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 registrationClinicalTrials.gov, identifier: NCT03990792

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 registrationClinicalTrials.gov, identifier: NCT03990792

Body mass index interacts with a genetic-risk score for depression increasing the risk of the disease in high-susceptibility individuals

Depression is strongly associated with obesity among other chronic physical diseases. The latest mega- and meta-analysis of genome-wide association studies have identified multiple risk loci robustly associated with depression. In this study, we aimed to investigate whether a genetic-risk score (GRS) combining multiple depression risk single nucleotide polymorphisms (SNPs) might have utility in the prediction of this disorder in individuals with obesity. A total of 30 depression-associated SNPs were included in a GRS to predict the risk of depression in a large case-control sample from the Spanish PredictD-CCRT study, a national multicentre, randomized controlled trial, which included 104 cases of depression and 1546 controls. An unweighted GRS was calculated as a summation of the number of risk alleles for depression and incorporated into several logistic regression models with depression status as the main outcome. Constructed models were trained and evaluated in the whole recruited sample. Non-genetic-risk factors were combined with the GRS in several ways across the five predictive models in order to improve predictive ability. An enrichment functional analysis was finally conducted with the aim of providing a general understanding of the biological pathways mapped by analyzed SNPs. We found that an unweighted GRS based on 30 risk loci was significantly associated with a higher risk of depression. Although the GRS itself explained a small amount of variance of depression, we found a significant improvement in the prediction of depression after including some non-genetic-risk factors into the models. The highest predictive ability for depression was achieved when the model included an interaction term between the GRS and the body mass index (BMI), apart from the inclusion of classical demographic information as marginal terms (AUC = 0.71, 95% CI = [0.65, 0.76]). Functional analyses on the 30 SNPs composing the GRS revealed an over-representation of the mapped genes in signaling pathways involved in processes such as extracellular remodeling, proinflammatory regulatory mechanisms, and circadian rhythm alterations. Although the GRS on its own explained a small amount of variance of depression, a significant novel feature of this study is that including non-genetic-risk factors such as BMI together with a GRS came close to the conventional threshold for clinical utility used in ROC analysis and improves the prediction of depression. In this study, the highest predictive ability was achieved by the model combining the GRS and the BMI under an interaction term. Particularly, BMI was identified as a trigger-like risk factor for depression acting in a concerted way with the GRS component. This is an interesting finding since it suggests the existence of a risk overlap between both diseases, and the need for individual depression genetics-risk evaluation in subjects with obesity. This research has therefore potential clinical implications and set the basis for future research directions in exploring the link between depression and obesity-associated disorders. While it is likely that future genome-wide studies with large samples will detect novel genetic variants associated with depression, it seems clear that a combination of genetics and non-genetic information (such is the case of obesity status and other depression comorbidities) will still be needed for the optimization prediction of depression in high-susceptibility individuals

Patients’ Opinions about Knowing Their Risk for Depression and What to Do about It. The PredictD-Qualitative Study

[Background] The predictD study developed and validated a risk algorithm for predicting the onset of major depression in primary care. We aimed to explore the opinion of patients about knowing their risk for depression and the values and criteria upon which these opinions are based. [Methods] A maximum variation sample of patients was taken, stratified by city, age, gender, immigrant status, socio-economic status and lifetime depression. The study participants were 52 patients belonging to 13 urban health centres in seven different cities around Spain. Seven Focus Groups (FGs) were given held with primary care patients, one for each of the seven participating cities. [Results] The results showed that patients generally welcomed knowing their risk for depression. Furthermore, in light of available evidence several patients proposed potential changes in their lifestyles to prevent depression. Patients generally preferred to ask their General Practitioners (GPs) for advice, though mental health specialists were also mentioned. They suggested that GPs undertake interventions tailored to each patient, from a “patient-centred” approach, with certain communication skills, and giving advice to help patients cope with the knowledge that they are at risk of becoming depressed. [Conclusions] Patients are pleased to be informed about their risk for depression. We detected certain beliefs, attitudes, values, expectations and behaviour among the patients that were potentially useful for future primary prevention programmes on depression.This work was supported by grants from the Andalusian Council of Health [grant reference: 2008/0195][www.juntadeandalucia.es/fundacionprogres​oysalud]; the Department of Health of the Basque Government [grant reference: 2008/111021][www.osakidetza.euskadi.net]; the Spanish Network of Primary Care Research “redIAPP” (RD06/0018), the “Aragón group” (RD06/0018/0020), the “Sant Joan de Deu group” (RD07/0018/0017), “Bizkaya group” (RD07/0018/0018), “Castilla-León group” (RD07/0018/0027) and the “SAMSERAP group” (RD06/0018/0039 and CTS-587) [www.rediapp.org]

A personalized intervention to prevent depression in primary care: cost-effectiveness study nested into a clustered randomized trial

Abstract 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.This work was supported by grants from the Spanish Ministry of Health, the Institute of Health Carlos III (ISCIII) and the European Regional Development Fund (ERDF) ’A way to build Europe’(grant references PS09/02272, PS09/02147, PS09/01095, PS09/00849 and PS09/00461); the Andalusian Council of Health (grant reference PI-0569-2010); the Spanish Network of Primary Care Research ’redIAPP’ (RD06/0018, RD12/0005/0001); the ’Aragón group’ (RD06/0018/0020, RD12/0005/0006); the ’Bizkaya group’ (RD06/0018/0018, RD12/0005/0010); the Castilla-León Group (RD06/0018/0027); the Mental Health (SJD) Barcelona Group (RD06/0018/0017, RD12/0005/0008); and the Mental-Health, Services and Primary Care (SAMSERAP) MálagaGroup (RD06/0018/0039, RD12/0005/0005)

Intervención sobre los pacientes hiperutilizadores de atención primaria

Tesis Univ. Granada. Departamento de Medicina Legal, Toxicología y Psiquiatría. Leída el 14 de julio de 200

Oferta de actividades preventivas propuestas por médicos residentes de Medicina Familiar en Atención Primaria y su relación con las habilidades comunicacionales.

To determine the offer of preventive activities by resident physicians of family medicine in the Primary Care consultations and the relation with their communication habilities. A descriptive multicentre study assessing medical consultations video recording. Eight Primary Healthcare centres in Jaen (Andalucia). Seventy-three resident physicians (4th year) filmed and observed with patients. Offer of preventive activities (according to the Spanish Program of Preventive Activities and Health Promotion -PAPPS-). Doctor, patient and consultation characteristics. Peer-review of the communication between physicians and patients, using a CICAA scale. A descriptive, bivariate, logistic regression analysis was performed. Two hundred and sixty interviews were evaluated (duration 8.5±4.0min) of 73 residents (50.7% women, mean age 32.9±7.7 years, 79% urban environment). The patient is more frequently a woman (60%) who comes alone (72%) due to acute processes (80%) and with 2.1±1.0 demands. Preventive activities are offered in 47% (duration less than one minute) of primary (70%) and secondary (59%) prevention, offered through advice (72%) or screening (52%) and focused on the cardiovascular area (52%) and lifestyles (53%). Eighty percent related to the patient's reason for consultation. Communication skills 41% improvable, 26% adequate, 23% excellent. The offer of preventive activities is related to the duration of the consultation (OR=1.1, 95% CI 1.01; 1.16) and communication skills (OR=1.03, 95% CI 1.01; 1.10). Preventive activities are carried out in almost half of the consultations, although focused on advice and screening and linked to the patient's demand. Consultation time and communication skills favor a greater preventive offer

Patients with severe mental illness and their carers’ expectations for GPs’ communication skills: a qualitative approach in Spain

Background: Effective communication with GPs (General Practitioners) enables higher rates of patient satisfaction and adherence to treatment plans. People with severe mental illness (SMI) and their caregivers present unique characteristics that present difficulties in the GP–carer–patient communication process. Aim: To explore the expectations of patients with SMI and their caregivers regarding GPs’ communication skills in primary care consultations. Design & setting: Face-to-face interviews, using focus group methodology, which were undertaken in southern Spain. Method: Forty-two participants took part in 21 paired semi-structured interviews with an average duration of 19±7.2 minutes. Information was audio-recorded and transcribed verbatim. Qualitative content analysis was undertaken, obtaining a codification in categories by means of triangulation. Results: Four themes emerged from the analysis. Theme 1 was interviewer communication characteristics. The ability of GPs to use a language that was colloquial and adapted to each person was perceived as a determinant of the quality of care provided. An empathetic attitude, low reactivity, and efficient time management were the most valued communication skills. Theme 2 was telemedicine: telephone consultation and video consultation. The telephone consultation was perceived as a useful tool to care for people with SMI. Video consultation was valued as a requirement in isolated rural areas. Theme 3 was the role of the caregiver during the clinical interview. The caregiver was considered by the patients as an ally who improves the clinical interview. Theme 4 was the perceived barriers and facilitators during the clinical interview. The continuity of care, defined by a low turnover of GPs, determined the quality perceived by those who required care. Conclusion: Themes emerging from this study have suggested that people with SMI require an inclusive, collaborative, and personalised approach in the care they receive from the public health system. Improved communication between GPs and patients with SMI is an essential requirement for quality medical care

Influencia del acompañante en las consultas de Atención Primaria sobre las habilidades en comunicación y el tiempo de entrevista.

To know the influence of the companion in triadic clinical encounter on the quality of doctor-patient communication and the duration of the interview. Cross-sectional descriptive study. 10 Primary Care Centers. Resident doctors of Family and Community Medicine. Peer review of video recordings of clinical demand consultations. CICAA-2 questionnaire to assess communication skills (improvable, acceptable or adequate); age and sex, reasons for consultation and duration of the interview. Bivariate and multivariate analyses. Ethical authorization, oral informed consent and custody of the video recordings. 73 RD (53.8% women, 32.9±7.7 years) participated with 260 interviews (60.3% women and 2.1±1.0 clinical demands). 27.7% of consultations with a companion (female sex 65.3%). The mean duration of the interviews was 8.5±4.0min. Clinical encounters lasted longer when a companion attended (2.7±0.5min more; p Triadic communications challenge the clinician's communication skills, improving their abilities to identify and understand patient problems, albeit at the cost of a greater investment of time

Common mental disorders in primary care: diagnostic and therapeutic difficulties, and new challenges in prediction and prevention. SESPAS Report 2020

In primary health care only chronic pain surpass depression and anxiety in loss of quality-adjusted life years. More than 70% of people suffering from common mental disorders consulted their GPs for this reason. However, 'the declining halves rule' is a reality: less than 50% of primary care attendees with common mental disorders were correctly diagnosed, of these less than 50% received adequate treatment (pharmacological or psychological) and of these less than 50% patients were adherent. Collaborative models of common mental disorders care in primary health care have demonstrated their effectiveness through clinical trials; however, its implementation in a more general and real context is difficult and its effectiveness remains unclear. Risk algorithms have been developed and validated in primary health care to predict the onset and prognosis of common mental disorders; which are useful for their treatment and prevention. There is evidence that psychological and psychoeducational interventions (and possibly those of physical exercise) are effective for the primary prevention of common mental disorders, even in primary health care; although their effects are small or moderate. These interventions have a high potential to be scalable in schools, workplace and primary health care; in addition, when they are administered through information and communication technologies (e.g. by App), in self-guided or minimally guided programs, they have demonstrated their effectiveness for the treatment and prevention of common mental disorders. They are also very accessible, have low cost and contribute to the massive implementation of these interventions in different settings.YesEn atención primaria solo el dolor crónico supera a la depresión y la ansiedad en la pérdida de años de vida ajustados por calidad. Más del 70% de las personas que sufrían enfermedades mentales comunes consultaron por ello a su médico/a de familia. Sin embargo, «la regla de las mitades decrecientes» es una realidad: menos del 50% de las personas consultantes de atención primaria con enfermedades mentales comunes fueron diagnosticadas correctamente, y de ellas, menos del 50% recibieron un tratamiento (farmacológico o psicológico) adecuado, y de estas, menos del 50% fueron adherentes. Los modelos colaborativos de atención a las enfermedades mentales comunes en atención primaria han demostrado su efectividad en ensayos clínicos, pero su implementación en un contexto más general y real es difícil y su efectividad todavía es poco conocida. Se han desarrollado y validado algoritmos de riesgo para predecir el inicio y el pronóstico de las enfermedades mentales comunes en atención primaria que son útiles para su tratamiento y prevención. Existen evidencias de que las intervenciones psicológicas, psicoeducativas y de ejercicio físico son efectivas en prevención primaria, incluso en atención primaria, aunque su efecto es pequeño o moderado. Estas intervenciones tienen un gran potencial para ser escalables en las escuelas, el ámbito laboral y la atención primaria; además, cuando se administran mediante tecnologías de la información y la comunicación (p. ej., App), en programas autoguiados o mínimamente guiados, han demostrado su efectividad para el tratamiento y la prevención de las enfermedades mentales comunes. También son muy accesibles y de bajo coste, y contribuyen a la implementación masiva de estas intervenciones en diferentes contextos