Patients with severe mental illness and their carers' expectations for GPs' communication skills: a qualitative approach in Spain.

BACKGROUND: Effective communication with GPs (General Practitioners) enables higher rates of patient satisfaction and adherence to treatment plans. People with severe mental illness (SMI) and their caregivers present unique characteristics that present difficulties in the GP-carer-patient communication process. AIM: To explore the expectations of patients with SMI and their caregivers regarding GPs' communication skills in primary care consultations. DESIGN & SETTING: Face-to-face interviews, using focus group methodology, which were undertaken in southern Spain. METHOD: Forty-two participants took part in 21 paired semi-structured interviews with an average duration of 19±7.2 minutes. Information was audio-recorded and transcribed verbatim. Qualitative content analysis was undertaken, obtaining a codification in categories by means of triangulation. RESULTS: Four themes emerged from the analysis. Theme 1 was interviewer communication characteristics. The ability of GPs to use a language that was colloquial and adapted to each person was perceived as a determinant of the quality of care provided. An empathetic attitude, low reactivity, and efficient time management were the most valued communication skills. Theme 2 was telemedicine: telephone consultation and video consultation. The telephone consultation was perceived as a useful tool to care for people with SMI. Video consultation was valued as a requirement in isolated rural areas. Theme 3 was the role of the caregiver during the clinical interview. The caregiver was considered by the patients as an ally who improves the clinical interview. Theme 4 was the perceived barriers and facilitators during the clinical interview. The continuity of care, defined by a low turnover of GPs, determined the quality perceived by those who required care. CONCLUSION: Themes emerging from this study have suggested that people with SMI require an inclusive, collaborative, and personalised approach in the care they receive from the public health system. Improved communication between GPs and patients with SMI is an essential requirement for quality medical care.

A personalized intervention to prevent depression in primary care based on risk predictive algorithms and decision support systems: protocol of the e-predictD study.

The predictD is an intervention implemented by general practitioners (GPs) to prevent depression, which reduced the incidence of depression-anxiety and was cost-effective. The e-predictD study aims to design, develop, and evaluate an evolved predictD intervention to prevent the onset of major depression in primary care based on Information and Communication Technologies, predictive risk algorithms, decision support systems (DSSs), and personalized prevention plans (PPPs). A multicenter cluster randomized trial with GPs randomly assigned to the e-predictD intervention + care-as-usual (CAU) group or the active-control + CAU group and 1-year follow-up is being conducted. The required sample size is 720 non-depressed patients (aged 18-55 years), with moderate-to-high depression risk, under the care of 72 GPs in six Spanish cities. The GPs assigned to the e-predictD-intervention group receive brief training, and those assigned to the control group do not. Recruited patients of the GPs allocated to the e-predictD group download the e-predictD app, which incorporates validated risk algorithms to predict depression, monitoring systems, and DSSs. Integrating all inputs, the DSS automatically proposes to the patients a PPP for depression based on eight intervention modules: physical exercise, social relationships, improving sleep, problem-solving, communication skills, decision-making, assertiveness, and working with thoughts. This PPP is discussed in a 15-min semi-structured GP-patient interview. Patients then choose one or more of the intervention modules proposed by the DSS to be self-implemented over the next 3 months. This process will be reformulated at 3, 6, and 9 months but without the GP-patient interview. Recruited patients of the GPs allocated to the control-group+CAU download another version of the e-predictD app, but the only intervention that they receive via the app is weekly brief psychoeducational messages (active-control group). The primary outcome is the cumulative incidence of major depression measured by the Composite International Diagnostic Interview at 6 and 12 months. Other outcomes include depressive symptoms (PHQ-9) and anxiety symptoms (GAD-7), depression risk (predictD risk algorithm), mental and physical quality of life (SF-12), and acceptability and satisfaction ('e-Health Impact' questionnaire) with the intervention. Patients are evaluated at baseline and 3, 6, 9, and 12 months. An economic evaluation will also be performed (cost-effectiveness and cost-utility analysis) from two perspectives, societal and health systems. Trial registration: ClinicalTrials.gov, identifier: NCT03990792.

Qualitative study on the use of emergency services by people with serious mental disorder in Spain.

BACKGROUND: The population with severe mental disorders (SMD) is a frequent user of emergency services. Situations of psychiatric decompensation can have devastating consequence and can cause problems in getting urgent medical care. The objective was to study the experiences and needs of these patients and their caregivers regarding the demand for emergency care in Spain. METHODS: Qualitative methodology involving patients with SMD and their informal caregivers. Purposive sampling by key informants in urban and rural areas. Paired interviews were carried out until data saturation. A discourse analysis was conducted, obtaining a codification in categories by means of triangulation. RESULTS: Forty-two participants in twenty-one paired interviews (19 ± 7.2 min as mean duration). Three categories were identified. 1º Reasons for urgent care: poor self-care and lack of social support, as well as difficulties in accessibility and continuity of care in other healthcare settings. 2º Urgent care provision: trust in the healthcare professional and the information patients receive from the healthcare system is crucial, telephone assistance can be a very useful resource. 3º Satisfaction with the urgent care received: they request priority care without delays and in areas separated from the other patients, as well as the genuine interest of the professional who attends them. CONCLUSIONS: The request for urgent care in patients with SMD depends on different psychosocial determinants and not only on the severity of the symptoms. There is a demand for care that is differentiated from the other patients in the emergency department. The increase in social networks and alternative systems of care would avoid overuse of the emergency departments.

Influencia del acompañante en las consultas de Atención Primaria sobre las habilidades en comunicación y el tiempo de entrevista / Influence of the companion in Primary Care consultations on communication skills and interview time

Objetivos: Valorar la influencia del acompañante en consulta sobre la calidad de la comunicación médico-paciente y la duración de la consulta. Diseño: Descriptivo transversal. Emplazamiento: Diez centros de salud. Participantes: Médicos residentes de Medicina Familiar y Comunitaria. Intervenciones: Auditoría por pares de videograbaciones de consultas a demanda. Mediciones principales: Habilidades en comunicación utilizando el cuestionario CICAA-2 (mejorable, aceptable o adecuada); edad (MIR), sexo (MIR, paciente y acompañante), motivos de consulta y duración de la entrevista. Análisis bivariante y multivariante. Autorización del CEI, consentimiento informado oral y custodia de las videograbaciones. Resultados: Participaron 73 MIR (53,8% mujeres, 32,9±7,7 años) valorando 260 entrevistas (60,3% mujeres, 2,1±1,0 motivos de consulta). Un 27,7% de consultas con acompañante (sexo femenino 65,3%). La duración media de las entrevistas fue de 8,5±4,0 minutos, superior 2,7±0,5 minutos en consultas con acompañante (p<0,001 t de Student) y con mayor número de motivos de consulta (40% con ≥ 3 motivos, p=0,048 X2). El valor medio de la puntuación total de la escala CICAA-2 (46,9±16,5) fue superior en las consultas con acompañante (diferencia 4,6±2,3), al igual que la tarea 2 (39,3±15,8 con diferencia 4,4±2,2) (p<0,05 t de Student). El modelo obtenido con regresión logística binaria muestra una mayor duración de la consulta con acompañante (OR 1,2; IC [1,1-1,3]) y posiblemente mejor puntuación en la tarea 2 (OR 1,02; IC [0,99-1,1]). Conclusiones: Las comunicaciones triádicas suponen un desafío para las habilidades de comunicación del médico, que mejora sus capacidades para identificar y comprender los problemas del paciente, aunque a costa de una mayor inversión de tiempo.(AU)

Objetives: To know the influence of the companion in triadic clinical encounter on the quality of doctor–patient communication and the duration of the interview. Design: Cross-sectional descriptive study. Location: 10 Primary Care Centers. Participants: Resident doctors of Family and Community Medicine. Interventions: Peer review of video recordings of clinical demand consultations. Main measurements: CICAA-2 questionnaire to assess communication skills (improvable, acceptable or adequate); age and sex, reasons for consultation and duration of the interview. Bivariate and multivariate analyses. Ethical authorization, oral informed consent and custody of the video recordings. Results: 73 RD (53.8% women, 32.9±7.7 years) participated with 260 interviews (60.3% women and 2.1±1.0 clinical demands). 27.7% of consultations with a companion (female sex 65.3%). The mean duration of the interviews was 8.5±4.0min. Clinical encounters lasted longer when a companion attended (2.7±0.5min more; p<.001 Student t) and with a greater number of clinical demands (40% with ≥3 reasons, p=0.048 X2). The mean value of the total score of the CICAA-2 scale (46.9±16.5; difference 4.6±2.3) and Task 2 (39.3±15.8 with difference 4.4±2.2) were higher when companion was present (p<.05 Student t). The model obtained with logistic regression shows a longer duration of the consultation with a companion (OR 1.2; CI [1.1–1.3]) and possibly a better score in Task 2 communication skills (OR 1.02; CI [0.99–1.1]). Conclusions: Triadic communications challenge the clinician's communication skills, improving their abilities to identify and understand patient problems, albeit at the cost of a greater investment of time.(AU)

[Influence of the companion in Primary Care consultations on communication skills and interview time]. / Influencia del acompañante en las consultas de Atención Primaria sobre las habilidades en comunicación y el tiempo de entrevista.

OBJETIVES: To know the influence of the companion in triadic clinical encounter on the quality of doctor-patient communication and the duration of the interview. DESIGN: Cross-sectional descriptive study. LOCATION: 10 Primary Care Centers. PARTICIPANTS: Resident doctors of Family and Community Medicine. INTERVENTIONS: Peer review of video recordings of clinical demand consultations. MAIN MEASUREMENTS: CICAA-2 questionnaire to assess communication skills (improvable, acceptable or adequate); age and sex, reasons for consultation and duration of the interview. Bivariate and multivariate analyses. Ethical authorization, oral informed consent and custody of the video recordings. RESULTS: 73 RD (53.8% women, 32.9±7.7 years) participated with 260 interviews (60.3% women and 2.1±1.0 clinical demands). 27.7% of consultations with a companion (female sex 65.3%). The mean duration of the interviews was 8.5±4.0min. Clinical encounters lasted longer when a companion attended (2.7±0.5min more; p<.001 Student t) and with a greater number of clinical demands (40% with ≥3 reasons, p=0.048 X2). The mean value of the total score of the CICAA-2 scale (46.9±16.5; difference 4.6±2.3) and Task 2 (39.3±15.8 with difference 4.4±2.2) were higher when companion was present (p<.05 Student t). The model obtained with logistic regression shows a longer duration of the consultation with a companion (OR 1.2; CI [1.1-1.3]) and possibly a better score in Task 2 communication skills (OR 1.02; CI [0.99-1.1]). CONCLUSIONS: Triadic communications challenge the clinician's communication skills, improving their abilities to identify and understand patient problems, albeit at the cost of a greater investment of time.

Body mass index interacts with a genetic-risk score for depression increasing the risk of the disease in high-susceptibility individuals.

Depression is strongly associated with obesity among other chronic physical diseases. The latest mega- and meta-analysis of genome-wide association studies have identified multiple risk loci robustly associated with depression. In this study, we aimed to investigate whether a genetic-risk score (GRS) combining multiple depression risk single nucleotide polymorphisms (SNPs) might have utility in the prediction of this disorder in individuals with obesity. A total of 30 depression-associated SNPs were included in a GRS to predict the risk of depression in a large case-control sample from the Spanish PredictD-CCRT study, a national multicentre, randomized controlled trial, which included 104 cases of depression and 1546 controls. An unweighted GRS was calculated as a summation of the number of risk alleles for depression and incorporated into several logistic regression models with depression status as the main outcome. Constructed models were trained and evaluated in the whole recruited sample. Non-genetic-risk factors were combined with the GRS in several ways across the five predictive models in order to improve predictive ability. An enrichment functional analysis was finally conducted with the aim of providing a general understanding of the biological pathways mapped by analyzed SNPs. We found that an unweighted GRS based on 30 risk loci was significantly associated with a higher risk of depression. Although the GRS itself explained a small amount of variance of depression, we found a significant improvement in the prediction of depression after including some non-genetic-risk factors into the models. The highest predictive ability for depression was achieved when the model included an interaction term between the GRS and the body mass index (BMI), apart from the inclusion of classical demographic information as marginal terms (AUC = 0.71, 95% CI = [0.65, 0.76]). Functional analyses on the 30 SNPs composing the GRS revealed an over-representation of the mapped genes in signaling pathways involved in processes such as extracellular remodeling, proinflammatory regulatory mechanisms, and circadian rhythm alterations. Although the GRS on its own explained a small amount of variance of depression, a significant novel feature of this study is that including non-genetic-risk factors such as BMI together with a GRS came close to the conventional threshold for clinical utility used in ROC analysis and improves the prediction of depression. In this study, the highest predictive ability was achieved by the model combining the GRS and the BMI under an interaction term. Particularly, BMI was identified as a trigger-like risk factor for depression acting in a concerted way with the GRS component. This is an interesting finding since it suggests the existence of a risk overlap between both diseases, and the need for individual depression genetics-risk evaluation in subjects with obesity. This research has therefore potential clinical implications and set the basis for future research directions in exploring the link between depression and obesity-associated disorders. While it is likely that future genome-wide studies with large samples will detect novel genetic variants associated with depression, it seems clear that a combination of genetics and non-genetic information (such is the case of obesity status and other depression comorbidities) will still be needed for the optimization prediction of depression in high-susceptibility individuals.

[Common mental disorders in primary care: diagnostic and therapeutic difficulties, and new challenges in prediction and prevention. SESPAS Report 2020]. / Enfermedades mentales comunes en atención primaria: dificultades diagnósticas y terapéuticas, y nuevos retos en predicción y prevención. Informe SESPAS 2020.

In primary health care only chronic pain surpass depression and anxiety in loss of quality-adjusted life years. More than 70% of people suffering from common mental disorders consulted their GPs for this reason. However, 'the declining halves rule' is a reality: less than 50% of primary care attendees with common mental disorders were correctly diagnosed, of these less than 50% received adequate treatment (pharmacological or psychological) and of these less than 50% patients were adherent. Collaborative models of common mental disorders care in primary health care have demonstrated their effectiveness through clinical trials; however, its implementation in a more general and real context is difficult and its effectiveness remains unclear. Risk algorithms have been developed and validated in primary health care to predict the onset and prognosis of common mental disorders; which are useful for their treatment and prevention. There is evidence that psychological and psychoeducational interventions (and possibly those of physical exercise) are effective for the primary prevention of common mental disorders, even in primary health care; although their effects are small or moderate. These interventions have a high potential to be scalable in schools, workplace and primary health care; in addition, when they are administered through information and communication technologies (e.g. by App), in self-guided or minimally guided programs, they have demonstrated their effectiveness for the treatment and prevention of common mental disorders. They are also very accessible, have low cost and contribute to the massive implementation of these interventions in different settings.

Enfermedades mentales comunes en atención primaria: dificultades diagnósticas y terapéuticas, y nuevos retos en predicción y prevención. Informe SESPAS 2020 / Common mental disorders in primary care: diagnostic and therapeutic difficulties, and new challenges in prediction and prevention. SESPAS Report 2020

En atención primaria solo el dolor crónico supera a la depresión y la ansiedad en la pérdida de años de vida ajustados por calidad. Más del 70% de las personas que sufrían enfermedades mentales comunes consultaron por ello a su médico/a de familia. Sin embargo, «la regla de las mitades decrecientes» es una realidad: menos del 50% de las personas consultantes de atención primaria con enfermedades mentales comunes fueron diagnosticadas correctamente, y de ellas, menos del 50% recibieron un tratamiento (farmacológico o psicológico) adecuado, y de estas, menos del 50% fueron adherentes. Los modelos colaborativos de atención a las enfermedades mentales comunes en atención primaria han demostrado su efectividad en ensayos clínicos, pero su implementación en un contexto más general y real es difícil y su efectividad todavía es poco conocida. Se han desarrollado y validado algoritmos de riesgo para predecir el inicio y el pronóstico de las enfermedades mentales comunes en atención primaria que son útiles para su tratamiento y prevención. Existen evidencias de que las intervenciones psicológicas, psicoeducativas y de ejercicio físico son efectivas en prevención primaria, incluso en atención primaria, aunque su efecto es pequeño o moderado. Estas intervenciones tienen un gran potencial para ser escalables en las escuelas, el ámbito laboral y la atención primaria; además, cuando se administran mediante tecnologías de la información y la comunicación (p. ej., App), en programas autoguiados o mínimamente guiados, han demostrado su efectividad para el tratamiento y la prevención de las enfermedades mentales comunes. También son muy accesibles y de bajo coste, y contribuyen a la implementación masiva de estas intervenciones en diferentes contextos

In primary health care only chronic pain surpass depression and anxiety in loss of quality-adjusted life years. More than 70% of people suffering from common mental disorders consulted their GPs for this reason. However, 'the declining halves rule' is a reality: less than 50% of primary care attendees with common mental disorders were correctly diagnosed, of these less than 50% received adequate treatment (pharmacological or psychological) and of these less than 50% patients were adherent. Collaborative models of common mental disorders care in primary health care have demonstrated their effectiveness through clinical trials; however, its implementation in a more general and real context is difficult and its effectiveness remains unclear. Risk algorithms have been developed and validated in primary health care to predict the onset and prognosis of common mental disorders; which are useful for their treatment and prevention. There is evidence that psychological and psychoeducational interventions (and possibly those of physical exercise) are effective for the primary prevention of common mental disorders, even in primary health care; although their effects are small or moderate. These interventions have a high potential to be scalable in schools, workplace and primary health care; in addition, when they are administered through information and communication technologies (e.g. by App), in self-guided or minimally guided programs, they have demonstrated their effectiveness for the treatment and prevention of common mental disorders. They are also very accessible, have low cost and contribute to the massive implementation of these interventions in different settings

Oferta de actividades preventivas propuestas por médicos residentes de Medicina Familiar en Atención Primaria y su relación con las habilidades comunicacionales / Accomplishment of preventive activities proposed by resident doctors of Family Medicine in Primary Care and its relationship with communication skills

Objetivo: Conocer la oferta de actividades preventivas propuestas por médicos residentes de medicina familiar en la consulta a demanda de Atención Primaria y su relación con las habilidades comunicacionales. Diseño: Estudio descriptivo multicéntrico mediante videograbación de la consulta médica. Emplazamiento: Ocho centros de salud de Jaén (Andalucía). Participantes: Setenta y tres médicos residentes de cuarto año. Mediciones principales: Se valora la oferta de actividades preventivas (según el Programa español de actividades preventivas y promoción de la salud -PAPPS-) y las características del médico, el paciente y la consulta. Valoración por pares de la comunicación médico-paciente mediante la escala CICAA. Análisis descriptivo, bivariable y de regresión logística. Resultados: Se valoran 260 entrevistas (duración 8,5 ± 4,0 min) de 73 residentes (50,7% mujeres, edad media 32,9 ± 7,7 años, 79% medio urbano). El paciente es más frecuentemente mujer (60%), que acude sola (72%) por procesos agudos (80%) y con 2,1 ± 1,0 motivos de consulta. Se ofertan actividades preventivas en un 47% (duración inferior al minuto) de tipo primario (70%) y secundario (59%) mediante consejo (72%) o cribado (52%), centradas en el área cardiovascular (52%) y estilos de vida (53%). Un 80% se relaciona con el motivo de consulta. Habilidades en comunicación: 41% mejorables, 26% adecuadas, 23% excelentes. La oferta de actividades preventivas se relaciona con la duración de la consulta (OR = 1,1; IC 95% 1,01; 1,16) y la puntuación del CICAA (OR = 1,03; IC 95% 1,01; 1,10). Conclusiones: Se realizan actividades preventivas en casi la mitad de las consultas, aunque centradas en consejo y cribado y ligadas a la demanda del paciente. El tiempo de consulta y las habilidades de comunicación favorecen una mayor oferta preventiva

Objective: To determine the offer of preventive activities by resident physicians of family medicine in the Primary Care consultations and the relation with their communication habilities. Design: A descriptive multicentre study assessing medical consultations video recording. Location: Eight Primary Healthcare centres in Jaen (Andalucia). Participants: Seventy-three resident physicians (4th year) filmed and observed with patients. Principal measurements: Offer of preventive activities (according to the Spanish Program of Preventive Activities and Health Promotion -PAPPS-). Doctor, patient and consultation characteristics. Peer-review of the communication between physicians and patients, using a CICAA scale. A descriptive, bivariate, logistic regression analysis was performed. Results: Two hundred and sixty interviews were evaluated (duration 8.5 ± 4.0 min) of 73 residents (50.7% women, mean age 32.9 ± 7.7 years, 79% urban environment). The patient is more frequently a woman (60%) who comes alone (72%) due to acute processes (80%) and with 2.1 ± 1.0 demands. Preventive activities are offered in 47% (duration less than one minute) of primary (70%) and secondary (59%) prevention, offered through advice (72%) or screening (52%) and focused on the cardiovascular area (52%) and lifestyles (53%). Eighty percent related to the patient's reason for consultation. Communication skills 41% improvable, 26% adequate, 23% excellent. The offer of preventive activities is related to the duration of the consultation (OR = 1.1, 95% CI 1.01; 1.16) and communication skills (OR = 1.03, 95% CI 1.01; 1.10). Conclusions: Preventive activities are carried out in almost half of the consultations, although focused on advice and screening and linked to the patient's demand. Consultation time and communication skills favor a greater preventive offer

[Accomplishment of preventive activities proposed by resident doctors of Family Medicine in Primary Care and its relationship with communication skills]. / Oferta de actividades preventivas propuestas por médicos residentes de Medicina Familiar en Atención Primaria y su relación con las habilidades comunicacionales.

OBJECTIVE: To determine the offer of preventive activities by resident physicians of family medicine in the Primary Care consultations and the relation with their communication habilities. DESIGN: A descriptive multicentre study assessing medical consultations video recording. LOCATION: Eight Primary Healthcare centres in Jaen (Andalucia). PARTICIPANTS: Seventy-three resident physicians (4th year) filmed and observed with patients. PRINCIPAL MEASUREMENTS: Offer of preventive activities (according to the Spanish Program of Preventive Activities and Health Promotion -PAPPS-). Doctor, patient and consultation characteristics. Peer-review of the communication between physicians and patients, using a CICAA scale. A descriptive, bivariate, logistic regression analysis was performed. RESULTS: Two hundred and sixty interviews were evaluated (duration 8.5±4.0min) of 73 residents (50.7% women, mean age 32.9±7.7 years, 79% urban environment). The patient is more frequently a woman (60%) who comes alone (72%) due to acute processes (80%) and with 2.1±1.0 demands. Preventive activities are offered in 47% (duration less than one minute) of primary (70%) and secondary (59%) prevention, offered through advice (72%) or screening (52%) and focused on the cardiovascular area (52%) and lifestyles (53%). Eighty percent related to the patient's reason for consultation. Communication skills 41% improvable, 26% adequate, 23% excellent. The offer of preventive activities is related to the duration of the consultation (OR=1.1, 95% CI 1.01; 1.16) and communication skills (OR=1.03, 95% CI 1.01; 1.10). CONCLUSIONS: Preventive activities are carried out in almost half of the consultations, although focused on advice and screening and linked to the patient's demand. Consultation time and communication skills favor a greater preventive offer.

Family physicians' views on participating in prevention of major depression. The predictD-EVAL qualitative study.

BACKGROUND: The predictD intervention, a multicomponent intervention delivered by family physicians (FPs), reduced the incidence of major depression by 21% versus the control group and was cost-effective. A qualitative methodology was proposed to identify the mechanisms of action of these complex interventions. PURPOSE: To seek the opinions of these FPs on the potential successful components of the predictD intervention for the primary prevention of depression in primary care and to identify areas for improvement. METHOD: Qualitative study with FPs who delivered the predictD intervention at 35 urban primary care centres in seven Spanish cities. Face-to-face semi-structured interviews adopting a phenomenological approach. The data was triangulated by three investigators using thematic analysis and respondent validation was carried out. RESULTS: Sixty-seven FPs were interviewed and they indicated strategies used to perform the predictD intervention, including specific communication skills such as empathy and the activation of patient resources. They perceived barriers such as lack of time and facilitators such as prior acquaintance with patients. FPs recognized the positive consequences of the intervention for FPs, patients and the doctor-patient relationship. They also identified strategies for future versions and implementations of the predictD intervention. CONCLUSIONS: The FPs who carried out the predictD intervention identified factors potentially associated with successful prevention using this program and others that could be improved. Their opinions about the predictD intervention will enable development of a more effective and acceptable version and its implementation in different primary health care settings.

A personalized intervention to prevent depression in primary care: cost-effectiveness study nested into a clustered randomized trial.

BACKGROUND: Depression is viewed as a major and increasing public health issue, as it causes high distress in the people experiencing it and considerable financial costs to society. Efforts are being made to reduce this burden by preventing depression. A critical component of this strategy is the ability to assess the individual level and profile of risk for the development of major depression. This paper presents the cost-effectiveness of a personalized intervention based on the risk of developing depression carried out in primary care, compared with usual care. METHODS: Cost-effectiveness analyses are nested within a multicentre, clustered, randomized controlled trial of a personalized intervention to prevent depression. The study was carried out in 70 primary care centres from seven cities in Spain. Two general practitioners (GPs) were randomly sampled from those prepared to participate in each centre (i.e. 140 GPs), and 3326 participants consented and were eligible to participate. The intervention included the GP communicating to the patient his/her individual risk for depression and personal risk factors and the construction by both GPs and patients of a psychosocial programme tailored to prevent depression. In addition, GPs carried out measures to activate and empower the patients, who also received a leaflet about preventing depression. GPs were trained in a 10- to 15-h workshop. Costs were measured from a societal and National Health care perspective. Qualityadjustedlife years were assessed using the EuroQOL five dimensions questionnaire. The time horizon was 18 months. RESULTS: With a willingness-to-pay threshold of €10,000 (£8568) the probability of cost-effectiveness oscillated from 83% (societal perspective) to 89% (health perspective). If the threshold was increased to €30,000 (£25,704), the probability of being considered cost-effective was 94% (societal perspective) and 96%, respectively (health perspective). The sensitivity analysis confirmed these results. CONCLUSIONS: Compared with usual care, an intervention based on personal predictors of risk of depression implemented by GPs is a cost-effective strategy to prevent depression. This type of personalized intervention in primary care should be further developed and evaluated. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01151982. Registered on June 29, 2010.

Effectiveness of Psychological and/or Educational Interventions in the Prevention of Anxiety: A Systematic Review, Meta-analysis, and Meta-regression.

Importance: To our knowledge, no systematic reviews or meta-analyses have been conducted to assess the effectiveness of preventive psychological and/or educational interventions for anxiety in varied populations. Objective: To evaluate the effectiveness of preventive psychological and/or educational interventions for anxiety in varied population types. Data Sources: A systematic review and meta-analysis was conducted based on literature searches of MEDLINE, PsycINFO, Web of Science, EMBASE, OpenGrey, Cochrane Central Register of Controlled Trials, and other sources from inception to March 7, 2017. Study Selection: A search was performed of randomized clinical trials assessing the effectiveness of preventive psychological and/or educational interventions for anxiety in varying populations free of anxiety at baseline as measured using validated instruments. There was no setting or language restriction. Eligibility criteria assessment was conducted by 2 of us. Data Extraction and Synthesis: Data extraction and assessment of risk of bias (Cochrane Collaboration's tool) were performed by 2 of us. Pooled standardized mean differences (SMDs) were calculated using random-effect models. Heterogeneity was explored by random-effects meta-regression. Main Outcomes and Measures: Incidence of new cases of anxiety disorders or reduction of anxiety symptoms as measured by validated instruments. Results: Of the 3273 abstracts reviewed, 131 were selected for full-text review, and 29 met the inclusion criteria, representing 10 430 patients from 11 countries on 4 continents. Meta-analysis calculations were based on 36 comparisons. The pooled SMD was -0.31 (95% CI, -0.40 to -0.21; P < .001) and heterogeneity was substantial (I2 = 61.1%; 95% CI, 44% to 73%). There was evidence of publication bias, but the effect size barely varied after adjustment (SMD, -0.27; 95% CI, -0.37 to -0.17; P < .001). Sensitivity analyses confirmed the robustness of effect size results. A meta-regression including 5 variables explained 99.6% of between-study variability, revealing an association between higher SMD, waiting list (comparator) (ß = -0.33 [95% CI, -0.55 to -0.11]; P = .005) and a lower sample size (lg) (ß = 0.15 [95% CI, 0.06 to 0.23]; P = .001). No association was observed with risk of bias, family physician providing intervention, and use of standardized interviews as outcomes. Conclusions and Relevance: Psychological and/or educational interventions had a small but statistically significant benefit for anxiety prevention in all populations evaluated. Although more studies with larger samples and active comparators are needed, these findings suggest that anxiety prevention programs should be further developed and implemented.

Effectiveness of Psychological and Educational Interventions to Prevent Depression in Primary Care: A Systematic Review and Meta-Analysis.

PURPOSE: Although evidence exists for the efficacy of psychosocial interventions to prevent the onset of depression, little is known about its prevention in primary care. We aimed to evaluate the effectiveness of psychological and educational interventions to prevent depression in primary care. METHODS: We conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs) examining the effect of psychological and educational interventions to prevent depression in nondepressed primary care attendees. We searched MEDLINE, PsycINFO, Web of Science, OpenGrey Repository, Cochrane Central Register of Controlled Trials, and other sources up to May 2016. At least 2 reviewers independently evaluated the eligibility criteria, extracted data, and assessed the risk of bias. We calculated standardized mean differences (SMD) using random-effects models. RESULTS: We selected 14 studies (7,365 patients) that met the inclusion criteria, 13 of which were valid to perform a meta-analysis. Most of the interventions had a cognitive-behavioral orientation, and in only 4 RCTs were the intervention clinicians primary care staff. The pooled SMD was -0.163 (95%CI, -0.256 to -0.070; P = .001). The risk of bias and the heterogeneity (I2 = 20.6%) were low, and there was no evidence of publication bias. Meta-regression detected no association between SMD and follow-up times or SMD and risk of bias. Subgroup analysis suggested greater effectiveness when the RCTs used care as usual as the comparator compared with those using placebo. CONCLUSIONS: Psychological and educational interventions to prevent depression had a modest though statistically significant preventive effect in primary care. Further RCTs using placebo or active comparators are needed.

Intervention to Prevent Major Depression in Primary Care: A Cluster Randomized Trial.

BACKGROUND: Not enough is known about universal prevention of depression in adults. OBJECTIVE: To evaluate the effectiveness of an intervention to prevent major depression. DESIGN: Multicenter, cluster randomized trial with sites randomly assigned to usual care or an intervention. (ClinicalTrials.gov: NCT01151982). SETTING: 10 primary care centers in each of 7 cities in Spain. PARTICIPANTS: Two primary care physicians (PCPs) and 5236 nondepressed adult patients were randomly sampled from each center; 3326 patients consented and were eligible to participate. INTERVENTION: For each patient, PCPs communicated individual risk for depression and personal predictors of risk and developed a psychosocial program tailored to prevent depression. MEASUREMENTS: New cases of major depression, assessed every 6 months for 18 months. RESULTS: At 18 months, 7.39% of patients in the intervention group (95% CI, 5.85% to 8.95%) developed major depression compared with 9.40% in the control (usual care) group (CI, 7.89% to 10.92%) (absolute difference, -2.01 percentage points [CI, -4.18 to 0.16 percentage points]; P = 0.070). Depression incidence was lower in the intervention centers in 5 cities and similar between intervention and control centers in 2 cities. LIMITATION: Potential self-selection bias due to nonconsenting patients. CONCLUSION: Compared with usual care, an intervention based on personal predictors of risk for depression implemented by PCPs provided a modest but nonsignificant reduction in the incidence of major depression. Additional study of this approach may be warranted. PRIMARY FUNDING SOURCE: Institute of Health Carlos III.

Patients' opinions about knowing their risk for depression and what to do about it. The predictD-qualitative study.

BACKGROUND: The predictD study developed and validated a risk algorithm for predicting the onset of major depression in primary care. We aimed to explore the opinion of patients about knowing their risk for depression and the values and criteria upon which these opinions are based. METHODS: A maximum variation sample of patients was taken, stratified by city, age, gender, immigrant status, socio-economic status and lifetime depression. The study participants were 52 patients belonging to 13 urban health centres in seven different cities around Spain. Seven Focus Groups (FGs) were given held with primary care patients, one for each of the seven participating cities. RESULTS: The results showed that patients generally welcomed knowing their risk for depression. Furthermore, in light of available evidence several patients proposed potential changes in their lifestyles to prevent depression. Patients generally preferred to ask their General Practitioners (GPs) for advice, though mental health specialists were also mentioned. They suggested that GPs undertake interventions tailored to each patient, from a "patient-centred" approach, with certain communication skills, and giving advice to help patients cope with the knowledge that they are at risk of becoming depressed. CONCLUSIONS: Patients are pleased to be informed about their risk for depression. We detected certain beliefs, attitudes, values, expectations and behaviour among the patients that were potentially useful for future primary prevention programmes on depression.

Preventing the onset of major depression based on the level and profile of risk of primary care attendees: protocol of a cluster randomised trial (the predictD-CCRT study).

BACKGROUND: The 'predictD algorithm' provides an estimate of the level and profile of risk of the onset of major depression in primary care attendees. This gives us the opportunity to develop interventions to prevent depression in a personalized way. We aim to evaluate the effectiveness, cost-effectiveness and cost-utility of a new intervention, personalized and implemented by family physicians (FPs), to prevent the onset of episodes of major depression. METHODS/DESIGN: This is a multicenter randomized controlled trial (RCT), with cluster assignment by health center and two parallel arms. Two interventions will be applied by FPs, usual care versus the new intervention predictD-CCRT. The latter has four components: a training workshop for FPs; communicating the level and profile of risk of depression; building up a tailored bio-psycho-family-social intervention by FPs to prevent depression; offering a booklet to prevent depression; and activating and empowering patients. We will recruit a systematic random sample of 3286 non-depressed adult patients (1643 in each trial arm), nested in 140 FPs and 70 health centers from 7 Spanish cities. All patients will be evaluated at baseline, 6, 12 and 18 months. The level and profile of risk of depression will be communicated to patients by the FPs in the intervention practices at baseline, 6 and 12 months. Our primary outcome will be the cumulative incidence of major depression (measured by CIDI each 6 months) over 18 months of follow-up. Secondary outcomes will be health-related quality of life (SF-12 and EuroQol), and measurements of cost-effectiveness and cost-utility. The inferences will be made at patient level. We shall undertake an intention-to-treat effectiveness analysis and will handle missing data using multiple imputations. We will perform multi-level logistic regressions and will adjust for the probability of the onset of major depression at 12 months measured at baseline as well as for unbalanced variables if appropriate. The economic evaluation will be approached from two perspectives, societal and health system. DISCUSSION: To our knowledge, this will be the first RCT of universal primary prevention for depression in adults and the first to test a personalized intervention implemented by FPs. We discuss possible biases as well as other limitations. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01151982.

Clinical differences between first and recurrent episodes in depressive patients.

BACKGROUND: Depressive disorder is one of the most common mental disorders in primary care. Depression is often a chronic disorder with recurrent episodes. Little is known about the differences in clinical profile between first and recurrent episodes. The aim of the study is to analyze the differences between clinical presentation of first and subsequent episodes of depressive disorders in primary care patients. METHOD: A cross-sectional epidemiologic study in primary care centers in Spain was designed. A total of 10,257 primary care patients having a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive episode were analyzed. Clinical symptoms were measured using the Montgomery Asberg Depression Scale. Patient Health Questionnaire was used to assess somatic symptoms. RESULTS: There were 40.6% of patients who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for recurrent depression. Compared with those diagnosed of their first major depressive disorder, recurrent patients had greater rates and severity of depressive (t = -7.85, P < .001) and somatic symptoms (t = 5.64, P < .001). The severity of symptoms also increases with number of episodes (F = 40.2, P < .001, for depressive symptoms; F = 27.8, P < .001, for somatic symptoms). First-episode patients were more likely to experience reduced appetite (adjusted odds ratio, 1.2) and suicidal thoughts (adjusted odds ratio, 1.2). CONCLUSION: There are differences in the clinical profile of initial and recurrent episodes in primary care depressive patients. Each recurrent depressive episode seems to have a greater impact on symptoms and well-being. The identification of a specific depression symptom profile in first or recurrent episodes is needed to improve the long-term management of major depressive episode patients in primary care settings.

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