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.

Mediators in psychological and psychoeducational interventions for the prevention of depression and anxiety. A systematic review.

Although efforts have been undertaken to determine how psychological interventions exert their effects, research on mediators and mechanisms of change remains limited, especially in the field of prevention. We aimed to assess available evidence on mediators of psychological and psychoeducational interventions for the prevention of depression and anxiety in varied populations. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and the Cochrane Central Register of Controlled Trials was performed. Two independent reviewers assessed the eligibility criteria of all articles, extracted data, determined the risk of bias in randomized controlled trials, and the requirements for mediators. The outcomes were mediators of the incidence of depression or anxiety and/or the reduction of symptoms of depression or anxiety. We identified 28 nested mediator studies within randomized controlled trials involving 7442 participants. Potential cognitive, behavioral, emotional and interpersonal mediators were evaluated in different psychological and psychoeducational interventions to prevent depression and anxiety. The effects were mediated mainly by cognitive variables, which were the most commonly assessed factors. For depression, the mediator with the strongest empirical support was negative thinking in adults. Cognitive change is an important mediator in preventive psychological and psychoeducational interventions for both anxiety and depression. REGISTRATION DETAILS: Registration number (PROSPERO): CRD42018092393.

Development of the therapeutic language coding system (SICOLENTE): Reliability and construct validity.

Since the use of language is a core aspect of psychotherapy, its study requires instruments that allow for further research. The aim of this study is to present an observational instrument capable of analyzing the language used in psychotherapeutic settings, both by therapists and clients. The SICOLENTE instrument was applied to two different samples: The Three Approaches to Psychotherapy film and a naturalistic sample. 7710 utterances from 31 sessions (three from the demonstration film and 28 from a naturalistic setting) were coded. Two studies were conducted: in the first study, inter and intra coder reliability (dimension and category levels) and Generalizability theory analyzes were assessed, whilst in the second study, construct validity was tested with several hypotheses. The final instrument resulted in 20 categories with three dimensions: Conversational Act (7 categories), Therapeutic topic (6 categories) and Content (7 categories). The three dimensions showed excellent inter and intra coder reliability and the generalizability coefficients were excellent. Out of the 24 validity hypothesis proposed,19 were accepted. The finding suggests that the SICOLENTE is a reliable and valid instrument that can be applied to investigate the performance of various theoretical models. Its three dimensional structure gives it the flexibility to be able to carry out macroscopic or microscopic language research.

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.

Validación de una escala de control personal: una medida específica de las expectativas de control percibido de búsqueda de empleo / Validation of a personal control scale: a specific measure of perceived control expectations in job search

Los técnicos en orientación profesional necesitan herramientas especializadas para medir la motivación de búsqueda de empleo. Entre los elementos que motivan a una persona a buscar trabajo destacan sus expectativas. Con el objetivo de evaluarlas, se creó la escala de Expectativas de Control Percibido de Búsqueda de Empleo (ECPBE) partiendo del modelo de Expectativas Generalizadas de Control (EGC) de Palenzuela. Se estudia la validez convergente-discriminante, la fiabilidad (consistencia interna y homogeneidad) y la validez factorial. Se obtienen correlaciones con las subescalas próximas teóricamente significativas y se confirma la presencia de cuatro factores para los ítems de autoeficacia, expectativas de éxito, locus de control interno y locus de control externo. Se puede considerar la ECPBE como una escala válida para medir las expectativas propuestas desde el modelo de EGC adaptado a la situación de búsqueda de empleo, presentando un adecuado nivel de homogeneidad y consistencia en la medida (AU)

Experts in career guidance need specialised tools to measure motivation for job search. Among the remarkable elements that motivate a person to search for a job are their own expectations. Aiming at evaluating expectations, the Perceived Control Expectations in Job Search (PCEJS) scale has been created based on Palenzuela's model of Generalized Expectancies of Control (GEC). Convergent-discriminant validity, reliability (internal consistency and homogeneity), and factorial validity are addressed in this study. Correlations are found among theoretically closed sub-scales, and the presence of 4 factors for the items of self-efficacy, expectations of success, internal locus of control and external locus of control is substantiated. The PCEJS can be considered a valid scale to measure expectations as proposed by the GEC model when adapted to a job search situation, showing an appropriate level of homogeneity and consistency in the measurement (AU)

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.

El cliente en psicoterapia: contribución al resultado terapéutico / Clients in psychotherapy: contribution to therapeutic outcome

En este trabajo se revisan las evidencias empíricas que apuntan a que los clientes son los principales responsables de los resultados de los tratamientos. Para ello se presentan dos tipos de datos: a) los que demuestran que las personas se enfrentan exitosamente a los problemas sin ayuda: estudios sobre la resiliencia, la recuperación espontánea, la auto-ayuda o el efecto placebo; y b) los que avalan que los usuarios de una psicoterapia son agentes activos durante todo el proceso terapéutico. Finalmente se hacen sugerencias sobre cómo adaptar las prácticas terapéuticas a esta nueva visión de los cliente

In this paper the empirical evidence pointing that customers are primarily responsible for the results is reviewed. Two types of data are presented: (a) those which demonstrate that people successfully face problems without help: studies on resilience, spontaneous recovery, self-help or placebo effect; and (b) those which show that the users of a psychotherapy are active agents throughout the therapeutic process. Finally, suggestions are made on how to adapt the therapeutic practices to this new visión

Effectiveness of psychological and/or educational interventions to prevent the onset of episodes of depression: A systematic review of systematic reviews and meta-analyses.

OBJECTIVE: To determine the effectiveness of psychological and/or educational interventions to prevent the onset of episodes of depression. METHODS: Systematic review of systematic reviews and meta-analyses (SR/MA). We searched PubMed, PsycINFO, Cochrane Database of Systematic Reviews, OpenGrey, and PROSPERO from their inception until February 2014. Two reviewers independently evaluated the eligibility criteria of all SR/MA, abstracted data, and determined bias risk (AMSTAR). RESULTS: Twelve SR/MA (156 non-repeated trials and 56,158 participants) were included. Of these, 142 (91%) were randomized-controlled, 13 (8.3%) controlled trials, and 1 (0.6%) had no control group. Five SR/MA focused on children and adolescents, four on specific populations (women after childbirth, of low socioeconomic status, or unfavorable circumstances; patients with severe traumatic physical injuries or stroke) and three addressed the general population. Nine (75%) SR/MA concluded that interventions to prevent depression were effective. Of the 156 trials, 137 (87.8%) reported some kind of effect size calculation. Effect sizes were small in 45 (32.8%), medium in 26 (19.1%), and large in 25 (18.2%) trials; 41 (29.9%) trials were not effective. Of the 141 trials for which follow-up periods were available, only 34 (24.1%) exceeded 12 months. CONCLUSION: Psychological and/or educational interventions to prevent onset of episodes of depression were effective, although most had small or medium effect sizes.

Risk factors for the onset of panic and generalised anxiety disorders in the general adult population: a systematic review of cohort studies.

BACKGROUND: We aimed to assess available evidence on risk factors associated with the onset of panic disorder (PD) and/or generalised anxiety disorder (GAD) in cohort studies in the general adult population. METHODS: Systematic review using MEDLINE, PsycINFO and Embase. Search terms included panic disorder, generalised anxiety disorder, cohort studies and risk factors. RESULTS: We finally selected 21 studies, involving 163,366 persons with a median follow-up of 5 years. 1) Sociodemographic factors: PD was associated with age, female gender, and few economic resources. GAD was associated with age, non-Hispanics and Blacks, being divorced or widowed, and few economic resources. 2) Psychosocial factors: PD was associated with smoking and alcohol problems. GAD was associated with stressful life events in childhood and adulthood, and personality. 3) Physical and mental health factors: PD was associated with the number of physical diseases suffered and the joint hypermobility syndrome. PD was also associated with a parental history of mental disorders, as well as with other anxiety disorders and other mental health problems in the person affected. GAD was associated with a parental history of mental disorders, as well as with other anxiety disorders and other mental health problems in the person affected, plus already having received psychiatric care. LIMITATIONS: Few studies examined the same risk factors. CONCLUSIONS: Sociodemographic, psychosocial and mental-physical health risk factors were determinant for the onset of PD and GAD in the general adult population. These findings could be useful for developing preventive interventions in PD and GAD.

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.

Expectativas y duración del desempleo / Expectancies and unemployment length

En este artículo se analiza la relación entre una serie de expectativas medidas en personas que buscan trabajo y la duración de su situación de desempleo, considerando también las variables edad y sexo. Para ello se propone un modelo explicativo de la conducta motivada de los desempleados donde las expectativas tienen un papel preponderante. Se utiliza como medida cognitiva la escala Expectativas de Control Percibido en Búsqueda de Empleo (ECPBE) y como método de estudio estadístico el análisis de supervivencia (regresión de Cox). Los resultados muestran una relación significativa entre la motivación y la duración del desempleo encontrándose que las personas con puntuaciones altas en el ECPBE tardan como media 14 meses menos en conseguir trabajo que los que puntúan bajo. También se confirman valores más altos que la media en la duración del desempleo para mujeres y los mayores de 30 años(AU)

This article presents a study analysing the relationships between a set of psychological variables and the time people spend in getting a job. Age and gender are also considered. An expectations-based model to explain motivated behaviour in finding a job is suggested. The Perceived Control Expectancies in Job Finding Scale (PCEJFS) is used as a cognitive variable. Survival Analysis (Cox regression) is used as statistical analysis. The results show a significant relationship between motivation and duration of unemployment. Comparing people with higher and lower scores in PCEJF scales, it takes people with higher scores an average of 14 months shorter to find a job than people with lower scores. Females and people over thirty spend longer in securing employment(AU)

La investigación de resultados y el futuro de la psicoterapia: alternativas a los tratamiento empíricamente validados / No disponible

La realidad de partida es que un mismo problema psicológico puede ser tratado, más o menos exitosamente, con diferentes alternativas de tratamiento, y que la elección de la alternativa va a depender más de la historia de aprendizaje del terapeuta que la aplica, que de lo que establecen los estudios científicos al respecto. El buen funcionamiento de nuestros Servicios de Salud Mental exige que se establezcan criterios de eficacia para seleccionar los tratamientos psicológicos que en ellos se practican. A nuestro país ha llegado en los últimos años la filosofía estadounidense de los Tratamientos Empíricamente Validados, con sus criterios y su metodología para determinar qué tratamientos podemos considerar exitosos. En este artículo se discute dicha filosofía y se proponen alternativas que entendemos más ajustadas al contexto de salud mental español (AU)

The point of departure is the reality that the same psychological problem can be treated, more or less successfully, with different treatment alternatives, and that the choice of alternative will depend more on the learning history of the therapist who applies it, than on what is established by the scientific studies on the topic. The proper functioning of our Mental Health Services demands the establishment of efficacy criteria for the selection of the psychological treatments practiced within these Services. In recent years, our country has witnessed the arrival of the North American philosophy of Empirically Validated Treatments, with its criteria and its methodology for the determination of which treatments can be considered successful. This article discusses the aforementioned philosophy, and proposes alternatives that we consider to be better suited to the Spanish mental health context (AU)