Economic Evaluation of a Web Application Implemented in Primary Care for the Treatment of Depression in Patients With Type 2 Diabetes Mellitus: Multicenter Randomized Controlled Trial.

BACKGROUND: Depressive disorder and type 2 diabetes mellitus (T2DM) are prevalent in primary care (PC). Pharmacological treatment, despite controversy, is commonly chosen due to resource limitations and difficulties in accessing face-to-face interventions. Depression significantly impacts various aspects of a person's life, affecting adherence to medical prescriptions and glycemic control and leading to future complications and increased health care costs. To address these challenges, information and communication technologies (eg, eHealth) have been introduced, showing promise in improving treatment continuity and accessibility. However, while eHealth programs have demonstrated effectiveness in alleviating depressive symptoms, evidence regarding glycemic control remains inconclusive. This randomized controlled trial aimed to test the efficacy of a low-intensity psychological intervention via a web app for mild-moderate depressive symptoms in individuals with T2DM compared with treatment as usual (TAU) in PC. OBJECTIVE: This study aimed to analyze the cost-effectiveness and cost-utility of a web-based psychological intervention to treat depressive symptomatology in people with T2DM compared with TAU in a PC setting. METHODS: A multicenter randomized controlled trial was conducted with 49 patients with T2DM, depressive symptoms of moderate severity, and glycosylated hemoglobin (HbA1c) of 7.47% in PC settings. Patients were randomized to TAU (n=27) or a web-based psychological treatment group (n=22). This web-based treatment consisted of cognitive behavioral therapy, improvement of diabetes self-care behaviors, and mindfulness. Cost-effectiveness analysis for the improvement of depressive symptomatology was conducted based on reductions in 3, 5, or 50 points on the Patient Health Questionnaire-9 (PHQ-9). The efficacy of diabetes control was estimated based on a 0.5% reduction in HbA1c levels. Follow-up was performed at 3 and 6 months. The cost-utility analysis was performed based on quality-adjusted life years. RESULTS: Efficacy analysis showed that the web-based treatment program was more effective in improving depressive symptoms than TAU but showed only a slight improvement in HbA1c. Incremental cost-effectiveness ratios of 186.76 for a 3-point reduction in PHQ-9 and 206.31 for reductions of 5 and 50 percentage points were obtained. In contrast, the incremental cost-effectiveness ratio for improving HbA1c levels amounted to €1510.90 (€1=US $1.18 in 2018) per participant. The incremental cost-utility ratio resulted in €4119.33 per quality-adjusted life year gained. CONCLUSIONS: The intervention, using web-based modules incorporating cognitive behavioral therapy tools, diabetes self-care promotion, and mindfulness, effectively reduced depressive symptoms and enhanced glycemic control in patients with T2DM. Notably, it demonstrated clinical efficacy and economic efficiency. This supports the idea that eHealth interventions not only benefit patients clinically but also offer cost-effectiveness for health care systems. The study emphasizes the importance of including specific modules to enhance diabetes self-care behaviors in future web-based psychological interventions, emphasizing personalization and adaptation for this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/S12888-019-2037-3.

A Systematic Review of the Adherence to Home-Practice Meditation Exercises in Patients with Chronic Pain.

Mindfulness-, compassion-, and acceptance-based (i.e., "third wave") psychotherapies are effective for treating chronic pain conditions. Many of these programs require that patients engage in the systematic home practice of meditation experiences so they can develop meditation skills. This systematic review aimed at evaluating the frequency, duration, and effects of home practice in patients with chronic pain undergoing a "third wave" psychotherapy. A comprehensive database search for quantitative studies was conducted in PubMed, Embase, and Web of Sciences Core Collection; 31 studies fulfilled the inclusion criteria. The reviewed studies tended to indicate a pattern of moderately frequent practice (around four days/week), with very high variability in terms of time invested; most studies observed significant associations between the amount of practice and positive health outcomes. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy were the most common interventions and presented low levels of adherence to home practice (39.6% of the recommended time). Some studies were conducted on samples of adolescents, who practiced very few minutes, and a few tested eHealth interventions with heterogeneous adherence levels. In conclusion, some adaptations may be required so that patients with chronic pain can engage more easily and, thus, effectively in home meditation practices.

Preventive Gambling Programs for Adolescents and Young Adults: A Systematic Review.

Gambling disorder in youth is an emerging public health problem, with adolescents and young adults constituting a vulnerable age group for the development of gambling-related problems. Although research has been conducted on the risk factors for gambling disorder, very few rigorous studies can be found on the efficacy of preventive interventions in young people. The aim of this study was to provide best practice recommendations for the prevention of disordered gambling in adolescents and young adults. We reviewed and synthesized the results of existing RCTs and quasi-experimental studies covering nonpharmacological prevention programs for gambling disorder in young adults and adolescents. We applied the PRISMA 2020 statement and guidelines to identify 1483 studies, of which 32 were included in the systematic review. All studies targeted the educational setting, i.e., high school and university students. Most studies followed a universal prevention strategy, that particularly targeted adolescents, and an indicated prevention strategy for university students. The reviewed gambling prevention programs generally showed good results in terms of reducing the frequency and severity of gambling, and also regarding cognitive variables, such as misconceptions, fallacies, knowledge, and attitudes towards gambling. Finally, we highlight the need to develop more comprehensive prevention programs that incorporate rigorous methodological and assessment procedures before they are widely implemented and disseminated.

Environmental enrichment for reptiles in European zoos: Current status and perspectives.

Zoos and aquaria are paying increasing attention to environmental enrichment, which has proven an effective tool for the improvement of animal welfare. However, several ongoing issues have hampered progress in environmental enrichment research. Foremost among these is the taxonomic bias, which hinders our understanding of the value of enrichment for neglected groups, such as reptiles. In this study, we evaluated the status of environmental enrichment for reptiles in European zoos using a survey approach. A total of 121 zoos (32% response rate) completed our main survey, focusing on the use of different enrichment types for reptiles. We found significant differences in the use and/or type of enrichment between reptile groups. Tortoises (family Testudinidae) and monitor lizards (genus Varanus) were the most enriched taxa while venomous snakes were the least. The enrichment types most used across taxa were structural/habitat design and dietary. A second, more detailed, questionnaire followed, where participants were questioned about specific enrichment techniques. A total of 42 enrichment methods were reported, with two being represented across all taxa: increasing structural/thermal complexity and enrichment objects. Finally, we present information from participating zoos on enrichment goals, assessment methods, sources of information for enrichment ideas, and whether enrichment for reptiles is considered essential and/or implemented routinely. Results suggest that, although usage is widespread across European zoos, our understanding of enrichment for reptiles needs to be re-evaluated, since many of the techniques reported tread a fine line between basic husbandry and actual enrichment.

Implementation of a psychological online intervention for low to moderate depression in primary care: study protocol.

Background: Depression affects millions of people all over the world and implies a great socioeconomic burden. Despite there are different effective evidence-based interventions for treating depression, only a small proportion of these patients receives an appropriate treatment. In this regard, information and communication technologies (ICTs) can be used with therapeutic aims and this can contribute to make interventions more accessible. One example is "Smiling is fun", an internet-based treatment which has proved to be effective and cost-effective for treating depression in Spanish Primary Care (PC). However, the "know-do gap" between research and clinical settings implies that the actual implementation of such interventions could last up to 20 years. To overcome this obstacle, the implementation research establishes the methodology to implement the advances developed in the laboratories to the health care services maintaining the validity of the intervention and offering specific strategies for the implementation process. Objective: This is the protocol of an implementation study for the Internet-based program "Smiling is fun", which will be conducted on patients with mild-to-moderate depression of Spanish PC settings. In the implementation study, the feasibility, efficacy, cost-efficacy, acceptability, adoption, appropriateness, fidelity, penetration, normalization, and sustainability will be assessed. Methods: The current investigation is a Hybrid Effectiveness-Implementation Type II design. A Stepped Wedge randomized controlled trial design will be used, with a cohort of 420 adults diagnosed with depression (mild-to-moderate) who will undergo a first control phase (no treatment) followed by the intervention, which will last 16 weeks, and finishing with an optional use of the intervention. All patients will be assessed at baseline, during the treatment, and at post-treatment. The study will be conducted in three Spanish regions: Andalusia, Aragon, and the Balearic Islands. Two primary care centers of each region will participate, one located in the urban setting and the other in the rural setting. The primary outcome will be implementation success of the intervention assessing the reach, clinical effect, acceptability, appropriateness, adoption, feasibility, fidelity, penetration, implementation costs and sustainability services. Discussion: "Smiling is Fun", which has already been established as effective and cost-effective, will be adapted according to users' experiences and opinions, and the efficacy and cost-efficacy of the program will again be assessed. The study will point out barriers and facilitators to consider in the implementation process of internet-based psychological interventions in health services. The ultimate goal is to break the research-to-practice split, which would undoubtedly contribute to reduce the high burden of depression in our society. Trial registration: ClinicalTrials.gov, Identifier: NCT05294614.

Effectiveness and implementation of an online intervention (MINDxYOU) for reducing stress and promote mental health among healthcare workers in Spain: a study protocol for a stepped-wedge cluster randomized trial.

BACKGROUND: The World Health Organization has formally recognized that healthcare professionals are at risk of developing mental health problems; finding ways to reduce their stress is mandatory to improve both their quality of life and, indirectly, their job performance. In recent years, particularly since the COVID-19 pandemic outbreak, there has been a proliferation of online interventions with promising results. The purpose of the present study is twofold: to test the effectiveness of an online, self-guided intervention, MINDxYOU, to reduce the stress levels of healthcare workers; and to conduct an implementation study of this intervention. Additionally, an economic evaluation of the intervention will be conducted. METHODS: The current study has a hybrid effectiveness-implementation type 2 design. A stepped wedge cluster randomized trial design will be used, with a cohort of 180 healthcare workers recruited in two Spanish provinces (Malaga and Zaragoza). The recruitment stage will commence in October 2022. Frontline health workers who provide direct care to people in a hospital, primary care center, or nursing home setting in both regions will participate. The effectiveness of the intervention will be studied, with perceived stress as the main outcome (Perceived Stress Scale), while other psychopathological symptoms and process variables (e.g., mindfulness, compassion, resilience, and psychological flexibility) will be also assessed as secondary outcomes. The implementation study will include analysis of feasibility, acceptability, adoption, appropriateness, fidelity, penetration, and sustainability. The incremental costs and benefits, in terms of quality-adjusted life years, will be examined by means of cost-utility and cost-effectiveness analyses. DISCUSSION: MINDxYOU is designed to reduce healthcare workers' stress levels through the practice of mindfulness, acceptance, and compassion, with a special focus on how to apply these skills to healthy habits and considering the particular stressors that these professionals face on a daily basis. The present study will show how implementation studies are useful for establishing the framework in which to address barriers to and promote facilitators for acceptability, appropriateness, adoption, feasibility, fidelity, penetration, and sustainability of online interventions. The ultimate goal is to reduce the research-to-practice gap. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov on 29/06/2022; registration number: NCT05436717.

The Gambling Habits of University Students in Aragon, Spain: A Cross-Sectional Study.

Gambling has become a routine form of entertainment for many young people. The aim of this study was to describe the gambling behavior that university students are developing in Aragon, Spain, and to analyze whether these habits are more common among students of sports science, on the assumption that they are more likely to have a higher exposure to betting company marketing. A cross-sectional design was applied, with data collected on advertising exposure, gambling habits and experiences, and opinions on the impact of gambling and its regulation from 516 undergraduate students from the University of Zaragoza. The online survey included ad hoc questions and the "Pathological Gambling Short Questionnaire" to screen for potential gambling disorders. Almost half of the sample had bet money at least once in their life (48.1%), and 2.4% screened positive for consideration of a possible diagnosis of pathological gambling. Betting shops (44.2%) were the most common gambling option, and students of sports science showed a higher prevalence of pathological gambling and had greater tendencies to make bets. Gambling is perceived as a normal leisure activity by a significant part of university students. The development of transversal strategies is required to raise awareness towards the potential dangers of gambling.

Analysis of the Calls Received during the COVID-19 Lockdown by the Mental Health Crisis Helpline Operated by the Professional College of Psychology of Aragon.

COVID-19 has had a direct impact on the physical and mental health of millions of people worldwide. Therefore, a Mental Health Crisis Helpline (MHCH) was set up and offered free of charge by the Professional College of Psychology of Aragon (COPPA) during the lockdown period. This research aims to study the reasons for the calls, to describe the population segments that used it, and to analyse the possible relationships between the variables studied. A total of 1411 calls were answered and 598 were registered. The main reasons for the calls were: anxiety symptoms, concern for a relative, previous mental health problems, conflicts, and depressive symptoms. Significantly more men called for anxiety symptoms (60.8% vs. 49.5%) versus more women calling regarding a chronic physical illness (3.5% vs. 0.7%), concern about a relative (22.7% vs. 12.4%), care guidelines (6% vs. 1.3%), and bereavement (6.2% vs. 2%). Calls regarding conflict increased slightly as the lockdown period progressed (p < 0.001; r = 0.15), in contrast with calls regarding previous psychological conditions and anxiety symptoms (p = 0.035; r = −0.09; p = 0.005; r = −0.12). These results highlight the intensive use of the MHCH, confirming the need for the implementation of specific psychological care resources in times of crisis.

Viability, behavior, and color expression in the offspring of matings between common wall lizard Podarcis muralis color morphs.

Color polymorphisms are widely studied to identify the mechanisms responsible for the origin and maintenance of phenotypic variability in nature. Two of the mechanisms of balancing selection currently thought to explain the long-term persistence of polymorphisms are the evolution of alternative phenotypic optima through correlational selection on suites of traits including color and heterosis. Both of these mechanisms can generate differences in offspring viability and fitness arising from different morph combinations. Here, we examined the effect of parental morph combination on fertilization success, embryonic viability, newborn quality, antipredator, and foraging behavior, as well as inter-annual survival by conducting controlled matings in a polymorphic lacertid Podarcis muralis, where color morphs are frequently assumed to reflect alternative phenotypic optima (e.g., alternative reproductive strategies). Juveniles were kept in outdoor tubs for a year in order to study inter-annual growth, survival, and morph inheritance. In agreement with a previous genome-wide association analysis, morph frequencies in the year-old juveniles matched the frequencies expected if orange and yellow expressions depended on recessive homozygosity at 2 separate loci. Our findings also agree with previous literature reporting higher reproductive output of heavy females and the higher overall viability of heavy newborn lizards, but we found no evidence for the existence of alternative breeding investment strategies in female morphs, or morph-combination effects on offspring viability and behavior. We conclude that inter-morph breeding remains entirely viable and genetic incompatibilities are of little significance for the maintenance of discrete color morphs in P. muralis from the Pyrenees.

The TELE-DD Randomised Controlled Trial on Treatment Adherence in Patients with Type 2 Diabetes and Comorbid Depression: Clinical Outcomes after 18-Month Follow-Up.

Clinical depression is associated with poorer adherence to hypoglycaemic medication in patients with diabetes mellitus, leading to poorer glycaemic control, diabetes management, and increased complications. The main aim of the TELE-DD trial was to demonstrate the efficacy of a proactive and psychoeducational telephonic intervention based on motivational interviewing and collaborative care to reduce nonadherence and improve prognosis in individuals with diabetes mellitus and concurrent depression. DESIGN: The TELE-DD project is a three-phased prospective study including a nested randomised controlled trial. METHODS: The baseline cohort included the entire population of adult patients diagnosed with type 2 diabetes and concurrent depression. A randomised controlled trial was conducted in a selection of patients from the baseline cohort, distributed into a control group (n = 192) and an intervention group (n = 192). Monthly telephonic interventions delivered by specifically trained research nurses were centred on a psychoeducational individualised monitoring protocol including motivational interviewing and collaborative care strategies. Clinical and patient-centred data were systematically collected during an 18-month follow-up including HbA1c, Patient Health Questionnaire, and the Diabetes Distress Scale. RESULTS: During the trial, 18-month follow-up HbA1C levels significantly (p < 0.001) decreased in the intervention group at every follow-up from an average of 8.72 (SD:1.49) to 7.03 (SD:1.09), but slightly increased in the control group from 8.65 (SD:1.40) to 8.84 (SD:1.38). Similar positive results were obtained in depression severity and diabetes distress, LDL-cholesterol, and systolic and diastolic blood pressure, but only at the 18-month follow-up in body mass index reduction. CONCLUSIONS: This is the first trial to concurrently decrease biological and psychological outcomes with a monthly brief telephonic intervention, pointing out that a combined biopsychosocial intervention and collaborative care strategy is essential for current world health challenges. CLINICALTRIALS: gov Identifier: NCT04097483. Patient or Public Contribution: Diabetic patients not belonging to the TELE-DD population or trial sample were consulted during the study design to review and guarantee the clarity and understanding of the trial psychoeducational materials.

The TELE-DD project on treatment nonadherence in the population with type 2 diabetes and comorbid depression.

Diabetic patients have increased depression rates, diminished quality of life, and higher death rates due to depression comorbidity or diabetes complications. Treatment adherence (TA) and the maintenance of an adequate and competent self-care are crucial factors to reach optimal glycaemic control and stable quality of life in these patients. In this report, we present the baseline population analyses in phase I of the TELE-DD project, a three-phased population-based study in 23 Health Centres from the Aragonian Health Service Sector II in Zaragoza, Spain. The objectives of the present report are: (1) to determine the point prevalence of T2D and clinical depression comorbidity and treatment nonadherence; (2) to test if HbA1c and LDL-C, as primary DM outcomes, are related to TA in this population; and (3) to test if these DM primary outcomes are associated with TA independently of shared risk factors for DM and depression, and patients' health behaviours. A population of 7,271 patients with type-2 diabetes and comorbid clinical depression was investigated for inclusion. Individuals with confirmed diagnoses and drug treatment for both illnesses (n = 3340) were included in the current phase I. A point prevalence of 1.9% was found for the T2D-depression comorbidity. The prevalence of patients nonadherent to treatment for these diseases was 35.4%. Multivariate analyses confirmed that lower diabetes duration, increased yearly PCS visits, HbA1c and LDL-C levels were independently related to treatment nonadherence. These findings informed the development of a telephonic monitoring platform for treatment of nonadherence for people with diabetes and comorbid depression and further trial, cost-effectiveness, and prognostic studies (phases II and III).

Protective role of mindfulness, self-compassion and psychological flexibility on the burnout subtypes among psychology and nursing undergraduate students.

AIMS: To explore the relationship between mindfulness, self-compassion and psychological flexibility, and the burnout subtypes in university students of the Psychology and Nursing degrees, and to analyse possible risk factors for developing burnout among socio-demographic and studies-related characteristics. DESIGN: Cross-sectional study conducted on a sample of 644 undergraduate students of Nursing and Psychology from two Spanish universities. METHODS: The study was conducted between December 2015 and May 2016. Bivariate Pearson's correlations were computed to analyse the association between mindfulness facets, self-compassion and psychological flexibility, and levels of burnout. Multivariate linear regression models and bivariate and multivariate binary logistic regressions were also computed. RESULTS: The three subtypes of burnout presented significant correlations with psychological flexibility, self-compassion and some mindfulness facets. Psychological flexibility, self-compassion and the mindfulness facets of observing and acting with awareness were significantly associated to burnout. Among the risk factors, 'year of study' was the only variable to show significantly higher risk for every burnout subtype. CONCLUSION: The significant associations found between mindfulness, self-compassion, psychological flexibility and burnout levels underline the need of including these variables as therapeutic targets when addressing the burnout syndrome in university students. IMPACT: Undergraduate students, especially those of health sciences, often experience burnout. This study delves into the protective role of some psychological variables: mindfulness, self-compassion and psychological flexibility. These should be considered as potentially protective skills for developing burnout, and therefore, undergraduate students could be trained on these abilities to face their studies and their future profession to prevent experiencing burnout syndrome.

No evidence for differential sociosexual behavior and space use in the color morphs of the European common wall lizard (Podarcis muralis).

Explaining the evolutionary origin and maintenance of color polymorphisms is a major challenge in evolutionary biology. Such polymorphisms are commonly thought to reflect the existence of alternative behavioral or life-history strategies under negative frequency-dependent selection. The European common wall lizard Podarcis muralis exhibits a striking ventral color polymorphism that has been intensely studied and is often assumed to reflect alternative reproductive strategies, similar to the iconic "rock-paper-scissors" system described in the North American lizard Uta stansburiana. However, available studies so far have ignored central aspects in the behavioral ecology of this species that are crucial to assess the existence of alternative reproductive strategies. Here, we try to fill this gap by studying the social behavior, space use, and reproductive performance of lizards showing different color morphs, both in a free-ranging population from the eastern Pyrenees and in ten experimental mesocosm enclosures. In the natural population, we found no differences between morphs in site fidelity, space use, or male-female spatial overlap. Likewise, color morph was irrelevant to sociosexual behavior, space use, and reproductive success within experimental enclosures. Our results contradict the commonly held hypothesis that P. muralis morphs reflect alternative behavioral strategies, and suggest that we should instead turn our attention to alternative functional explanations.

Efficacy of a blended low-intensity internet-delivered psychological programme in patients with multimorbidity in primary care: study protocol for a randomized controlled trial.

BACKGROUND: The World Health Organization (WHO) has included comorbidity between depression and a chronic disease among the 10 leading global health priorities. Although there is a high prevalence of multimorbidity, health care systems are mainly designed for the management of individual diseases. Given the difficulty in delivering face-to-face psychological treatments, alternative models of treatment delivery have been proposed, emphasizing the role of technologies such as the Internet. The aim of this study is to assess the efficacy in Primary Care (PC) of a blended low-intensity psychological intervention applied using information and communication technologies (ICTs) for the treatment of multimorbidity in PC (depression and type 2 diabetes/low back pain) by means of a randomized controlled trial (RCT). Our main hypothesis is that improved usual care combined with psychological therapy applied using ICTs will be more efficacious for improvement in the symptomatology of multimorbidity, compared to a group with only improved treatment as usual six months after the end of treatment. METHODS: A protocol has been designed combining a face-to-face intervention with a supporting online programme that will be tested by an RCT conducted in three different regions (Andalusia, Aragon and the Balearic Islands). The RCT will evaluate three hundred participants diagnosed with depression and type 2 diabetes/low back pain. Four highly experienced research groups specializing in clinical psychology are involved in this trial, and there will be ample possibilities for translation and transfer to usual clinical practice. DISCUSSION: This clinical trial will lead to improvement in financial sustainability, maximizing the use of resources and responding to principles of efficiency and effectiveness. Furthermore, based on the evaluation of the feasibility of implementing this intervention in primary care facilities, we expect to be able to suggest the intervention for incorporation into public policy. In conclusion, positive results of this study could have a significant impact on one of the most important health-related problems, multimorbidity. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03426709 . Registered retrospectively on 08 February 2018.

Through the eye of a lizard: hue discrimination in a lizard with ventral polymorphic coloration.

Colour polymorphisms are thought to be maintained by complex evolutionary processes, some of which require that the colours of the alternative morphs function as chromatic signals to conspecifics. Unfortunately, a key aspect of this hypothesis has rarely been studied: whether the study species perceives its own colour variation as discrete rather than continuous. The European common wall lizard (Podarcis muralis) presents a striking colour polymorphism: the ventral surface of adults of both sexes may be coloured orange, white, yellow or with a mosaic of scales combining two colours (orange-white, orange-yellow). Here, we used a discrimination learning paradigm to test whether P. muralis is capable of discriminating colour stimuli designed to match the ventral colours of conspecifics. We trained 20 lizards to eat from colour-coded wells bored in wooden blocks. Blocks had four colour-coded wells (orange, white, yellow and an achromatic control), but only one contained food (mealworm larvae). After six trials, the lizards performed significantly better than expected by chance, showing a decrease in both the number of wells explored and the latency to finding the food. Using visual modelling techniques, we found that, based on their spectral properties and the lizards' cone sensitivities, the ventral colours of P. muralis correspond to discrete rather than continuous colour categories, and that colour discriminability (i.e. distance in perceptual space) varies depending on the morphs compared, which may have implications for signal detection and discrimination. These results suggest that P. muralis can discriminate hue differences matching their own ventral colour variation.