and evaluate an online personalized intervention based on a risk algorithm for the universal prevention of anxiety disorders in the general population. Methods: A randomized controlled trial (RCT) with two parallel arms (prevANS vs usual care) and 1-year follow-up including 2000 participants without anxiety disorders from Spain and Portugal will be conducted.The prevANS intervention will be self-guided and can be implemented from the prevANS web or from the participants' Smartphone (through an App). The prevANS intervention will have different intensities depending on the risk level of the population, evaluated from the risk algorithm for anxiety: predictA. Both low and moderate-high risk participants will receive information on their level and profile (risk factors) of anxiety disorders, will have access to stress management tools and psychoeducational information periodically. In addition, participants with a moderate-high risk of anxiety disorders will also have access to cognitive-behavioral training (problem-solving, decision-making, communication skills, and working with thoughts). The control group will not receive any intervention, but they will fill out the same questionnaires as the intervention group.Assessments will be completed at baseline, 6 and 12-month follow-up. The primary outcome is the cumulative incidence of anxiety disorders. Secondary outcomes include depressive and anxiety symptoms, risk probability of anxiety disorders (predictA algorithm) and depression (predictD algorithm), improvement in physical and mental quality of life, and acceptability and satisfaction with the intervention. In addition, cost-effectiveness and cost-utility analyses will also be carried out from two perspectives, societal and health system, and analyses of mediators and moderators will also be performed. Discussion: To the best of our knowledge, prevANS study will be the first to evaluate the effectiveness and cost-effectiveness of a personalized online intervention based on a risk predictive algorithm for the universal prevention of anxiety disorders. Trial registration: ClinicalTrials.gov: NCT05682365.

Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain.

BACKGROUND: The different incidence rates of, and risk factors for, depression in different countries argue for the need to have a specific risk algorithm for each country or a supranational risk algorithm. We aimed to develop and validate a predictD-Spain risk algorithm (PSRA) for the onset of major depression and to compare the performance of the PSRA with the predictD-Europe risk algorithm (PERA) in Spanish primary care. METHOD: A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multi-level logistic regression and inverse probability weighting to build the PSRA. In Spain (4574), Chile (2133) and another five European countries (5184), 11 891 non-depressed adult primary care attendees formed our at-risk population. The main outcome was DSM-IV major depression (CIDI). RESULTS: Six variables were patient characteristics or past events (sex, age, sex×age interaction, education, physical child abuse, and lifetime depression) and six were current status [Short Form 12 (SF-12) physical score, SF-12 mental score, dissatisfaction with unpaid work, number of serious problems in very close persons, dissatisfaction with living together at home, and taking medication for stress, anxiety or depression]. The C-index of the PSRA was 0.82 [95% confidence interval (CI) 0.79-0.84]. The Integrated Discrimination Improvement (IDI) was 0.0558 [standard error (s.e.)=0.0071, Zexp=7.88, p<0.0001] mainly due to the increase in sensitivity. Both the IDI and calibration plots showed that the PSRA functioned better than the PERA in Spain. CONCLUSIONS: The PSRA included new variables and afforded an improved performance over the PERA for predicting the onset of major depression in Spain. However, the PERA is still the best option in other European countries.

Reasons for medication non-initiation: A qualitative exploration of the patients' perspective.

BACKGROUND: Non-initiation occurs when the doctor prescribes a new pharmacological treatment to a patient who does not fill the prescription. Non-initiation prevalence estimates range between 6% and 28% in Primary Care (PC) and it is associated with poorer clinical outcomes, more sick-leave days and higher costs. To date, the reasons for non-initiation have not been explored using a qualitative framework. OBJECTIVE: The aim of the present study was to identify reasons for medication non-initiation among PC patients with distinct treatment profiles (acute, chronic symptomatic and asymptomatic, and mental disorders). METHODS: An exploratory, explanatory qualitative study based on Grounded Theory. We conducted individual semi-structured interviews with 30 PC patients. A constant comparative method of analysis was performed. RESULTS: The results were similar for all therapeutic groups. The decision to initiate treatment is multifactorial. Users make a risk-benefit assessment which is influenced by their beliefs about the pathology and the medication, their emotional reaction, health literacy and cultural factors. The patients' context and relationship with the health system influence decision-making. CONCLUSIONS: The decision to initiate a treatment is strongly influenced by factors that health professionals can discuss with patients. Health professionals should explore patients' beliefs about benefits and risks to help them make informed decisions and promote shared decision-making. General practitioners should ensure that patients understand the benefits and risks of disease and treatment, while explaining alternative treatments, encouraging patients to ask questions and supporting their treatment decisions.

Validity of self reported utilisation of primary health care services in an urban population in Spain.

STUDY OBJECTIVE: To assess the validity and factors related with the validity of self reported numbers of visits to a primary health care centre, in comparison with the recorded number. DESIGN: Cross sectional study. SETTING: The urban area served by the Zaidín-Sur Primary Health Care Centre (Granada, Spain). PARTICIPANTS: Two population samples (236 high users and 420 normal users) who were seen at the centre from 1985 to 1991 were interviewed in 1993. MAIN RESULTS: A net tendency to overreport the actual number of visits was observed. Absolute concordance between self reported and recorded utilisation decreased as time interval lengthened, although this mainly reflected the increase in maximum variability both with time interval length and with the number of recorded visits. Corrected Spearman rho coefficients obtained between the number of self reported and recorded visits ranged from 0.602 for the two weeks before the interview to 0.678 for the year before. Regression slopes of self reported utilisation upon recorded utilisation did not change between periods. In multiple regression analyses the actual number of visits was the main factor associated with both underreporting and overreporting. Older age was also significantly associated with underreporting. Poor health status and high satisfaction with health care were significantly associated with overreporting. CONCLUSIONS: There was a substantial degree of inaccuracy in self reported utilisation, with a net tendency to overreport the number of visits. In relative terms, however, accuracy of self reports did not seem to decrease appreciably as the recall time lengthened. To compare the accuracy of different measures, it is important to take into account the maximum variability of each one. Otherwise, contradictory results may be obtained.

GP frequent attendance in Liverpool and Granada: the impact of depressive symptoms.

BACKGROUND: Frequent attendance in general practice increases workload and affects doctor-patient relationships. It is a complex phenomenon, but patients' psychological problems appear to be important. AIM: To assess whether frequent attendance is more likely to be associated with depressive symptoms than with physical health problems. METHOD: The study was carried out in two general practices: one in Liverpool and one in Granada. Subjects comprised 127 frequent attenders (FAs) plus 175 matched controls, stratified by age and sex. Measures included demographic factors, Beck Depression Inventory (BDI), self-reported health, and current health problems classified by ICHPPC-2 criteria. RESULTS: Seventy-five (59%) FAs had a BDI score > or = 13, compared with 9 (5%) controls (odds ratio [OR] = 26.6, 95% confidence interval [CI] = 12.4 to 56.8, P < 0.001). A total of 136 (78%) controls reported their health to be good or excellent, compared with 40 (31%) FAs (OR = 7.6, 95% CI = 4.5 to 12.7, P < 0.001). Respiratory problems were present in 50 (39%) FAs and 47 (27%) controls (chi 2 = 6.992, P < 0.03). Depression rates were similar in Liverpool and Granada, although Liverpool subjects were less likely to report good health. On logistic regression, BDI status was the major predictor of frequent attendance (OR = 17.18, 95% CI = 7.54 to 39.01). Self-reported ill health (OR = 2.67, 95% CI = 1.40 to 5.10) and respiratory problems (OR = 2.20, 95% CI = 1.11 to 4.37) were also associated with frequent attendance. CONCLUSION: Depressive symptoms were the major predictor of frequent attendance in this study. Clinical and research activity should therefore concentrate on the identification and management of psychological problems among FAs in general practice.

The risk for depression conferred by stressful life events is modified by variation at the serotonin transporter 5HTTLPR genotype: evidence from the Spanish PREDICT-Gene cohort.

We report results from the PREDICT-Gene case-control study nested in a prospective cohort designed to identify predictors of the onset of depression among adult primary-care attendees. We tested the potential gene-by-environment interaction between 5HTTLPR genotype at the serotonin transporter gene and previous exposure to threatening life events (TLEs) in depression. A total of 737 consecutively recruited participants were genotyped. Additional information was gathered on exposure to TLEs over a 6-month period, socio-demographic data and family history of psychological problems among first-degree relatives. Diagnoses of depression were ascertained using the Composite International Diagnostic Interview (CIDI) by trained interviewers. Two different depressive outcomes were used (ICD-10 depressive episode and ICD-10 severe depressive episode). Both the s/s genotype and exposure to increasing number of TLEs were significantly associated with depression. Moreover, the 5HTTLPR s/s genotype significantly modified the risk conferred by TLEs for both depressive outcomes. Thus, s/s homozygous participants required minimal exposure to TLE (1 TLE) to acquire a level of risk for depression that was only found among l/s or l/l individuals after significantly higher exposure to TLEs (two or more TLEs). The interaction was more apparent when applied to the diagnosis of ICD-10 severe depressive episode and after adjusting for gender, age and family history of psychological problems. Likelihood ratios tests for the interaction were statistically significant for both depressive outcomes (ICD-10 depressive episode: LR X(2)=4.7, P=0.09 (crude), LR-X(2)=6.4, P=0.04 (adjusted); ICD-10 severe depressive episode: LR X(2)=6.9, P=0.032 (crude), LR-X(2)=8.1, P=0.017 (adjusted)).

Psychosocial and health belief variables associated with frequent attendance in primary care.

BACKGROUND: The reasons for high use of primary care, and in particular the role of psychosocial factors, remain unclear. METHODS: We identified and interviewed 236 frequent attenders and 420 normal users, matched by age and sex, of a public Health Centre in Granada, Spain. Users were questioned about mental health (GHQ-28), social support (Duke-UNC-11), family dysfunction (family APGAR) and health beliefs (health belief model, locus of health control and medical care expectations). We also measured a set of individual, social and illness variables. RESULTS: Multiple logistic regression analyses showed that mental health was the main factor associated with frequent attender status (odds ratio = 3.1; 2.4-3.9). The association was stronger than that between frequent attender status and perceived illness, and between the former and reported chronic illness. Family dysfunction and perceived susceptibility to and severity of disease were also significantly but more weakly associated with frequent attender status. Affective support was more strongly associated with FA status than was confidant support, but both associations disappeared when mental health and family function were controlled for. CONCLUSIONS: Our findings document the association of psychosocial factors and primary health care use. We suggest that the effective management of mental health problems from a family-based approach may reduce primary health care high use.

[Comparative study of the quality of prenatal care at health centers and hospitals]. / Estudio comparativo de la calidad de la atención prenatal entre centros de salud y hospital.

The quality of prenatal care offered in health centers (HC) and in the hospital (H) have been compared. Two samples were evaluated. One consisted of 476 pregnant women seen in HC and another of 213 who were seen in H. Five out of the 22 selected markers did not show differences in both levels (date of delivery; weight gain in g/week; measurement of uterine weight and height; and hypertension detection). Ten markers were better fulfilled in H than in HC (obstetrical formula; gynecological examination, fetal heart beats and edema examination; detection of diabetes, urinary tract infection and anemia). By contrast, there were seven markers that were better fulfilled in HC (serological tests for syphilis and hepatitis B; treatment of urinary tract infection and anemia; and compliance with follow up). The better fulfillment of the markers in H might be due to the recent inclusion of prenatal care programs in HC. The fact that in the first level of care the controls are earlier and more frequent shows that this level facilitates the access of pregnant women to services and their follow up.