A multifaceted provider-centred intervention versus usual care to improve the recognition and diagnosis of depression in primary health care: a hybrid study.

BACKGROUND: The aim of this study was to evaluate the impact of a multifaceted intervention to implement an adapted guideline for the management of depression in primary health care. METHODS: A hybrid trial was carried out to determine the effect of a multicomponent provider-centred intervention to improve the detection and diagnosis of depression in primary care, as part of the guideline implementation process, and to collect information about barriers and facilitators in a real-world context. Before the multicomponent intervention, a descriptive cross-sectional study was performed to assess the population prevalence of depression in the participating health centres and to detect possible differences. Subsequently, a quasi-experimental two-phase study was carried out with a concurrent control group to assess the impact of the multicomponent intervention on the main outcomes (detection of depression, evaluation of its severity and the use of structured methods to support the diagnosis). RESULTS: Nine-hundred seventy-four patients took part in the first phase. According to their clinical records, the prevalence of depression ranged from 7.2% to 7.9%, and there were no significant differences between the health centres scheduled to receive the intervention and those in the control group. In the experimental phase, 797 randomly selected participants received the multicomponent intervention. Adjusted multivariable analysis performed before the implementation revealed no significant differences in depression between the experimental and control groups. However, after the intervention, modest but significant differences were observed, which persisted at 1 year after the intervention. CONCLUSIONS: A multicomponent intervention for the implementation of a clinical guideline for the management of depression in primary care produced improvements in the identification of depression and in the degree of severity recorded.

"It's That They Treated Me Like an Object": A Qualitative Study on the Participation of People Diagnosed with Psychotic Disorders in Their Health Care.

The mental health recovery model is based on shared decision making, in which patients' preferences and perceptions of the care received are taken into account. However, persons with psychosis usually have very few opportunities to participate in this process. The present study explores the experiences and perceptions of a group of patients with psychosis-in some cases longstanding, in others more recently diagnosed-concerning their participation in the decisions taken about the approach to their condition and about the attention received from healthcare professionals and services. For this purpose, we performed a qualitative analysis of the outcomes derived from five focus groups and six in-depth interviews (36 participants). Two major themes, with five sub-themes, were identified: shared decision-making (drug-centred approach, negotiation process, and lack of information) and the care environment and styles of clinical practice as determinants (aggressive versus person-centred environments, and styles of professional practice). The main conclusions drawn are that users want to participate more in decision making, they want to be offered a range of psychosocial options from the outset and that their treatment should be based on accessibility, humanity and respect. These findings are in line with the guidelines for clinical practice and should be taken into account in the design of care programmes and the organisation of services for persons with psychosis.

A new form of checking obsessive-compulsive disorder in physicians: Another consequence of the COVID-19 pandemic. A case series.

The current article provides information that facilitates early identification of a new form of checking obsessive-compulsive disorder (OCD) detected in physicians during the COVID-19 pandemic. This article describes three cases of professional checking OCD in physicians. Physicians with checking OCD are obsessively concerned about making a mistake that will result in fatal consequences. The most frequent strategies of neutralization include avoiding direct contact with patients by taking sick or vacation leaves; compulsively studying for many hours daily (neglecting other aspects of life); checking the status of their patients by arranging additional follow-up consultations or making phone calls even out of working hours; repeatedly checking the medical history of their patients, and persistently recalling the last appointment. Physicians with check OCD often seek reassurance from their colleagues and consult the scientific literature for information about issues they used to be competent in. These patients may also experience anticipatory anxiety and mental blocks. However, egodystony is milder than in other forms of OCD. The COVID pandemic may have exacerbated these neutralization behaviors, since it has forced physicians to adapt to a new work environment. The recommended treatments (Exposure with Response Prevention Therapy or/and SSRI) provide beneficial effects in a short time.

Study protocol: a randomised, controlled trial of a nurse navigator program for the management of hepatitis C virus in patients with severe mental disorder.

BACKGROUND: To evaluate the impact of a nurse navigation program on treatment adherence and resolution of hepatitis C infection in patients with severe mental disorder. METHODS: An open, randomized, controlled trial with blinded outcome assessment. The intervention group will engage in a nurse navigation program designed by mental health nurses. The program involves active screening for patients with severe mental disorder. The patients and caregivers included in the program will receive information, training, support and guidance throughout the treatment and recovery process, which involves different healthcare professionals and units. The control group will receive the standard of care, which includes follow-up by a family physician, referral to the hepatologist, serological testing, new referral to the hepatologist, onset of treatment, and follow-up. Multidisciplinary care will be provided along a coordinated and seamless clinical pathway led by a nurse navigator. The primary endpoints are total recovery (hepatitis C cure) and treatment adherence. Occurrence of symptoms of schizophrenia and health-related quality of life will be also recorded. Follow-up of patients will be performed three and six months after the administration of antiviral treatment. The study was authorised by the Ethics Committee of Malaga in December 2021. Funding was approved in March 2021. DISCUSSION: If this intervention is proven to be effective in improving treatment access and adherence, it will represent a step forward in addressing a chronic health issue that is 16 times more prevalent in the population with severe mental disease. Finally, this intervention may lead to the detection of undertreated HCV infection in this population of patients. TRIAL REGISTRATION: This protocol has been registered in ClinicalTrials.gov with identifier code NCT04891445 on May 18, 2021.

'I do not know where it comes from, I am suspicious of some childhood trauma' association of trauma with psychosis according to the experience of those affected.

Background: Trauma-related symptoms are often experienced after a first psychotic episode. Objective: In this study, we conduct a qualitative analysis of referred traumatic experiences of outpatients diagnosed with psychotic disorders. Method: Focus groups were formed and in-depth interviews conducted with 30 participants, focusing on their experience with the disorder and the health care received. Given the frequency with which trauma and psychosis have been associated in the scientific literature, the nature of this relation is addressed as a secondary objective, via a qualitative analysis. Results: Analysis revealed two main themes in the patients' discourse. On many occasions, traumatic experiences were related to the development of the disorder. Although most participants referred to traumatic experiences during childhood, episodes during adult life were also reported, which may have triggered the disorder. The second theme was that of the interlocking relationship between the psychotic experience and certain coercive practices undergone during the provision of health care for psychosis, and the traumatic effects thus generated. Conclusions: The participants considered both themes to be highly important. Accordingly, these issues should be carefully assessed and managed in order to provide appropriate person-centred care.

Antecedentes: Los síntomas relacionados con el trauma a menudo se experimentan después de un primer episodio psicótico.Objetivo: En este estudio, realizamos un análisis cualitativo de experiencias traumáticas de pacientes ambulatorios diagnosticados con trastornos psicóticos.Método: Se conformaron grupos focales y se realizaron entrevistas en profundidad a 30 participantes, enfocándose en su experiencia con el trastorno y la atención médica recibida. Dada la frecuencia con la que el trauma y la psicosis se han asociado en la literatura científica, la naturaleza de esta relación se aborda como un objetivo secundario, a través de un análisis cualitativo.Resultados: El análisis reveló dos temas principales en el discurso de los pacientes. En muchas ocasiones, las experiencias traumáticas se relacionaron con el desarrollo del trastorno. Aunque la mayoría de los participantes se refirieron a experiencias traumáticas durante la infancia, también se informaron episodios durante la vida adulta, los que pueden haber desencadenado el trastorno. El segundo tema fue el de la relación entrelazada entre la experiencia psicótica y ciertas prácticas coercitivas sufridas durante la prestación de atención médica para la psicosis, y los efectos traumáticos generados por ésta.Conclusiones: Los participantes consideraron que ambos temas eran de gran importancia. En consecuencia, estas situaciones deben evaluarse y gestionarse cuidadosamente para proporcionar una atención adecuada centrada en la persona.

Predictors of Adherence in Three Low-Intensity Intervention Programs Applied by ICTs for Depression in Primary Care.

Depression is one of the most common disorders in psychiatric and primary care settings, and is associated with disability, loss in quality of life, and economic costs. Internet-based psychological interventions have been shown to be effective in depression treatment but present problems with a low degree of adherence. The main aim of this study is to analyze the adherence predictors in three low-intensity interventions programs applied by Information and Communication Technologies (ICTs) for depression. A multi-center, randomized, controlled clinical trial was conducted with 164 participants with depression, who were allocated to: Healthy Lifestyle Program, Positive Affect Promotion Program or Mindfulness Program. Sociodemographic characteristics, Patient Health Questionnaire-9, Visual Analog Scale, Short Form Health Survey, Positive and Negative Affect Schedule, Five Facets Mindfulness Questionnaire, Pemberton Happiness Index and Treatment Expectancy Questionnaire were used to study adherence. Results showed that positive affect resulted in a predictor variable for Healthy Lifestyle Program and Positive Affect Promotion Program. Perceived health was also a negative adherence predictor for the Positive Affect Promotion Program. Our findings demonstrate that there are differences in clinical variables between treatment completers and non-completers and we provide adherence predictors in two intervention groups. Although new additional predictors have been examined, further research is essential in order to improve tailored interventions and increase adherence treatment.

Use of the ADAPTE method to develop a clinical guideline for the improvement of psychoses and schizophrenia care: Example of involvement and participation of patients and family caregivers.

INTRODUCTION: The aim of this study is to analyse different ways of participation during the development of a clinical guideline to improve the early detection of psychosis and to deploy a comprehensive treatment plan to improve prognosis and social integration. MATERIALS AND METHOD: The clinical guideline was developed using the ADAPTE method with the participation of 40 authors and 80 external reviewers. The process was divided into three major phases: set up, adaptation and finalization. During adaptation and completion, a total of 44 patients and 18 family caregivers were involved. RESULTS AND CONCLUSIONS: The different roles assumed by the patients and their family caregivers were described, depending on the panel in which they participated, with diverse grades of complexity: a user as author, integration of the results of qualitative research with the participation of local users and family caregivers, 13 users as individual external reviewers and the participation of users and caregiver organizations in the external review. In the guideline, contributions from patients during the qualitative research were included in an innovative way, placing them just behind the recommendations. On the other hand, the results of the family caregivers' study were included in a specific area of uncertainty. Further, the expressed point of view was considered as the collective demands of users and family caregivers' organizations in the cost-benefit analysis made by the organizing committee. There were diverse ways to conduct direct patient participation during the guideline development, ensuring that their individual experiences contributed significantly to the final version.

Efficacy of Three Low-Intensity, Internet-Based Psychological Interventions for the Treatment of Depression in Primary Care: Randomized Controlled Trial.

BACKGROUND: Primary care is a major access point for the initial treatment of depression, but the management of these patients is far from optimal. The lack of time in primary care is one of the major difficulties for the delivery of evidence-based psychotherapy. During the last decade, research has focused on the development of brief psychotherapy and cost-effective internet-based interventions mostly based on cognitive behavioral therapy (CBT). Very little research has focused on alternative methods of treatment for depression using CBT. Thus, there is a need for research into other therapeutic approaches. OBJECTIVE: This study aimed to assess the effectiveness of 3 low-intensity, internet-based psychological interventions (healthy lifestyle psychoeducational program [HLP], focused program on positive affect promotion [PAPP], and brief intervention based on mindfulness [MP]) compared with a control condition (improved treatment as usual [iTAU]). METHODS: A multicenter, 4-arm, parallel randomized controlled trial was conducted between March 2015 and March 2016, with a follow-up of 12 months. In total, 221 adults with mild or moderate major depression were recruited in primary care settings from 3 Spanish regions. Patients were randomly distributed to iTAU (n=57), HLP (n=54), PAPP (n=56), and MP (n=54). All patients received iTAU from their general practitioners. The main outcome was the Spanish version of the Patient Health Questionnaire-9 (PHQ-9) from pretreatment (time 1) to posttreatment (time 2) and up to 6 (time 3) and 12 (time 4) months' follow-up. Secondary outcomes included the visual analog scale of the EuroQol, the Short-Form Health Survey (SF-12), the Positive and Negative Affect Schedule (PANAS), and the Pemberton Happiness Index (PHI). We conducted regression models to estimate outcome differences along study stages. RESULTS: A moderate decrease was detected in PHQ-9 scores from HLP (ß=-3.05; P=.01) and MP (ß=-3.00; P=.01) compared with iTAU at posttreatment. There were significant differences between all intervention groups and iTAU in physical SF-12 scores at 6 months after treatment. Regarding well-being, MP and PAPP reported better PHI results than iTAU at 6 months post treatment. PAPP intervention significantly decreased PANAS negative affect scores compared with iTAU 12 months after treatment. CONCLUSIONS: The low-intensity, internet-based psychological interventions (HLP and MP) for the treatment of depression in primary care are more effective than iTAU at posttreatment. Moreover, all low-intensity psychological interventions are also effective in improving medium- and long-term quality of life. PAPP is effective for improving health-related quality of life, negative affect, and well-being in patients with depression. Nevertheless, it is important to examine possible reasons that could be implicated for PAPP not being effective in reducing depressive symptomatology; in addition, more research is still needed to assess the cost-effectiveness analysis of these interventions. TRIAL REGISTRATION: ISRCTN Registry ISRCTN82388279; http://www.isrctn.com/ISRCTN82388279. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12888-015-0475-0.

Development of a guideline for the treatment of generalized anxiety disorder with the ADAPTE method.

OBJECTIVE: The aim was to develop a clinical guideline for managing generalised anxiety disorder in Primary Health Care and Mental Health, using guideline adaptation methods. DESIGN: A clinical guideline was developed, following the methods of the ADAPTE group, and implemented in a Primary Health Care District and in Mental Health Services in Spain. SETTING: Regional University Hospital of Málaga and District of Primary Health Care Málaga-Guadalhorce (Spain). PARTICIPANTS: The participants were family physicians, psychiatrists and clinical psychologists. The phases of the process included definition of clinical scenarios, literature search and guidelines appraisal, elaboration of recommendations, conducting focus groups with users diagnosed with generalised anxiety disorder, linking the testimonials of users with recommendations, external review and implementation by multifaceted interventions. RESULTS: The final release included 49 Recommendations, of which 47 are from the 2011 NICE guidance for GAD and 2 of the 2011 NICE guideline for common mental disorder. Finally, seven recommendations needed to be adapted to the Spanish health care context, and three recommendations were excluded. CONCLUSIONS: A guideline aimed to improve the quality and effectiveness of the care provided to people with generalised anxiety disorder has been released. The use of adaptation methods has simplified the use of resources and time. This guideline and the process designed for its implementation constitute a suitable collection of resources for the improvement on detection and treatment of GAD in primary health care. Adaptation methods play a key role in the knowledge translation continuum.

'I have anxiety, but I have values and preferences' Experiences of users with generalized anxiety disorder: A qualitative study.

To understand the experience and perceptions of people diagnosed with generalized anxiety disorder, along the whole process and their role through the decision-making process for their treatment. A qualitative study through focus groups composed of people diagnosed with generalized anxiety disorder was carried out. Content analysis was carried out to explore the most representative issues. Five thematic categories were identified: onset of the disorder, symptoms and course; daily life with the disorder; coping with the disorder; demand of healthcare for anxiety, and treatment options and decision-making. Most of the patients reported physical symptoms of anxiety. The majority of participants perceived little social support from their environment and occupational interferences. Coping seems to differ among participant that have recovered or not recovered. The involvement of users with generalized anxiety disorder was scarce, and pharmacological treatment was always the first option offered. There is scarce orientation to elicit preferences and values of patients across the process of care for people with generalized anxiety disorder. The consequence is a biased predisposition of the healthcare system to provide pharmacological treatment as the first option and ignore the perspective of patients on how to cope with their illness.

Place preferences induced by electrical stimulation of the external lateral parabrachial subnucleus in a sequential learning task: Place preferences induced by NLPBe stimulation.

It is known that electrical stimulation of the external lateral parabrachial nucleus (NLPBe) can sustain concurrent taste and place learning. Place preferences can be learned through different procedures. Previous studies demonstrated that electrical stimulation of the PBNLe can generate aversive and preference place learning using concurrent procedures. In the concurrent procedure, the animals can move freely in the maze, and intracranial electrical stimulation is associated with their voluntary stay in one of the two maze compartments. However, the rewarding properties of most stimuli, whether natural or drugs of abuse, have usually been investigated using the sequential procedure, in which animals are confined while receiving the unconditioned stimulus and then undergo a choice test without stimulation in a later phase. This study examined whether this stimulation can sustain place preference learning in sequential tasks. Results demonstrated that place preferences can also be induced by the electrical stimulation of the NLBe using sequential procedures. These findings suggest that the NLPBe may form part of a brain reward axis that shares certain characteristics with those observed in the processing of natural rewarding agents and especially of drugs of abuse.

Tolerance to rewarding brain electrical stimulation: Differential effects of contingent and non-contingent activation of parabrachial complex and lateral hypothalamus.

Electrical stimulation of the parabrachial complex and related insular cortex induces concurrent conditioned place preference (CPP) in a naloxone-dependent manner. Furthermore, repeated rewarding activation of these regions generates tolerance, i.e., a reduction of the reinforcing effect. This study examined the effects of contingent and non-contingent stimulation in a CPP task. In the former modality, the animals can voluntarily select areas of the maze and thereby determine whether or not they receive stimulation. In the non-contingent procedure, the animals passively receive the administration of the rewarding electrical current while confined in the preferred place. Tolerance to the rewarding stimulation was observed in the non-contingent procedure, in which the external lateral parabrachial subnucleus (LPBe) was stimulated in a behaviorally passive task, but not in the contingent procedure. In contrast, no tolerance was observed in the group receiving rewarding stimulation of the lateral hypothalamus after either contingent or non-contingent brain activation. These findings are discussed in terms of the rewarding effects induced after contingent or non-contingent administration of electrical or chemical rewarding agents.

Tiapride prevents the aversive but not the rewarding effect induced by parabrachial electrical stimulation in a place preference task.

The parabrachial complex has been related to the processing of both rewarding and aversive signals. This pontine area is activated after the gastrointestinal administration of rewarding nutrients, in taste aversion learning, and in response to the reinforcing and aversive effects of some drugs of abuse. Electrical stimulation of this region can induce, in different animals, preference or aversion behaviors towards a place in a rectangular three-chamber maze task. This study examined the effect of tiapride, a D2/D3 receptor antagonist, on the aversive or rewarding effects induced by electrical stimulation of the external lateral parabrachial subnucleus (NLPBe). As previously observed, administration of tiapride interrupted the aversive effect induced by NLPBe electrical stimulation. However, in contrast to the effects of dopamine antagonists on other rewarding systems, tiapride did not impair the place preference induced by NLPBe stimulation, an activation effect that is subject to tolerance. Tiapride administration also appeared to have no effect on the horizontal motor activity (crossings) of the electrically stimulated animals. We discuss the specific relevance of parabrachial reward with respect to other reinforcing brain components or systems, especially in relation to the preference effect of drugs of abuse, such as opiates, after dopamine antagonist administration.

Use of the ADAPTE Method to Develop a Guideline for the Improvement of Depression Care in Primary Care.

Depression is the most frequent psychiatric disorder in primary health care, and the evidence shows that there is suboptimal management by primary care practitioners, perhaps owing to difficulties in decision making. Because clinical guidelines can improve decision making and management, a clinical guideline to manage depression in primary health care was developed in adherence to the ADAPTE method and was implemented in the Málaga Primary Health Care District in Spain. This column reports on the guideline development process, which produced a set of resources to improve the quality of primary health care-based depression care in Spain.

Naloxone blocks the aversive effects of electrical stimulation of the parabrachial complex in a place discrimination task.

The parabrachial complex is known to participate in various rewarding and aversive processes, including those related to the learning of taste or place discrimination and the motivational effects of drugs of abuse, such as morphine. This study shows that electrical stimulation of the external lateral parabrachial (LPBe) subnucleus induces consistent place avoidance or place preference in three-compartment rectangular mazes. Administration of naloxone, an opiate antagonist, blocks both motivational effects induced by the intracranial electrical stimulation. Subsequent re-administration of the electrical stimulation was found to recover its aversive but not its rewarding effects after vehicle administration. These results are discussed in relation to different natural and artificial agents involved in the induction of avoidance and preference motivational processes, especially with regard to the opioid system.

Tolerance to repeated rewarding electrical stimulation of the parabrachial complex.

The parabrachial complex has been related to various rewarding behavioral processes. As previously shown, electrical stimulation of the lateral parabrachial external (LPBe) subnucleus induces opiate-dependent concurrent place preference. In this study, two groups of animals (and their respective controls) were subjected to sessions of rewarding brain stimulation daily or on alternate days. The rats stimulated every other day maintained a consistent preference for the place associated with the brain stimulation. However, as also found in the Insular Cortex, there was a progressive decay in the initial place preference of animals receiving daily stimulation. These data suggest that the rewarding effects induced by electrical stimulation of LPBe subnucleus may be subject to tolerance. These findings are discussed with respect to other anatomical areas showing reward decay and to the reinforcing effects induced by various electrical and chemical rewarding agents.

Tolerance to repeated rewarding electrical stimulation of the insular cortex.

The insular cortex (IC) has been related to various reinforcing behavioral processes. This study examined the effect of electrical stimulation of the posterior agranular IC on concurrent place preferences. Two groups of animals and their respective controls underwent rewarding brain stimulation every day or on alternate days. While the rats stimulated every other day maintained their preference for the place associated with brain stimulation, those stimulated every day evidenced a reduction in their place preference, suggesting tolerance to the stimulation's rewarding effect. A 15% increase in the current intensity produced a recovery of the preferences of the daily-stimulated rats but had no effect on those stimulated on alternate days. These results are discussed in terms of the rewarding effects induced by different electrical and chemical rewarding agents.

Tiapride impairs the aversive effect of electrical stimulation of the parabrachial complex in a conditioned place task.

The parabrachial complex has been related to various rewarding or aversive behavioral processes, including taste aversion learning and conditioned place aversion. This study examined the effect of tiapride, an antagonist of D2/D3 dopaminergic receptors, on place aversion induced by electrical stimulation of the external lateral parabrachial (LPBe) nucleus. Results obtained show that brain-stimulated animals avoid the area of the maze associated with electrical stimulation but show no such behavioral rejection when they receive an injection of 30 mg/kg tiapride. Furthermore, tiapride did not appear to affect the horizontal motor activity (crossing) of the animals. These results are discussed in the context of the different natural and artificial modalities used to induce aversive behavior and their relationship with dopamine systems.

Identificacion de los estudios clinicos controlados y metaanalisis en las revistas de salud en Colombia 1948-1998: El caso colombiano / Clinical controlled trials and metaanalysis in Colombia

Objetivo: Identificar los estudios clínicos controlados (ECC), los estudios clínicos aleatorizados (RCT) y metaanálisis publicados en las revistas de salud de Colombia, en el período comprendido entre 1948 y 1998. Material y métodos: se ubicaron 255 revistas del listado suministrado por la Hemeroteca del Instituto Colombiano para la Educación Superior (ICFES), se seleccionaron 85 a nivel nacional y 42 que correspondían a la ciudad de Santafé de Bogotá que cumplían con los siguientes requisitos: 1) ser llevado a cabo en humanos; 2) comparar dos o más intervenciones entre sí; 3) asignación aleatoria de las intervenciones; 4) diseño prospectivo en la planificación de las intervenciones y asignación de los sujetos. Se utilizó la metodología "Guía para la búsqueda manual de ensayos clínicos controlados" propuesta por el Centro Cochrane Español. Resultados: en el período comprendido entre octubre del 98 y octubre del 99 se revisaron 22 publicaciones de la ciudad de Santafé de Bogotá, encontrándose un total de 151 estudios distribuidos así: 133 CCT, 16 RCT y dos metaanálisis, ocupando los primeros lugares: Revista Colombiana de Anestesiología, Revista Colombiana de Ginecología y Obstetricia, Acta de Otorrinolaringología y Cirugía de Cabeza y Cuello, Revista de la Sociedad Colombiana de Pediatría y Acta Médica Colombiana. Los temas más publicados fueron: ginecología y obstetricia 12 ensayos (sin clasificar), trauma seis ensayos, infectología cinco ensayos (sin clasificar) y patología osteomuscular tres ensayos. Conclusiones: la identificación de publicaciones con validez metodológica permite evaluar la calidad de la investigación y de las publicaciones en nuestro medio, además de comparar si corresponden a prioridades nuestras. Es necesario completar el estudio incluyendo el resto de las publicaciones identificadas en las diferentes ciudades del país.