Perceived barriers, facilitators and usefulness of a psychoeducational intervention for individuals with chronic musculoskeletal pain and depression in primary care.

Background and aims: Self-management interventions have the potential to improve patient' pain condition as they involve tasks aimed at managing symptoms and reducing interference with activities, mood and relationships due to pain. However, research on factors that facilitate or hinder pain self-management has overlooked patients with both chronic musculoskeletal pain and depression in primary care settings, also leaving unattended patient views on the usefulness of such programs. Thus, the main aim of this study was to gather meaningful information to help promoting adequate self-management. Specifically, it attempts to identify patients' perceptions of barriers and facilitators of group-based psychoeducational intervention and to explore its perceived usefulness in promoting self-management. Method: This qualitative study explored perceived barriers and facilitators of a psychoeducational intervention for the management of chronic musculoskeletal pain and depression previously tested in a Randomized Control Trial. We conducted focus groups and individual interviews with fifteen adult patients with both chronic musculoskeletal pain and depression recruited from primary care centres in Tarragona province (Catalonia, Spain). A content thematic analysis was carried out to examine the data. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Results: Findings revealed that perceived barriers included lack of motivation, time constraints, pain, depression, ineffectiveness of pain-relief strategies and activity avoidance. Facilitators were having a supportive family/friends, the positive effects of self-management, high motivation, being a proactive patient. Peer support and identification, the positive effect of sessions, and free expression were highlighted as key elements of the psychoeducational intervention. Conclusion: The psychoeducational intervention was perceived as useful in promoting self-management practices. Barriers and facilitators in using self-management strategies were related, mainly, to internal personal characteristics of the patients being similar among different cultural backgrounds and distinct chronic conditions. Implications: These findings can help to guide clinicians in the development and implementation of more effective pain self-management interventions for patients with chronic pain and depression by attending to their needs and preferences.

Effectiveness of a collaborative care intervention for managing major depression and chronic musculoskeletal pain in primary care: A cluster-randomised controlled trial.

BACKGROUND: Depression and chronic musculoskeletal pain commonly occur as comorbid conditions, which increases their negative effects on health outcomes. The objective of this study was to assess the effectiveness of the DROP (DepRessiOn and Pain) programme designed for the management of major depression and chronic musculoskeletal pain in primary care. METHODS: A cluster-randomised controlled trial was carried out between June 2015 and December 2017 with 328 patients with major depression and chronic musculoskeletal pain, randomly allocated to either intervention arm or usual care arm. The intervention included care management, optimised management of depression, and a psychoeducational programme. Outcomes were monitored using blinded interviews over a 12-month period. TRIAL REGISTRATION: NCT02605278 (ClinicalTrials.gov). RESULTS: After 12 months, 274 patients were evaluated (83.5% participation). The severity of depression (Hopkins Symptom Checklist score) was 0.23 points lower in the intervention arm [1.11 vs. 1.34; CI95% = -0.42 to -0.04]. Intervention arm's response rate to antidepressant treatment was 18.9% higher [39.6% vs. 20.7%; OR = 2.74; CI95% = 1.12-6.67] and its remission rate for depression was 9.0% higher [20.1% vs. 11.1%; OR = 2.13; CI95% = 0.94-4.85] compared to the usual care arm. There were no significant differences between the two arms in terms of pain severity (Brief Pain Inventory severity score) [6.23 vs. 6.66; difference = -0.39; CI95% = -1.13-0.35] or pain response rate [18.7% vs. 18.5%; OR = 1.02; CI95% = 0.46-2.26]. LIMITATIONS: This is a pragmatic study, and poor adherence to the programme by patients and physicians was a main limitation. CONCLUSION: The programme improves clinical outcomes for depression, although no clinical benefits were seen for pain.

Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI·i project).

BACKGROUND: Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice. METHODS: Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care. DESIGN: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system. PARTICIPANTS: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia). INTERVENTION: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework. MEASURES: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact. DISCUSSION: This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03285659 ; Registered 12th September, 2017.

Evaluation of a multicomponent programme for the management of musculoskeletal pain and depression in primary care: a cluster-randomised clinical trial (the DROP study).

BACKGROUND: Chronic musculoskeletal pain and depression are very common in primary care patients. Furthermore, they often appear as comorbid conditions, resulting in additive effect on adverse health outcomes. On the basis of previous studies, we hypothesise that depression and chronic musculoskeletal pain may benefit from an integrated management programme at primary care level. We expect positive effects on both physical and psychological distress of patients. OBJECTIVE: To determine whether a new programme for an integrated approach to chronic musculoskeletal pain and depression leads to better outcomes than usual care. DESIGN: Cluster-randomised controlled trial involving two arms: a) control arm (usual care); and b) intervention arm, where patients participate in a programme for an integrated approach to the pain-depression dyad. SETTINGS: Primary care centres in the province of Tarragona, Catalonia, Spain, Participants: We will recruit 330 patients aged 18-80 with moderate or severe musculoskeletal pain (Brief Pain Inventory, average pain subscale ≥5) for at least 3 months, and with criteria for major depression (DSM-IV). INTERVENTION: A multicomponent programme according to the chronic care model. The main components are care management, optimised antidepressant treatment, and a psychoeducational group action. Blind measurements: The patients will be monitored through blind telephone interviews held at 0, 3, 6 and 12 months. OUTCOMES: Severity of pain and depressive symptoms, pain and depression treatment response rates, and depression remission rates. ANALYSIS: The outcomes will be analysed on an intent-to-treat basis and the analysis units will be the individual patients. This analysis will consider the effect of the study design on any potential lack of independence between observations made within the same cluster. ETHICS: The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAP), Barcelona, (P14/142). DISCUSSION: This project strengthens and improves treatment approaches for a major comorbidity in primary care. The design of the intervention takes into account its applicability under typical primary care conditions, so that if the programme is found to be effective it will be feasible to apply it in a generalised manner. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02605278 ; Registered 28 September, 2015.

Persistence in the long term of the effects of a collaborative care programme for depression in primary care.

BACKGROUND: A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring. METHODS: Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life. TRIAL REGISTRATION: ISRCTN16384353. RESULTS: A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance. LIMITATIONS: The number of patients lost (31%) before follow-up may have introduced a bias. CONCLUSIONS: Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables.

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.

[Screening for attention deficit hyperactivity disorder in adult patients in primary care]. / Cribado para el trastorno por deficit de atencion/hiperactividad en pacientes adultos de atencion primaria.

AIMS. To estimate the proportion of adult patients in primary care with a positive screening test for attention deficit hyper-activity disorder (ADHD) and to analyse their characteristics. PATIENTS AND METHODS. A cross-sectional descriptive study was performed in nine primary care clinics in the province of Tarragona. The sample consisted of 432 consecutive patients in primary care who visited for any reason, with ages ranging from 18 to 55 years. Screening for ADHD was carried out by means of the Adult ADHD Self-Report Scale (ASRS). Data about functional impact (Sheehan Disability Inventory) were obtained and a review of the patient records provided data concerning psychiatric comorbidity and the consumption of psychopharmaceuticals. RESULTS. The percentage of positive results in the screening tests was 19.9% (95% CI = 16.4-23.9%). Taking into account the sensitivity and specificity of the ASRS, the 'real' prevalence was estimated to be 12.5% (95% CI = 8.2-16.8%). None of these patients were diagnosed or treated for ADHD. Positive screening tests are associated with occupational, social and familial dysfunction, and greater perceived stress. There is also a higher level of comorbidity with affective disorders and substance abuse, as well as greater use of psychopharmaceuticals. CONCLUSIONS. Screening for ADHD in adult patients in primary care gives rise to a notably high proportion of positive screening test results, which suggests that there could be a significant prevalence of patients with ADHD. These data contrast with the absence of this diagnosis in the patient records. Further research is needed to determine the usefulness of the diagnosis of ADHD and the possible role that must be played by primary care.

TITLE: Cribado para el trastorno por deficit de atencion/hiperactividad en pacientes adultos de atencion primaria.Objetivo. Estimar la proporcion de pacientes adultos de atencion primaria con cribado positivo para el trastorno por deficit de atencion/hiperactividad (TDAH) y estudiar sus caracteristicas. Pacientes y metodos. Estudio descriptivo transversal realizado en nueve consultas de atencion primaria de la provincia de Tarragona. La muestra estuvo formada por 432 pacientes consecutivos de atencion primaria visitados por cualquier motivo, con edades entre 18 y 55 anos. El cribado para TDAH se realizo mediante la Adult ADHD Self-Report Scale (ASRS). Se obtuvieron datos sobre impacto funcional (Sheehan Disability Inventory) y, mediante revision de historias clinicas, datos sobre comorbilidad psiquiatrica y consumo de psicofarmacos. Resultados. Se obtuvo una proporcion de cribados positivos del 19,9% (IC 95% = 16,4-23,9%). Considerando la sensibilidad y especificidad de la ASRS, la estimacion de la prevalencia 'real' fue del 12,5% (IC 95% = 8,2-16,8%). Ninguno de estos pacientes estaba diagnosticado o tratado por TDAH. El cribado positivo se asocia a disfuncion laboral, social y familiar, y a mayor estres percibido. Tambien hay mayor comorbilidad con trastornos afectivos y consumo de sustancias, asi como un uso mas elevado de psicofarmacos. Conclusiones. El cribado del TDAH en pacientes adultos de atencion primaria da lugar a una llamativa elevada proporcion de cribados positivos, lo que indica que puede haber una prevalencia relevante de pacientes con TDAH. Estos datos contrastan con la nula presencia de este diagnostico en las historias clinicas. Es necesario profundizar en la investigacion para determinar la utilidad del diagnostico de TDAH y el eventual papel que debe asumir la atencion primaria.

Cribado para el trastorno por déficit de atención/hiperactividad en pacientes adultos de atención primaria / Screening for attention deficit hyperactivity disorder in adult patients in primary care

Objetivo: Estimar la proporción de pacientes adultos de atención primaria con cribado positivo para el trastorno por déficit de atención/hiperactividad (TDAH) y estudiar sus características. Pacientes y métodos: Estudio descriptivo transversal realizado en nueve consultas de atención primaria de la provincia de Tarragona. La muestra estuvo formada por 432 pacientes consecutivos de atención primaria visitados por cualquier motivo, con edades entre 18 y 55 años. El cribado para TDAH se realizó mediante la Adult ADHD Self-Report Scale (ASRS). Se obtuvieron datos sobre impacto funcional (Sheehan Disability Inventory) y, mediante revisión de historias clínicas, datos sobre comorbilidad psiquiátrica y consumo de psicofármacos. Resultados: Se obtuvo una proporción de cribados positivos del 19,9% (IC 95% = 16,4-23,9%). Considerando la sensibilidad y especificidad de la ASRS, la estimación de la prevalencia "real" fue del 12,5% (IC 95% = 8,2-16,8%). Ninguno de estos pacientes estaba diagnosticado o tratado por TDAH. cribado positivo se asocia a disfunción laboral, social y familiar, y a mayor estrés percibido. También hay mayor comorbilidad con trastornos afectivos y consumo de sustancias, así como un uso más elevado de psicofármacos. Conclusiones: El cribado del TDAH en pacientes adultos de atención primaria da lugar a una llamativa elevada proporción de cribados positivos, lo que indica que puede haber una prevalencia relevante de pacientes con TDAH. Estos datos contrastan con la nula presencia de este diagnóstico en las historias clínicas. Es necesario profundizar en la investigación paradeterminar la utilidad del diagnóstico de TDAH y el eventual papel que debe asumir la atención primaria (AU)

Aims: To estimate the proportion of adult patients in primary care with a positive screening test for attention deficit hyperactivity disorder (ADHD) and to analyse their characteristics. Patients and methods: A cross-sectional descriptive study was performed in nine primary care clinics in the province of Tarragona. The sample consisted of 432 consecutive patients in primary care who visited for any reason, with ages ranging from 18 to 55 years. Screening for ADHD was carried out by means of the Adult ADHD Self-Report Scale (ASRS). Data about functional impact (Sheehan Disability Inventory) were obtained and a review of the patient records provided data concerning psychiatric comorbidity and the consumption of psychopharmaceuticals. Results: The percentage of positive results in the screening tests was 19.9% (95% CI = 16.4-23.9%). Taking into account the sensitivity and specificity of the ASRS, the "real" prevalence was estimated to be 12.5% (95% CI = 8.2-16.8%). None of these patients were diagnosed or tre ed for ADHD. Positive screening tests are associated with occupational, social and familial dysfunction, and greater perceived stress. There is also a higher level of comorbidity with affective disorders and substance abuse, as well as greater use of psychopharmaceuticals. Conclusions: Screening for ADHD in adult patients in primary care gives rise to a notably high proportion of positive screening test results, which suggests that there could be a significant prevalence of patients with ADHD. These data contrast with the absence of this diagnosis in the patient records. Further research is needed to determine the usefulness of the diagnosis of ADHD and the possible role that must be played by primary care (AU)

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.

Actitudes y opiniones de los médicos de familia frente a la depresión: una aproximación con el Depression Attitudes Questionnaire (DAQ) / Attitudes and opinions of family doctors on depression: application of the Depression Attitudes Questionnaire (DAQ)

ObjetivoDescribir las actitudes de los médicos de Atención Primaria hacia la depresión.DiseñoEstudio transversal basado en la aplicación de un cuestionario estandarizado.Emplazamiento y participantes112 médicos de Atención Primaria de los 20 Centros de Salud de la Dirección de Atención Primaria Tarragona-Reus (Institut Català de la Salut).MedicionesSe usó una adaptación española del Depression Attitudes Questionnaire.ResultadosEl 88,4% está de acuerdo en que hay un aumento en la presencia de pacientes depresivos en los últimos años. Aproximadamente la mitad de los médicos opinan que la depresión en Atención Primaria a menudo se debe a adversidades de la vida, pero el 72,3% reconoce el carácter biológico en los casos de depresión severa. El 81,2% cree que los antidepresivos usados en Atención Primaria son eficaces y la mayoría valora la psicoterapia como una opción terapéutica útil. Existe acuerdo en el papel de la enfermería en la atención al paciente deprimido y se reconoce el papel de la derivación al psiquiatra cuando no se obtiene un resultado satisfactorio en Atención Primaria. El 64,3% de los médicos consideran que el manejo de los pacientes deprimidos es duro, aunque el 57,1% se sienten cómodos y solamente el 19,7% consideran que esta dedicación no es gratificante.ConclusionesSe halla, en general, una favorable predisposición hacia el manejo de la depresión en Atención Primaria donde pueden establecerse y fructificar iniciativas formativas y organizativas para mejorar los resultados de la depresión(AU)

AimTo describe the attitudes of General Practitioners (GPs) towards depression in Primary Health Care Centres.DesignCross-sectional study based on the application of a standard questionnaire.Setting and participantsA total of 112 GPs from all of the 20 Primary Health Care Centres in the Tarragona-Reus Primary Care Area (Catalan Health Institute).MeasurementsA Spanish adaptation of Depression Attitudes Questionnaire was used.ResultsA 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.ConclusionsIn 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(AU)

[Attitudes and opinions of family doctors on depression: application of the Depression Attitudes Questionnaire (DAQ)]. / 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.

[Prevalence in adults of attention deficit hyperactivity disorder using the medical records of primary care]. / Prevalencia del déficit de atención e hiperactividad en personas adultas según el registro de las historias clínicas informatizadas de atención primaria.

BACKGROUND: ADHD in adults is not uncommon and, according to recent epidemiological data, has a population prevalence of 3-4%. However, there is major unawareness of this disorder among doctors, particularly in primary care. The aim of this study is to determine the prevalence of the diagnosis of ADHD recorded in adults and the proportion of patients with drug prescriptions for this disorder in primary care. METHODS: This is a cross-sectional study on databases of computerised primary care medical records. The target population is adults (18-44 years) assigned to primary care centres of the Catalan Health Institute (n = 2,452,107). We obtained the proportion of patients with ADHD (F90/ICD- 10 code) registered as active problem, and the proportion of patients with a specific prescription for ADHD in adults: methylphenidate, methylphenidate extended release or atomoxetine. RESULTS: The prevalence of recorded ADHD is 0.04% (0.07% in men, 0.02% in women). The percentage of patients with a specific prescription for ADHD is 0.07% (0.08% in men, 0.05% in women). 32.05% of ADHD patients had specific prescription. CONCLUSION: The diagnosis of ADHD in adults and specific treatment are extremely low in primary care. These results contrast with population data: registered ADHD is 1/85 of the population prevalence.

Prevalencia del déficit de atención e hiperactividad en personas adultas según el registro de las historias clínicas informatizadas de atención primaria / Prevalence in adults of attention deficit hyperactivity disorder using the medical records of primary care

Fundamento:El TDAH en adultos no es infrecuente y, según datos epidemiológicos recientes, tiene una prevalencia poblacional del 3-4%. Sin embargo, existe un gran desconocimiento sobre este trastorno entre los médicos, particularmente en atención primaria. El objetivo de este trabajo es determinar la prevalencia del diagnóstico registrado de TDAH en adultos y la proporción de pacientes con prescripción farmacológica para este trastorno en atención primaria. Métodos:Se trata de un estudio transversal sobre las bases de datos de las historias clínicas electrónicas de atención primaria. La población diana son los adultos (18-44 años) adscritos a centros de salud del Instituto Catalán de la Salud (n=2.452.107). Hemos obtenido la proporción de pacientes con diagnóstico de TDAH (código F90/CIE-10) en la lista de problemas activos, y la proporción de pacientes con prescripción activa de un fármaco específico para el TDAH en adultos: metilfenidato, metilfenidato de liberación prolongada o atomoxetina. Resultados:La prevalencia de TDAH registrado es del 0,04% (0,07% en hombres; 0,02% en mujeres). Los pacientes con prescripción para TDAH son el 0,07% (0,08% en hombres; 0,05% en mujeres). El 32,05% de los TDAH tenían prescripción específica. Conclusión:El diagnóstico en adultos de TDAH y el tratamiento específico son extremadamente bajos en atención primaria. Estos resultados contrastan con los datos poblacionales: el TDAH registrado es 1/85 de la prevalencia poblacional(AU)

Background:ADHD in adults is not uncommon and, according to recent epidemiological data, has a population prevalence of 3-4%. However, there is major unawareness of this disorder among doctors, particularly in primary care. The aim of this study is to determine the prevalence of the diagnosis of ADHD recorded in adults and the proportion of patients with drug prescriptions for this disorder in primary care. Methods:This is a cross-sectional study on databases of computerised primary care medical records. The target population is adults (18-44 years) assigned to primary care centres of the Catalan Health Institute (n = 2,452,107). We obtained the proportion of patients with ADHD (F90/ICD-10 code) registered as active problem, and the proportion of patients with a specific prescription for ADHD in adults: methylphenidate, methylphenidate extended release or atomoxetine. Results:The prevalence of recorded ADHD is 0.04% (0.07% in men, 0.02% in women). The percentage of patients with a specific prescription for ADHD is 0.07% (0.08% in men, 0.05% in women). 32.05% of ADHD patients had specific prescription. Conclusion:The diagnosis of ADHD in adults and specific treatment are extremely low in primary care. These results contrast with population data: registered ADHD is 1/85 of the population prevalence(AU)

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.

Assessment of an enhanced program for depression management in primary care: a cluster randomized controlled trial. The INDI project (Interventions for Depression Improvement).

BACKGROUND: Most 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. DESIGN: 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. DISCUSSION: The 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 REGISTRATION: ISRCTN16384353.