Depression in internal medicine inpatients at the time of hospital discharge and referral to primary care

Background and objectives. This is the first multi-center study intended to document the prevalence, characteristics, and associations of depression in Medicine patients at the time of hospital discharge and their referral to Primary Care (PC). Methods. Adult patients randomly selected among consecutive admissions to Medicine wards in 8 hospitals in Spain, covering health districts, were examined in a two-phase 'case-finding' procedure. Standardized, Spanish versions of instruments were used, including the Standardized Polyvalent Psychiatric Interview (SPPI) and Cumulative Illness Rating Scale (CIRS). Cases of depression were diagnosed according to ICD-10 general hospital research criteria. Results. Three hundred and twelve patients with treatable depression and 777 non-depressed controls were identified. In a conservative estimate, the global prevalence of major depression was 7.1%, dysthymia 4.2% and adjustment depression 7.1%, and 51.9% of cases were of moderate/ severe intensity. Depression was more frequent in women, the differences being significant in all categories of depression. The prevalence of depression was lower in individuals aged 85 or more years, the differences being significant in cases of both dysthymia and adjustment depression. A clear pattern of decreasing prevalence with age was observed in women. The depressed had as an average five medical systems affected, and higher CIRS scores compared with the controls, the differences being significant in cases of both major depression and dysthymia. Conclusions. This is the first report showing a considerable prevalence of treatable cases of depression in Medicine patients at the time of hospital discharge and referral to PC. Depression is associated with the severity of the medical condition, and differences observed by age and sex have clinical implications. Paper read at the 3rd Annual Meeting of the European Association of Psychosomatic Medicine, Nuremberg 2015.

Analysis of Retinal Layers in Fibromyalgia Patients with Premium Protocol in Optical Tomography Coherence and Quality of Life.

PURPOSE: To evaluate the inner retinal layers in fibromyalgia (FM) patients compared to control subjects using posterior pole protocol (PPole) analysis in optical coherence tomography (OCT) and to correlate structural retinal changes with subjective quality of life. METHODS: Seventy-four eyes of healthy subjects and 55 eyes of those with FM were analyzed. All subjects underwent retinal evaluation using the PPole protocol for Spectralis OCT (Heidelberg Engineering) to obtain measurements of the retinal nerve fiber layer (RNFL) and the ganglion cell layer (GCL) in the macular area. The EuroQol (EQ-5D) questionnaire and Fibromyalgia Impact Questionnaire (FIQ) were performed to analyze health-related quality of life. Additionally, the FM group was divided into three groups depending on the disease phenotype (atypical, depressive, and biological). RESULTS: Patients with FM presented with a reduction of the RNFL thickness compared to controls in 17/64 cells of the PPole area, and a reduction of the GCL thickness in 47/64 cells. Depressive FM phenotype showed the greatest number of cells with significant reduction compared with the control group in both RNFL and GCL layers. A correlation between temporal-inferior cells of the GCL and the EuroQol 5D questionnaire results was observed. CONCLUSIONS: Patients with FM present with a reduction of the inner retinal layers in the macular area. This degeneration correlates with disease severity/reduced quality of life in these patients. The PPole protocol for OCT is a non-invasive and fast tool that might help clinicians diagnose and monitor neurodegeneration in FM patients.

The use of optical coherence tomography in the evaluation of patients with bipolar disorder. / Utilidad de la tomografía de coherencia óptica en la evaluación de los pacientes con trastorno bipolar.

Bipolar disorder (BD) is a mental disorder characterised by episodes of extremal mood changes. In recent years, some researchers found neurodegeneration in patients with BD using Magnetic Resonance Imaging. Evaluation of the optic nerve and the retinal layers using optical coherence tomography (OCT) has proved to be a useful, non-invasive tool for diagnosis and monitoring of neurodegenerative diseases. Accordingly, a decrease in the retinal nerve fibre layer and the ganglion cell complex measured by OCT was found in patients with BD in different studies, suggesting that BD is a neurodegenerative process in addition to a psychiatric disorder. Therefore, the neuro-ophthalmological evaluation of these patients could be used as a marker for diagnosis of this disease. This work analyses literature on retinal degeneration in bipolar disorder patients, and evaluates the ability of OCT devices in the detection of neuronal degeneration affecting the different retinal layers in these patients, and its possible role in the diagnosis and monitoring of the disease.

Facilitators and barriers to modifying dietary and hygiene behaviours as adjuvant treatment in patients with depression in primary care: a qualitative study.

BACKGROUND: Major depression is a highly prevalent condition. Its pathogenesis is related to a wide variety of biological and psychosocial factors and among these is factors related to lifestyle. Lifestyle-based interventions seem to be appropriate strategies as coadjutant treatment. The objective of this study is to explore and identify expectations and experiences of both patients and healthcare professionals that can point to the main barriers and facilitators with regard to the promotion of healthy dietary and hygiene behaviours in patients suffering from major depression. METHODS: A qualitative design was used to collect information from a wide range of purposefully and theoretically guided samples of depressed patients and health professionals from Primary Care (PC). Both in-depth interviews and discussion groups were used. A standardized protocol was designed to guide the interviews and groups, including the preparation of a topic list to be addressed, with previously tested, open suggestions that could be of interest. A thematic analysis was performed from grounded theory in order to explore, develop and define until saturation the emergent categories of analysis derived from the individual interview and group data. RESULTS: Both patients as well as PC professionals noted a series of central aspects with respect to the implementation of a programme for the acquisition of healthy dietary and hygiene habits for depressive patients, which may be organized around 'personal', 'programmatic', and 'transversal' aspects. As for the personal aspects, categories regarding 'patient history', and 'disposition' were found; the programmatic aspects included categories such as 'presentation and monitoring', and modification of 'cognitive' and 'behavioural' habits; whereas the transversal aspects comprised the possibilities of 'social support' and defining categories of 'objectives'. CONCLUSION: The implementation of intervention programmes that combine dietary and hygiene-related factors in patients with depression is complex, given the nature of the disorder itself, and its symptoms such as apathy and feelings of guilt or incompetence. Key issues exist for the success of the intervention, such as the simplicity of guidelines, tailoring through motivational interviewing, prolonged and intense monitoring throughout the different stages of the disorder, and the provision of adequate feedback and social support. PC could be an appropriate level in which to implement these interventions.

Recommendations for the management of comorbidity in hidradenitis suppurativa.

BACKGROUND: The association between hidradenitis suppurativa (HS) and some diseases is becoming relevant in recent years. Providing appropriate management of HS from an early stage requires to include prompt diagnosis and treatment of concomitant diseases and to prevent any potential comorbidity. This approach should consider the adverse events of the drugs used to treat HS potentially related to the onset of a comorbidity. OBJECTIVE: To provide the dermatologist with an accurate, easily used tool that will inform the diagnosis of HS comorbidity, and to facilitate decision-making regarding the referral and treatment of patient with HS-associated comorbidity. METHODS: These recommendations have been developed by a working group composed of seven experts (three dermatologists, a cardiovascular specialist internist, a rheumatologist expert in spondyloarthritis, a gastroenterologist and a psychiatrist) and a team of three methodologist researchers. The expert group selected the HS comorbidities considered in these recommendations through a literature review. The recommendations on diagnostic criteria are based on the relevant clinical practice guidelines for each of the comorbidities and on the recommendations of the experts. The information regarding the repercussion of HS medical treatments on associated comorbid diseases was obtained from the summary of product characteristics of each drug. RESULTS: The comorbidities considered in this guide are as follows: cardiovascular risk factors (diabetes, dyslipidaemia, obesity, hypertension and metabolic syndrome), inflammatory bowel disease, inflammatory joint disorders and psychological disorders (anxiety and depression). In addition, the association between HS and the consumption of alcohol and tobacco is included. The tables and figures are a precise, easy-to-use tool to systematize the diagnosis of comorbidity in patients with HS and facilitate the decision-making process regarding referral and treatment of patients with an associated disease. CONCLUSION: The application of these recommendations will facilitate the dermatologist practice and benefit HS patients' health and quality of life.

Inflammatory Bowel Disease and Eating Disorders: A systematized review of comorbidity.

OBJECTIVE: Research has shown that there is an association between Inflammatory Bowel Disease, anxiety and mood disorders, however little is known about their association with Eating Disorders. In this paper we will present a case of a young female with a comorbid diagnosis of Inflammatory Bowel Disease and Eating Disorder, and then discuss the results from a systematic review of the literature, describing published cases of patients with the same condition. METHODS: A systematized review of the literature was conducted according to MOOSE guidelines. A computerized literature search of MEDLINE, PsycINFO and EMBASE, and a manual search through reference lists of selected original articles were performed to identify all published case-reports, case series and studies of Inflammatory Bowel Disease and Eating Disorders. RESULTS: Fourteen articles were included, encompassing 219 cases, including ours. The vast majority were females ranging from 10 to 44years old. Anorexia Nervosa (n=156) and Crohn's Disease (n=129) was the most frequent combination (n=90) reported in the literature. These cases present a poor prognosis because of corticoid refusal, medication abandon and/or deliberate exacerbation of IBD symptoms, in the context of trying to lose weight. CONCLUSION: Recent evidence suggests there is a possible association between Inflammatory Bowel Disease and Eating Disorders, although the mechanisms involved in its ethiopathogenesis are still unknown. To be aware of this association is important because a delayed diagnosis of this comorbidity may lead to worse prognosis. Further research and a multidisciplinary approach could facilitate earlier diagnosis and provide therapeutic interventions.

How to reduce the number of rating scale items without predictability loss?

Rating scales are used to elicit data about qualitative entities (e.g., research collaboration). This study presents an innovative method for reducing the number of rating scale items without the predictability loss. The "area under the receiver operator curve method" (AUC ROC) is used. The presented method has reduced the number of rating scale items (variables) to 28.57% (from 21 to 6) making over 70% of collected data unnecessary. Results have been verified by two methods of analysis: Graded Response Model (GRM) and Confirmatory Factor Analysis (CFA). GRM revealed that the new method differentiates observations of high and middle scores. CFA proved that the reliability of the rating scale has not deteriorated by the scale item reduction. Both statistical analysis evidenced usefulness of the AUC ROC reduction method.

Desmotivación del personal sanitario y síndrome de burnout. Control de las situaciones de tensión. La importancia del trabajo en equipo / Burnout Syndrome and Demotivation Among Health Care Personnel. Managing Stressful Situations: The Importance of Teamwork

Las personas invertimos casi un tercio de nuestra vida en el lugar de trabajo, donde se desarrollan gran parte de las relaciones interpersonales y las situaciones de tensión. El estrés laboral asociado a estas conlleva consecuencias para la salud física y mental de las personas. El estrés laboral y el síndrome del profesional quemado (burnout) son las principales consecuencias derivadas de las situaciones de tensión constantes en el trabajo. El estrés es la segunda causa de baja laboral en la Unión Europea, y alrededor de un 12% de los trabajadores europeos podría padecer actualmente el síndrome del profesional quemado. Por todo esto, es fundamental la detección en las organizaciones, grandes (hospitales y clínicas) y pequeñas (consultas), del personal desmotivado y estresado, ya que permitirá una prevención e intervención precoz en las situaciones de tensión generadas y una mejora en el funcionamiento de los equipos de trabajo

Almost one-third of our lives is spent in the workplace, where much of our interaction with others takes place and where we are exposed to stressful situations. Work-related stress has consequences for the individual's physical and mental health. Stress and professional burnout syndrome are the main consequences of work situations characterized by a constant state of tension. Stress is the second leading cause of absenteeism in the European Union, and around 12% of European workers are currently affected by burnout syndrome. It is therefore vital to identify demotivated and stressed staff in both large organizations (hospitals and clinics) and smaller centers (private practices) so as to facilitate preventive measures and ensure early intervention in situations of stress, with a view to improving the performance of work teams

Detección precoz de la enfermedad psicoemocional en dermatología / Early Detection of Emotional and Behavioral Disorders in Dermatology

Muchas enfermedades dermatológicas van asociadas a trastornos psiquiátricos. No es fácil la distinción entre la normalidad y el trastorno psiquiátrico cuando la intensidad de los síntomas psicológicos es leve, como suele ocurrir en dermatología. Por eso revisamos el concepto de trastorno psiquiátrico. Por otra parte, son necesarios instrumentos para detectar una enfermedad psicológica de forma precoz, cuando los síntomas son todavía menores. Para ello se han desarrollado cuestionarios breves, sencillos, autoadministrados por el propio paciente, que ayudan a dermatólogos y demás profesionales sanitarios a sospechar con alto grado de certeza la existencia de una enfermedad psiquiátrica. Nos centraremos en los cuestionarios más utilizados que detectan las 2 enfermedades psiquiátricas más frecuentes: ansiedad y depresión. Por último, describiremos las circunstancias en las que es recomendable derivar a un paciente dermatológico al psiquiatra para que sea este quien le siga de forma reglada

Many skin diseases are associated with mental disorders. When the psychological symptoms are mild, as is often the case in dermatology, it can be difficult to distinguish between normality and the manifestations of a mental disorder. To facilitate the distinction we review the concept of mental disorder in the present article. It is also important to have instruments that can facilitate early detection of psychological disease, i.e. when the symptoms are still mild. Short, simple, self-administered questionnaires have been developed to help dermatologists and other health professionals identify the presence of a mental disorder with a high degree of certainty. In this article, we focus on the questionnaires most often used to detect the 2 most common mental disorders: anxiety and depression. Finally, we describe the circumstances in which it is advisable to refer a dermatological patient to a psychiatrist, who can diagnose and treat the mental disorder in accordance with standard protocols

Burnout Syndrome and Demotivation Among Health Care Personnel. Managing Stressful Situations: The Importance of Teamwork. / Desmotivación del personal sanitario y síndrome de burnout. Control de las situaciones de tensión. La importancia del trabajo en equipo.

Almost one-third of our lives is spent in the workplace, where much of our interaction with others takes place and where we are exposed to stressful situations. Work-related stress has consequences for the individual's physical and mental health. Stress and professional burnout syndrome are the main consequences of work situations characterized by a constant state of tension. Stress is the second leading cause of absenteeism in the European Union, and around 12% of European workers are currently affected by burnout syndrome. It is therefore vital to identify demotivated and stressed staff in both large organizations (hospitals and clinics) and smaller centers (private practices) so as to facilitate preventive measures and ensure early intervention in situations of stress, with a view to improving the performance of work teams.

Early Detection of Emotional and Behavioral Disorders in Dermatology. / Detección precoz de la enfermedad psicoemocional en dermatología.

Many skin diseases are associated with mental disorders. When the psychological symptoms are mild, as is often the case in dermatology, it can be difficult to distinguish between normality and the manifestations of a mental disorder. To facilitate the distinction we review the concept of mental disorder in the present article. It is also important to have instruments that can facilitate early detection of psychological disease, i.e. when the symptoms are still mild. Short, simple, self-administered questionnaires have been developed to help dermatologists and other health professionals identify the presence of a mental disorder with a high degree of certainty. In this article, we focus on the questionnaires most often used to detect the 2 most common mental disorders: anxiety and depression. Finally, we describe the circumstances in which it is advisable to refer a dermatological patient to a psychiatrist, who can diagnose and treat the mental disorder in accordance with standard protocols.

El impacto emocional de la enfermedad dermatológica / The Emotional Impact of Skin Diseases

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Study of perfusion changes in the optic disc of patients with fibromyalgia syndrome using new colorimetric analysis software.

PURPOSE: We measured the amount of hemoglobin at the optic nerve head of fibromyalgia (FM) patients using new colorimetric analysis software. We also investigated whether perfusion defects of the optic nerve head in patients with FM lead to tissue atrophy and corresponding retinal nerve fiber layer (RNFL) thinning measured by optical coherence tomography (OCT). METHODS: We recruited for this cross-sectional study 118 FM patients and 76 sex- and age-matched healthy controls. All subjects underwent a complete neuro-ophthalmologic examination, which also included visual field testing using the Spark strategy in an Easyfield perimeter, and OCT examinations using the Spectralis. One photograph of the optic disc was obtained using a Cirrus™ Photo 800 multi-modality imager. We analyzed fundus photographs using Laguna ONhE software, a new method that allows hemoglobin levels to be measured at the optic nerve head. We compared hemoglobin percentages in different sectors of the nerve head and RNFL thicknesses between the two groups. RESULTS: Mean hemoglobin percentages and hemoglobin content in all optic nerve head sectors calculated by the Laguna ONhE program were significantly lower in FM patients than in healthy controls, and the main differences were detected in the outer ring, which corresponds with the neuroretinal rim. However, only the differences in the superotemporal RNFL were statistically significant. Correlations between the RNFL thickness and the percentage of hemoglobin in the different sectors were weak. CONCLUSION: Optic disc perfusion was decreased in patients with FM, especially within the neuroretinal rim, without clear involvement in the RNFL.

Lifestyle change recommendations in major depression: Do they work?

BACKGROUND: Modifying some lifestyle factors can be useful in depression, at least as an adjuvant treatment. Combining different lifestyle interventions seems to be an adequate strategy to increase their antidepressant efficacy according with preliminary studies, but this issue has not been enough investigated. METHODS: The present study is a randomized, double-blinded, multicentre, two arm-parallel clinical trials, with a 12 month follow-up. The sample consisted of 273 Primary Care patients. Four combined hygienic-dietary written recommendations were given to the patients about diet, exercise, light exposure and sleep hygiene. RESULTS: Both active and control interventions were associated with improvement on BDI (Beck Depression Inventory) scores. However, there were not statistically significant differences (7.0 vs. 7.6; p=0.594). LIMITATIONS: We were unable to monitor whether patients carry out recommendations. Intervention could be too difficult to accomplish for depressed patients without enough support and supervision. CONCLUSIONS: Just giving written lifestyle recommendations are not enough for depressive patients to benefit from them, so perhaps lifestyle change recommendations work or do not work on Depression depending on how they are presented to patients and on monitoring systems of their implementation.

The implementation of mindfulness in healthcare systems: a theoretical analysis.

OBJECTIVE: Evidence regarding the efficacy of mindfulness-based interventions (MBIs) is increasing exponentially; however, there are still challenges to their integration in healthcare systems. Our goal is to provide a conceptual framework that addresses these challenges in order to bring about scholarly dialog and support health managers and practitioners with the implementation of MBIs in healthcare. METHOD: This is an opinative narrative review based on theoretical and empirical data that address key issues in the implementation of mindfulness in healthcare systems, such as the training of professionals, funding and costs of interventions, cost effectiveness and innovative delivery models. RESULTS: We show that even in the United Kingdom, where mindfulness has a high level of implementation, there is a high variability in the access to MBIs. In addition, we discuss innovative approaches based on "complex interventions," "stepped-care" and "low intensity-high volume" concepts that may prove fruitful in the development and implementation of MBIs in national healthcare systems, particularly in Primary Care. CONCLUSION: In order to better understand barriers and opportunities for mindfulness implementation in healthcare systems, it is necessary to be aware that MBIs are "complex interventions," which require innovative approaches and delivery models to implement these interventions in a cost-effective and accessible way.

The effects of a single session of upper alpha neurofeedback for cognitive enhancement: a sham-controlled study.

The minimization of the non-specific factors of neurofeedback (NF) is an important aspect to further advance in the understanding of the effects of these types of procedures. This paper investigates the NF effects of a single session (25 min) of individual upper alpha enhancement following a sham-controlled experimental design (19 healthy participants). We measured immediate effects after the training and 1-day lasting EEG effects (eyes closed resting state and task-related activity), as well as the event-locked EEG effects during the execution of a mental rotation task. These metrics were computed in trained (upper alpha) and non-trained EEG parameters (lower alpha and lower beta). Several cognitive functions were assessed such as working memory and mental rotation abilities. The NF group showed increased upper alpha power after training in task-related activity (not significantly sustained 1 day after) and higher pre-stimulus power during the mental rotation task. Both groups improved cognitive performance, with a more prominent improvement for the NF group, however a single session seems to be insufficient to yield significant differences between groups. A higher number of training sessions seems necessary to achieve long-lasting effects on the electrophysiology and to enhance the behavioral effects.

The effects of individual upper alpha neurofeedback in ADHD: an open-label pilot study.

Standardized neurofeedback (NF) protocols have been extensively evaluated in attention-deficit/hyperactivity disorder (ADHD). However, such protocols do not account for the large EEG heterogeneity in ADHD. Thus, individualized approaches have been suggested to improve the clinical outcome. In this direction, an open-label pilot study was designed to evaluate a NF protocol of relative upper alpha power enhancement in fronto-central sites. Upper alpha band was individually determined using the alpha peak frequency as an anchor point. 20 ADHD children underwent 18 training sessions. Clinical and neurophysiological variables were measured pre- and post-training. EEG was recorded pre- and post-training, and pre- and post-training trials within each session, in both eyes closed resting state and eyes open task-related activity. A power EEG analysis assessed long-term and within-session effects, in the trained parameter and in all the sensors in the (1-30) Hz spectral range. Learning curves over sessions were assessed as well. Parents rated a clinical improvement in children regarding inattention and hyperactivity/impulsivity. Neurophysiological tests showed an improvement in working memory, concentration and impulsivity (decreased number of commission errors in a continuous performance test). Relative and absolute upper alpha power showed long-term enhancement in task-related activity, and a positive learning curve over sessions. The analysis of within-session effects showed a power decrease ("rebound" effect) in task-related activity, with no significant effects during training trials. We conclude that the enhancement of the individual upper alpha power is effective in improving several measures of clinical outcome and cognitive performance in ADHD. This is the first NF study evaluating such a protocol in ADHD. A controlled evaluation seems warranted due to the positive results obtained in the current study.

Validation of laughter for diagnosis and evaluation of depression.

BACKGROUND: In the medical field, laughter has been studied for its beneficial effects on health and as a therapeutic method to prevent and treat major medical diseases. However, very few works, if any, have explored the predictive potential of laughter and its potential use as a diagnostic tool. METHOD: We registered laughs of depressed patients (n=30) and healthy controls (n=20), in total 934 laughs (517 from patients and 417 from controls). All patients were tested by the Hamilton Depression Rating Scale (HDRS). The processing was made in Matlab, with calculation of 8 variables per laugh plosive. General and discriminant analysis distinguished patients, controls, gender, and the association between laughter and HDRS test. RESULTS: Depressed patients and healthy controls differed significantly on the type of laughter, with 88% efficacy. According to the Hamilton scale, 85.47% of the samples were correctly classified in males, and 66.17% in women, suggesting a tight relationship between laughter and the depressed condition. LIMITATIONS: (i) The compilation of humorous videos created to evoke laughter implied quite variable chances of laughter production. (ii) Some laughing subjects might not feel comfortable when recording. (iii) Evaluation of laughter episodes depended on personal inspection of the records. (iv) Sample size was relatively small and may not be representative of the general population afflicted by depression. CONCLUSIONS: Laughter may be applied as a diagnostic tool in the onset and evolution of depression and, potentially, of neuropsychiatric pathologies. The sound structures of laughter reveal the underlying emotional and mood states in interpersonal relationships.

EEG-based upper-alpha neurofeedback for cognitive enhancement in major depressive disorder: a preliminary, uncontrolled study.

Conditioning of the upper-alpha rhythm to improve cognitive performance in healthy users by means of neurofeedback (NF) has been evaluated by several studies, however its effectiveness in people with severe cognitive deficits, such as depressive subjects, remains underexplored. This paper reports on a preliminary uncontrolled study to assess the effects of an upper-alpha NF intervention on patients with major depressive disorder (MDD). The NF effects on the EEG and cognitive performance were assessed. The EEG results showed that patients were able to modulate the upper-alpha rhythm in task-related EEG and during training, in both cases across the executions of the NF sessions, and pre and post within each session. The behavioral results showed the effectiveness of this intervention in a variety of cognitive functions such as working memory, attention, and executive functions.