Perceived barriers, facilitators and usefulness of a psychoeducational intervention for individuals with chronic musculoskeletal pain and depression in primary care.

Background and aims: Self-management interventions have the potential to improve patient' pain condition as they involve tasks aimed at managing symptoms and reducing interference with activities, mood and relationships due to pain. However, research on factors that facilitate or hinder pain self-management has overlooked patients with both chronic musculoskeletal pain and depression in primary care settings, also leaving unattended patient views on the usefulness of such programs. Thus, the main aim of this study was to gather meaningful information to help promoting adequate self-management. Specifically, it attempts to identify patients' perceptions of barriers and facilitators of group-based psychoeducational intervention and to explore its perceived usefulness in promoting self-management. Method: This qualitative study explored perceived barriers and facilitators of a psychoeducational intervention for the management of chronic musculoskeletal pain and depression previously tested in a Randomized Control Trial. We conducted focus groups and individual interviews with fifteen adult patients with both chronic musculoskeletal pain and depression recruited from primary care centres in Tarragona province (Catalonia, Spain). A content thematic analysis was carried out to examine the data. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Results: Findings revealed that perceived barriers included lack of motivation, time constraints, pain, depression, ineffectiveness of pain-relief strategies and activity avoidance. Facilitators were having a supportive family/friends, the positive effects of self-management, high motivation, being a proactive patient. Peer support and identification, the positive effect of sessions, and free expression were highlighted as key elements of the psychoeducational intervention. Conclusion: The psychoeducational intervention was perceived as useful in promoting self-management practices. Barriers and facilitators in using self-management strategies were related, mainly, to internal personal characteristics of the patients being similar among different cultural backgrounds and distinct chronic conditions. Implications: These findings can help to guide clinicians in the development and implementation of more effective pain self-management interventions for patients with chronic pain and depression by attending to their needs and preferences.

Short and long-term predictors of pain severity and interference in primary care patients with chronic musculoskeletal pain and depression.

BACKGROUND: Chronic pain and depression are frequent comorbidities in primary care. Depression among other psychosocial factors play a role in the clinical course of chronic pain. OBJECTIVE: To study the short and long-term predictive factors of severity and interference of chronic pain in primary care patients with chronic musculoskeletal pain and major depression. METHODS: Longitudinal study of a cohort of 317 patients. The outcomes are severity and functional interference of pain (Brief Pain Inventory) measured at 3 and 12 months. We performed multivariate linear regression models to estimate the effects the explanatory baseline variables on the outcomes. RESULTS: 83% participants were women; average age was 60.3 years (SD = 10.2). In multivariate models, baseline pain severity predicted pain severity at 3 months (ß = 0.53; 95% CI = 0.37-0.68) and at 12 months (ß = 0.48; 95% CI = 0.29-0.67). Also, pain > 2 years of evolution predicted long term pain severity (ß = 0.91; CI95%=0.11-1.71). Baseline pain interference predicted interference at 3 and 12 months (ß = 0.27; 95%CI = 0.11-0.43 and ß = 0.21; 95%CI = 0.03-0.40, respectively). Baseline pain severity predicted interference at 3 and 12 months (ß = 0.26; 95%CI = 0.10-0.42 and ß = 0.20; 95%CI = 0.02-0.39, respectively). Pain > 2 years predicted greater severity and greater interference at 12 months (ß = 0.91; CI95%=0.11-1.71, and ß = 1.23; CI95%=0.41-2.04). Depression severity predicted more interference at 12 months (ß = 0.58; CI95%=0.04-1.11). Occupational status as active worker predicted less interference throughout the follow-up (ß=-0.74; CI95%=-1.36 to -0.13 and ß=-0.96; CI95%=-1.71 to -0.21, at 3 and 12 months). Currently working also predicts less pain severity at 12 months (ß=-0.77; CI95%=1.52 - 0.02). With regard to the psychological variables, pain catastrophizing predicted pain severity and interference at three months (ß = 0.03; 95% CI = 0.00-0.05 and ß = 0.03; 95% CI = 0.00-0.05), but not at long term. CONCLUSION: In a sample of adults with chronic pain and depression, this primary care study has identified prognostic factors that independently predict the severity and functional interference of pain. If confirmed in new studies, these factors should be targeted for individualized interventions. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02605278), registered 16/11/2015.

Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: a qualitative study of primary care physicians and nurses.

BACKGROUND: Primary care plays a central role in the treatment of depression. Nonetheless, shortcomings in its management and suboptimal outcomes have been identified. Collaborative care models improve processes for the management of depressive disorders and associated outcomes. We developed a strategy to implement the INDI collaborative care program for the management of depression in primary health care centers across Catalonia. The aim of this qualitative study was to evaluate a trial implementation of the program to identify barriers, facilitators, and proposals for improvement. METHODS: One year after the implementation of the INDI program in 18 public primary health care centers we performed a qualitative study in which the opinions and experiences of 23 primary care doctors and nurses from the participating centers were explored in focus groups. We performed thematic content analysis of the focus group transcripts. RESULTS: The results were organized into three categories: facilitators, barriers, and proposals for improvement as perceived by the health care professionals involved. The most important facilitator identified was the perception that the INDI collaborative care program could be a useful tool for reorganizing processes and improving the management of depression in primary care, currently viewed as deficient. The main barriers identified were of an organizational nature: heavy workloads, lack of time, high staff turnover and shortages, and competing demands. Additional obstacles were inertia and resistance to change among health care professionals. Proposals for improvement included institutional buy-in to guarantee enduring support and the organizational changes needed for successful implementation. CONCLUSIONS: The INDI program is perceived as a useful, viable program for improving the management of depression in primary care. Uptake by primary care centers and health care professionals, however, was poor. The identification and analysis of barriers and facilitators will help refine the strategy to achieve successful, widespread implementation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03285659 ; Registered 18th September, 2017.

Cost-effectiveness of a collaborative care program for managing major depression and chronic musculoskeletal pain in primary care: Economic evaluation alongside a randomized controlled trial.

BACKGROUND: We designed a collaborative care program for the integrated management of chronic musculoskeletal pain and depression, which frequently coexist in primary care patients. The aim of this study was to evaluate the cost-effectiveness of this program compared with care as usual. METHODS: We performed a cost-effectiveness analysis alongside a randomized clinical trial. Results were monitored over a 12-month period. The primary outcome was the incremental cost-effectiveness ratio (ICER). We performed cost-effectiveness analyses from the perspectives of the healthcare system and society using an intention-to-treat approach with imputation of missing values. RESULTS: We evaluated 328 patients (167 in the intervention group and 161 in the control group) with chronic musculoskeletal pain and major depression at baseline. From the healthcare system perspective, the mean incremental cost was €234 (p = .17) and the mean incremental effectiveness was 0.009 QALYs (p = .66), resulting in an ICER of €23,989/QALY. Costs from the societal perspective were €235 (p = .16), yielding an ICER of €24,102/QALY. These estimates were associated with a high degree of uncertainty illustrated on the cost-effectiveness plane. CONCLUSIONS: Contrary to our expectations, the collaborative care program had no significant effects on health status, and although the additional costs of implementing the program compared with care as usual were not high, we were unable to demonstrate a favorable cost-effectiveness ratio, largely due to the high degree of uncertainty surrounding the estimates.

Curso de formación online para la implementación de un nuevo modelo de atención a la depresión en atención primaria / An online training course for the implementation of a new clinical model for depression in primary care

INTRODUCCIÓN: En el marco de una estrategia para implementar un nuevo programa clínico para la depresión en atención primaria, desarrollamos un curso online con clases videograbadas dirigido a los médicos y enfermeras que van a introducir el programa en su práctica clínica. SUJETOS Y MÉTODOS: La evaluación del curso se realizó mediante un cuestionario estandarizado a los alumnos y un análisis temático de los contenidos de un foro de discusión. RESULTADOS: En la encuesta, los alumnos mostraron satisfacción respecto a sus expectativas, valorando positivamente el formato y el diseño general, los contenidos y su utilidad práctica, sin diferencias significativas según el perfil profesional. En el análisis cualitativo del foro se detectaron potencialidades del programa y del curso, destacando la percepción de que se abordaba una necesidad asistencial relevante. También se señalaron insuficiencias del curso y del programa, y obstáculos externos que pueden dificultar o impedir la implementación: falta de tiempo, inestabilidad en los equipos o exceso de trabajo y requerimientos en el día a día. CONCLUSIONES: Hemos ensayado un eficaz formato online para la formación de profesionales. La evaluación del curso ha sido satisfactoria. El feedback de los alumnos permitirá modelar y perfeccionar futuras ediciones del curso y el propio programa

INTRODUCTION: Within the framework of a strategy to implement a new clinical program for depression in primary care, we developed an online course with videotaped lectures targeted at doctors and nurses who will introduce the program into their clinical practice. SUBJECTS AND METHODS: The evaluation of the course was carried out by a standardized questionnaire for students and a thematic analysis of the contents of a discussion forum. RESULTS: In the survey, the students showed satisfaction regarding their expectations, positively valuing the format and the general design, the contents and their practical utility, without significant differences according to professional profile. In the qualitative analysis of the forum potentialities of the program and the course were detected, highlighting the perception that a relevant care need was addressed. There were also shortcomings of the course and the program, and external obstacles that may hinder or impede implementation: lack of time, instability in the staff, or excessive work and requirements on a day-to-day basis. CONCLUSIONS: We have tested an effective online format for the training of professionals. The evaluation of the course has been satisfactory. The feedback of the students will allow us to model and improve future editions of the course and the program itself

The Role of Pain-Related Cognitions in the Relationship Between Pain Severity, Depression, and Pain Interference in a Sample of Primary Care Patients with Both Chronic Pain and Depression.

OBJECTIVE: The aims of this study were twofold: 1) to better understand the associations between pain-related cognitions and pain severity, and psychological and physical function, and 2) to determine the extent to which these cognitions function as mediators in the association between pain severity and depression in a sample of primary care adult patients with chronic pain and depression. DESIGN: Cross-sectional design. METHODS: Three hundred twenty-eight patients with both depression and chronic pain from primary care centers responded to measures of pain severity, pain interference, depression severity, and pain-related cognitions (including measures of catastrophizing and other pain-related beliefs). We performed three hierarchical regression analyses and two multiple regression analyses. RESULTS: The helplessness domain of pain catastrophizing was positively associated with pain severity, depression severity, and pain interference and mediated the relationship between depression and pain severity and vice versa. Beliefs about disability showed a positive association with pain severity, pain interference, and depression severity, and also mediated the relationship between pain severity and depression. Believing in a medical cure was positively associated with pain interference and negatively associated with depression; emotion beliefs were positively associated with pain severity. CONCLUSIONS: These findings provide important new information about the associations between several pain-related cognitions and pain severity, depression, and pain interference and the potential mediating roles that these cognitions play in the associations between pain severity and depression in patients with both chronic pain and depression in the primary care setting.

Effectiveness of a collaborative care intervention for managing major depression and chronic musculoskeletal pain in primary care: A cluster-randomised controlled trial.

BACKGROUND: Depression and chronic musculoskeletal pain commonly occur as comorbid conditions, which increases their negative effects on health outcomes. The objective of this study was to assess the effectiveness of the DROP (DepRessiOn and Pain) programme designed for the management of major depression and chronic musculoskeletal pain in primary care. METHODS: A cluster-randomised controlled trial was carried out between June 2015 and December 2017 with 328 patients with major depression and chronic musculoskeletal pain, randomly allocated to either intervention arm or usual care arm. The intervention included care management, optimised management of depression, and a psychoeducational programme. Outcomes were monitored using blinded interviews over a 12-month period. TRIAL REGISTRATION: NCT02605278 (ClinicalTrials.gov). RESULTS: After 12 months, 274 patients were evaluated (83.5% participation). The severity of depression (Hopkins Symptom Checklist score) was 0.23 points lower in the intervention arm [1.11 vs. 1.34; CI95% = -0.42 to -0.04]. Intervention arm's response rate to antidepressant treatment was 18.9% higher [39.6% vs. 20.7%; OR = 2.74; CI95% = 1.12-6.67] and its remission rate for depression was 9.0% higher [20.1% vs. 11.1%; OR = 2.13; CI95% = 0.94-4.85] compared to the usual care arm. There were no significant differences between the two arms in terms of pain severity (Brief Pain Inventory severity score) [6.23 vs. 6.66; difference = -0.39; CI95% = -1.13-0.35] or pain response rate [18.7% vs. 18.5%; OR = 1.02; CI95% = 0.46-2.26]. LIMITATIONS: This is a pragmatic study, and poor adherence to the programme by patients and physicians was a main limitation. CONCLUSION: The programme improves clinical outcomes for depression, although no clinical benefits were seen for pain.

Rol de la enfermera en intervenciones en la cronicidad / No disponible

No disponible

Sobre el editorial "Atender necesidades sociosanitarias de las personas con capacidades diferentes" / On the editorial "Addressing the sociosanitary necessities of persons with special needs"

No disponible

Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI·i project).

BACKGROUND: Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice. METHODS: Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care. DESIGN: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system. PARTICIPANTS: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia). INTERVENTION: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework. MEASURES: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact. DISCUSSION: This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03285659 ; Registered 12th September, 2017.

Evaluation of a multicomponent programme for the management of musculoskeletal pain and depression in primary care: a cluster-randomised clinical trial (the DROP study).

BACKGROUND: Chronic musculoskeletal pain and depression are very common in primary care patients. Furthermore, they often appear as comorbid conditions, resulting in additive effect on adverse health outcomes. On the basis of previous studies, we hypothesise that depression and chronic musculoskeletal pain may benefit from an integrated management programme at primary care level. We expect positive effects on both physical and psychological distress of patients. OBJECTIVE: To determine whether a new programme for an integrated approach to chronic musculoskeletal pain and depression leads to better outcomes than usual care. DESIGN: Cluster-randomised controlled trial involving two arms: a) control arm (usual care); and b) intervention arm, where patients participate in a programme for an integrated approach to the pain-depression dyad. SETTINGS: Primary care centres in the province of Tarragona, Catalonia, Spain, Participants: We will recruit 330 patients aged 18-80 with moderate or severe musculoskeletal pain (Brief Pain Inventory, average pain subscale ≥5) for at least 3 months, and with criteria for major depression (DSM-IV). INTERVENTION: A multicomponent programme according to the chronic care model. The main components are care management, optimised antidepressant treatment, and a psychoeducational group action. Blind measurements: The patients will be monitored through blind telephone interviews held at 0, 3, 6 and 12 months. OUTCOMES: Severity of pain and depressive symptoms, pain and depression treatment response rates, and depression remission rates. ANALYSIS: The outcomes will be analysed on an intent-to-treat basis and the analysis units will be the individual patients. This analysis will consider the effect of the study design on any potential lack of independence between observations made within the same cluster. ETHICS: The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAP), Barcelona, (P14/142). DISCUSSION: This project strengthens and improves treatment approaches for a major comorbidity in primary care. The design of the intervention takes into account its applicability under typical primary care conditions, so that if the programme is found to be effective it will be feasible to apply it in a generalised manner. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02605278 ; Registered 28 September, 2015.

Relación entre la remisión de la depresión y la calidad de vida percibida por el paciente / No disponible

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