Prescripción de ejercicio físico en la depresión por parte de médicos de familia : factores involucrados

Introducción: El problema del sedentarismo es acuciante en sociedades desarrolladas y sus consecuencias para la salud de la población constituyen uno de los principales problemas de salud pública actuales. La depresión es un motivo de consulta muy habitual en las consultas de atención primaria de países occidentales. Se ha planteado la prescripción de ejercicio físico como una estrategia antidepresiva útil en depresiones leves-moderadas, con frecuencia de forma complementaria a los tratamientos de primera elección: psicoterapia y/o farmacoterapia. Sin embargo, los médicos de atención primaria no siempre lo prescriben y se desconoce de qué depende que lo hagan. Contribuir a aclarar esta cuestión es el objetivo del presente trabajo. Nuestra hipótesis era que el grado de prescripción depende de sus opiniones y experiencia sobre el tratamiento de la depresión.Método: Estudio descriptivo transversal en el que participaron 13 centros de salud. Utilizamos el cuestionario Depression Questionaire Attitude para valorar la actitud de los médicos hacia la depresión, y recogimos otras variables relacionadas con la importancia que otorgaban al ejercicio físico y a otros aspectos del estilo de vida en la salud física y mental.RESULTADOS: Se confirma que las opiniones y actitudes de los médicos frente a la depresión influyen en su disposición a recomendar ejercicio físico. Además, los médicos de atención primaria con menos años de práctica profesional valoran más el papel del ejercicio físico en la salud, tanto en la depresión como en otras patologías médicas. También se observa una correlación entre la importancia que se da al ejercicio físico en la salud y la que se da a otros factores ligados al estilo de vida, especialmente la dieta.Discusión: Aunque la utilidad de recomendar ejercicio físico en la depresión va acercándose al mismo nivel de importancia que en otros problemas de salud su empleo por parte de los médicos de atención primaria es muy mejorable. Por ello, es importante insistir en la necesidad de ofrecer apoyo y programas de formación continuada a los médicos de atención primaria para ayudarles en este propósito.A sedentary lifestyle is an urgent problem in developed societies and its consequences are one of the main current problems in public health. Depression is a common reason to attend primary care in Western countries. In many cases of low and mild depression, exercise is recommended as a complement to the main therapy: Psychotherapy and/or pharmacotherapy. Nevertheless, general practitioners do not always recommend exercise to depressive patients and it is unknown why they do not. The main aim of our study was to clarify how the degree of prescribing exercise relies on a general practitioner's opinion and experience in depression treatment. A cross-sectional design was undertaken in 13 public health centers. The Depression Attitude Questionnaire (DAQ) was used to evaluate general practitioners' attitude towards depression; other variables related to the importance accorded to physical exercise; and other lifestyle aspects of physical and mental health. Our results show that general practitioners' attitude towards depression influence their willingness to recommend exercise. Moreover, less experienced general practitioners (in years) tend to appreciate the importance of exercise in health, not only in depression. A positive relationship was found between importance of exercise and importance accorded to other factors linked to lifestyle, especially diet. Although recommendation of exercise in depression is similar to other medical conditions, its prescription may be improved. Hence, it is important to point out the need for education programs for general practitioners, in order to improve their capacity to deal with their task.O problema do sedentarismo é premente nas sociedades desenvolvidas e as suas consequências para a saúde da população constituem um dos principais problemas de saúde pública actuais. A depressão é um motivo muito habitual nas consultas de cuidados primários nos países ocidentais. Foi delineada a prescrição de exercício físico como uma estratégia antidepressiva útil em depressões leves-moderadas, de forma complementar aos tratamentos de primeira escolha. Contudo, os médicos de cuidados primários nem sempre o prescrevem e desconhece-se o porquê de o fazerem. Contribuir para clarificar esta questão é o objectivo d presente trabalho. A nossa hipótese era que o grau de prescrição depende das suas opiniões e experiências no tratamento da depressão. Trata-se de um estudo descritivo transversal no qual participaram 13 centros de saúde. Utilizámos o questionário Depression Questionaire Attitude para avaliar a atitude dos médicos face à depressão e medimos outras variáveis relacionadas com a importância que atribuíam ao exercício físico e a outros aspectos do estilo de vida na saúde física e mental. Os resultados confirmam que a atitude dos médicos face à depressão influí na sua disposição para recomendar exercício físico. Adicionalmente, os médicos de cuidados primários com menos anos de prática profissional valorizam mais o papel do exercício físico na saúde, tanto na depressão como noutras patologias médicas. Também se observa uma correlação entre a importância que se dá ao exercício físico na saúde e à que se dá a outros factores ligados ao estilo de vida, especialmente à dieta. Conclui-se que apesar da utilidade de recomendar exercício físico na depressão se ir aproximando do nível de importância atribuído a outros problemas de saúde, a sua utilização por parte dos médicos de cuidados primários pode ser substancialmente melhorada. Para tal, é importante insistir na necessidade de oferecer apoio e programas de formação continuada aos médicos de cuidados primários para ajudá-los neste propósito

Relación entre actividad física, gravedad clínica y perfil sociodemográfico en pacientes con Depresión Mayor

El ejercicio físico está demostrando en los últimos años ser una buena estrategia antidepresiva complementaria para muchos pacientes. La asociación entre el grado de actividad física y las características clínicas y sociodemográficas en la Depresión aún no se ha estudiado suficientemente en muestras amplias y representativas de pacientes. Hacerlo es importante para obtener información que posibilite mejorar el diseño de programas destinados a promover el ejercicio físico en estos pacientes. Se reclutaron 3374 pacientes con Depresión Mayor en tratamiento, que acudieron a consulta psiquiátrica por primera vez en Centros de Salud Mental distribuidos por toda España. Fueron clasificados en tres grupos de acuerdo con el nivel de actividad física semanal que declararon. En este estudio comparamos el grupo que comunicó mayor actividad física (n = 1033; 30.6%) con el que menos (n = 858; 25.4%). Los pacientes más activos tenían menor gravedad clínica de acuerdo con la puntuación en la escala Montgomery-Asberg Depression Rating Scale (MADRS). Además eran más jóvenes, con mejor nivel educativo y de empleo, menor aislamiento social y menor consumo de tabaco. Sin embargo, cuando todas estas variables fueron controladas, la diferencia en la puntuación en la MADRS seguía siendo estadísticamente significativa. De lo anterior deducimos que los pacientes depresivos con más edad o dificultades socioeconómicas tienden a hacer menos ejercicio espontáneamente, por lo que probablemente necesiten un apoyo especial al recomendárselo.Physical activity is showing in recent years to be a good antidepressant complementary strategy for many patients. The association between the degree of physical activity and clinical and sociodemographic characteristics in depression has still not been studied sufficiently in large and representative patient samples. Doing so is important to improve the design of programs that promote physical activity in depressive patients. 3374 patients with Major Depression who first came to psychiatric consultation in mental health centres in Spain were recruited. They were classified into three groups according to the level of weekly physical activity declared. In this study we compared the most physical activity declared group (n = 1033; 30.6%) with less physical activity declared group (n = 858; 25.4%). Most physically active patients had lower clinical depression severity according to the Montgomery-Asberg Depression Rating Scale (MADRS) scale. They were also younger, with higher education level and employment status; do not tend to live alone and less tobacco use. However, when all these variables were controlled, differences in MADRS Scores between groups remain statistically significant. Older and with socioeconomic difficulties depressive patients tend to do less physical activity, for this reason, it is probably that they need a particular support to recommend do exercise.A atividade física mostra nos últimos anos uma boa estratégia de antidepressivos complementares para muitos pacientes. A associação entre o grau de atividade física e as características clínicas e sociodemográcas na Depressão ainda não foi sucientemente estudada em amostras grandes e representativas de pacientes. Fazer isso é importante para obter informa- ções que permitam melhorar o design de programas destinados a promover a atividade física nesses pacientes. Registramos 3374 pacientes com maior depressão no tratamento, que participaram de consultas psiquiátricas pela primeira vez em centros de saúde mental distribuídos em toda a Espanha. Eles foram classicados em três grupos de acordo com o nível de atividade física semanal que relataram. Neste estudo, comparamos o grupo que relatou a maior atividade física (n = 1033, 30,6%) com o mínimo (n = 858, 25,4%). Os pacientes mais ativos tiveram menor gravidade clínica de acordo com a pontuação na Escala de Avaliação de Depressão de Montgomery-Asberg (MADRS). Eles também eram mais jovens, com melhores níveis educacionais e de emprego, menos isolamento social e menor consumo de tabaco. No entanto, quando todas essas variáveis foram controladas, a diferença no índice MADRS permaneceu estatisticamente signicante. A partir do acima, deduzimos que os pacientes deprimidos mais velhos ou as diculdades socioeconômicas tendem a uma atividade física espontaneamente menor, então eles provavelmente precisam de apoio especial ao recomendá-lo

A multiple health behaviour change intervention to prevent depression: A randomized controlled trial

Health behaviour; Major depressive disorders; Primary health care;Comportament de salut; Trastorns depressius majors; Atenció primària de salutComportamiento de salud; Trastornos depresivos mayores; Primeros auxiliosObjective: To examine the effectiveness of a 12-month MHBC intervention in the prevention of onset depression in primary health care (PHC). Methods: Twenty-two PHC centres took part in the cluster-randomized controlled trial. Patients were randomized to receive either usual care or an MHBC intervention. The endpoints were onset of major depression and reduction of depressive symptoms in participants without baseline depression at a 12-month follow-up. Results: 2531 patients agreed and were eligible to participate. At baseline, around 43% were smokers, 82% were non-adherent to the Mediterranean diet and 55% did not perform enough physical activity. The intervention group exhibited a greater positive change in two or more behaviours (OR 1.75 [95%CI: 1.17 to 2.62]; p = 0.006); any behaviour (OR 1.58 [95%CI: 1.13 to 2.20]; p = 0.007); and adherence to the Mediterranean diet (OR 1.94 [95%CI: 1.29 to 2.94]; p = 0.002), while this increase was not statistically significant for smoking and physical activity. The intervention was not effective in preventing major depression (OR 1.17; [95% CI 0.53 to 2.59)]; p =0.690) or reducing depressive symptoms (Mean difference: 0.30; [95% CI -0.77 to 1.36]; p = 0.726) during follow-up. Conclusions: As compared to usual care, the MHBC intervention provided a non-significant reduction in the incidence of major depression

Complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in primary health care (EIRA study): study protocol for a hybrid trial

CDATA[CDATA[Background: Health promotion is a key process of current health systems Primary Health Care (PHC) is the ideal setting for health promotion but multifaceted barriers make its integration difficult in the usual care. The majority of the adult population engages two 01 more risk behaviours, that is why a multiple intervention might be more effective and efficient The primary objectives are to evaluate the effectiveness, the cost effectiveness and an implementation strategy of a complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in PHC. CDATA[CDATA[Methods: This study is a cluster randomised controlled hybrid type 2 trial with two parallel groups comparing a complex multiple risk behaviour intervention with usual care It will be carried out in 26 PHC centres in Spam The study focuses on people between 45 and 75 years who carry out two or more of the following unhealthy behaviours tobacco use, low adherence to the Mediterranean dietary pattern or insufficient physical activity level The intervention is based on the Transtheoretical Model and it will be made by physicians and nurses in the routine care of PHC practices according to the conceptual framework of the ''5A''s" It will have a maximum duration of 12 months and it will be carried out to three different levels (individual, group and community) Incremental cost per quality adjusted life year gamed measured by the tanffs of the EuioQo! 5D questionnaire will be estimated. The implementation strategy is based on the ''Consolidated Framework for Implementation Research, a set of discrete implementation strategies and an evaluation framework. CDATA[CDATA[Discussion: EIRA study will determine the effectiveness and cost effectiveness of a complex multiple risk intervention and will provide a better understanding of implementation processes of health promotion interventions in PHC setting. It may contribute to increase knowledge about the individual and structural barriers that affect implementation of these interventions and to quantify the contextual factors that moderate the effectiveness of implementation

Multiple health behaviour change primary care intervention for smoking cessation, physical activity and healthy diet in adults 45 to 75 years old (EIRA study): a hybrid effectiveness-implementation cluster randomised trial

Methods: A cluster randomised effectiveness-implementation hybrid trial-type 2 with two parallel groups was conducted in 25 Spanish Primary Health Care (PHC) centres (3062 participants): 12 centres (1481 participants) were randomised to the intervention and 13 (1581 participants) to the control group (usual care). The intervention was based on the Transtheoretical Model and focused on all target behaviours using individual, group and community approaches. PHC professionals made it during routine care. The implementation strategy was based on the Consolidated Framework for Implementation Research (CFIR). Data were analysed using generalised linear mixed models, accounting for clustering. A mixed-methods data analysis was used to evaluate implementation outcomes (adoption, acceptability, appropriateness, feasibility and fidelity) and determinants of implementation success. Results: 14.5% of participants in the intervention group and 8.9% in the usual care group showed a positive change in two or all the target behaviours. Intervention was more effective in promoting dietary behaviour change (31.9% vs 21.4%). The overall adoption rate by professionals was 48.7%. Early and final appropriateness were perceived by professionals as moderate. Early acceptability was high, whereas final acceptability was only moderate. Initial and final acceptability as perceived by the participants was high, and appropriateness moderate. Consent and recruitment rates were 82.0% and 65.5%, respectively, intervention uptake was 89.5% and completion rate 74.7%. The global value of the percentage of approaches with fidelity ≥50% was 16.7%. Eight CFIR constructs distinguished between high and low implementation, five corresponding to the Inner Setting domain. Conclusions: Compared to usual care, the EIRA intervention was more effective in promoting MHBC and dietary behaviour change. Implementation outcomes were satisfactory except for the fidelity to the planned intervention, which was low. The organisational and structural contexts of the centres proved to be significant determinants of implementation effectiveness

Comparative efficacy of two primary care interventions to assist withdrawal from long term benzodiazepine use: A protocol for a clustered, randomized clinical trial

<p>Abstract</p> <p>Background</p> <p>Although benzodiazepines are effective, long-term use is not recommended because of potential adverse effects; the risks of tolerance and dependence; and an increased risk of hip fractures, motor vehicle accidents, and memory impairment. The estimated prevalence of long-term benzodiazepine use in the general population is about 2,2 to 2,6%, is higher in women and increases steadily with age. Interventions performed by General Practitioners may help patients to discontinue long-term benzodiazepine use. We have designed a trial to evaluate the effectiveness and safety of two brief general practitioner-provided interventions, based on gradual dose reduction, and will compare the effectiveness of these interventions with that of routine clinical practice.</p> <p>Methods/Design</p> <p>In a three-arm cluster randomized controlled trial, general practitioners will be randomly allocated to: a) a group in which the first patient visit will feature a structured interview, followed by visits every 2-3 weeks to the end of dose reduction; b) a group in which the first patient visit will feature a structured interview plus delivery of written instructions to self-reduce benzodiazepine dose, or c) routine care. Using a computerized pharmaceutical prescription database, 495 patients, aged 18-80 years, taking benzodiazepine for at least 6 months, will be recruited in primary care health districts of three regions of Spain (the Balearic Islands, Catalonia, and Valencia). The primary outcome will be benzodiazepine use at 12 months. The secondary outcomes will include measurements of anxiety and depression symptoms, benzodiazepine dependence, quality of sleep, and alcohol consumption.</p> <p>Discussion</p> <p>Although some interventions have been shown to be effective in reducing benzodiazepine consumption by long-term users, the clinical relevance of such interventions is limited by their complexity. This randomized trial will compare the effectiveness and safety of two complex stepped care interventions with that of routine care in a study with sufficient statistical power to detect clinically relevant differences.</p> <p>Trial Registration</p> <p>Current Controlled Trials: <a href="http://www.controlled-trials.com/ISRCTN13024375">ISRCTN13024375</a></p

Eficacia de una intervención del médico de familia para la retirada del consumo prolongado de benzodiacepinas

[spa] Las benzodiacepinas constituyen un conjunto de principios activos con propiedades ansiolíticas, hipnóticas, miorelajantes y anticonvulsivantes. Sus indicaciones principales son el tratamiento a corto plazo de la ansiedad y el insomnio, coadyuvantes en el manejo de la depresión y la deshabituación alcohólica y relajante musculares. Su eficacia a corto plazo es indiscutible, sin embargo, su uso prolongado se considera inapropiado ya que producen dependencia y se han relacionado con alteraciones de la memoria, aumento del riesgo de accidentes de tráfico, caídas y fracturas de cadera e incluso un incremento de mortalidad global. A pesar de que las recomendaciones de prescripción aconsejan administrar la dosis mínima eficaz y con una duración que no sobrepase las 4-8 semanas, son ampliamente consumidas en España y en países de nuestro entorno y se aprecia una especial tendencia al consumo prolongado. En los últimos años se han evaluado distintas estrategias para la retirada del consumo prolongado de benzodiacepinas. Dichas estrategias van desde el envío de una carta a quien las consume explicándole como retirarlas, hasta intervenciones sistematizadas con pauta de reducción escalonada de dosis acompañada o no de sesiones de psicoterapia o de medicación. Ningún estudio había sido realizado en nuestro país con nuestros condicionantes socio-culturales y en el contexto de nuestro sistema sanitario. Por ello, esta tesis se ha centrado en primer lugar en evaluar mediante un ensayo clínico aleatorio la eficacia en nuestro entorno sanitario de una intervención breve que consiste en un mensaje estructurado junto con una pauta de retirada gradual de la medicación, realizada por el médico de familia, para conseguir el cese del consumo de benzodiacepinas y, en segundo lugar, en analizar que ocurre a largo plazo tras tres años de haber finalizado la intervención. Los resultados a los doce meses sugieren que la intervención es cinco veces más eficaz que la práctica clínica habitual y que además es factible en cuanto a tiempo y facilidad de manejo en las consultas de atención primaria. Después de tres años se ha observado que la eficacia de la intervención persiste aunque el efecto es menor. Se observa una elevada tasa de recaída pero por otra parte muchos de aquellos pacientes que no fueron deshabituados a los doce meses lo hacen a lo largo de estos tres años debido un efecto paralelo sobre el profesional que ha aprendido e incorporado la técnica de deshabituación a su práctica clínica habitual. La tercera parte de esta tesis es el protocolo de estudio de ensayo clínico multicéntrico para evaluar la eficacia de dos intervenciones para la reducción del consumo crónico de benzodiacepinas; una consiste en una entrevista estructurada y una pauta de reducción escalonada de dosis con visitas de seguimiento y otra en idéntica entrevista estructurada y apoyada en información escrita de refuerzo, con la pauta individualizada de retirada y sin visitas de seguimiento. Ambas comparadas con la práctica clínica habitual. Se evaluará también la seguridad de dichas intervenciones. Hemos reclutado una amplia muestra de pacientes y un número elevado de médicos participantes con el objetivo de incrementar la precisión y la validez externa del estudio. Conclusiones: Nuestros resultados evidencian que una intervención que consiste en una entrevista estructurada y una pauta de retirada gradual, guiada por el médico de familia, para disminuir el consumo de benzodiacepinas es cinco veces más eficaz que la práctica habitual y parece ser factible en nuestro entorno sanitario. Dicha eficacia, aunque disminuye, perdura en el tiempo y se constata un efecto paralelo sobre el profesional. Concluye con el planteamiento de un proyecto multicéntrico para evaluar dos intervenciones de distinta complejidad sobre una muestra amplia de pacientes y médicos participantes para darle mayor precisión y validez externa.[eng] Benzodiazepines are a group of anxiolytic, hypnotic and anticonvulsant drugs. They are mainly used for the short term treatment of insomnia and anxiety and as adjuvant therapy in depression and alcohol withdrawal and as muscle relaxant. Their effectiveness in the short-term is well established but the clinical benefit of long-term use is uncertain and has been associated with dependence, cognitive impairment and increased risk of falls leading to injuries, traffic accidents and global mortality. Even though Guidelines recommend restricting their use to no more than 4-8 weeks, they are widely prescribed in Spain and in most of the western countries and long-term use remains widespread. In the last years several studies have been designed to asses some strategies to discontinue long-term benzodiazepine use. It goes from minimal interventions where general practitioners send a letter inviting their patients to cease the benzodiazepine use explaining how to do it, to systematic discontinuation programs with gradual tapering of medication sometimes augmented with psychological support as psychotherapy or psychotropic medication. None experience had been developed in our country neither in our Healthcare Service conditions. The main objective of the present thesis has been, firstly, to evaluate the effectiveness of a general practitioner structured intervention consisting of a brief advice and a stepwise dose reduction to cease benzodiazepine use, and secondly, to determine the long-term effectiveness of this intervention in a, three-year after the end of the trial, follow up. Results at twelve months show that gradual taper of medication is five times more effective in withdrawing benzodiazepines than usual care and its simplicity and not too much time-consuming make it feasible in primary care. In the long-term we observe that effectiveness remains even if there’s a high relapse rate. Moreover, many patients who did not successfully complete the taper program were benzodiazepine-free at the three-year follow-up. It is supposed to be due to the fact that general practitioners who took part in the trial have incorporated the management of benzodiazepine withdrawal as a tool in his routine clinical practice. The third part of this thesis is the study protocol of a trial to evaluate the effectiveness of two interventions to withdraw chronic benzodiazepine use; one is an educational intervention with gradual taper of medication and follow-up visits, and the other, the same educational intervention reinforced by written support without follow-up visits. Both compared with routine care. The study is also designed to evaluate the safety of such interventions. We have recruited a large sample and many general practitioners are taking part in it. We aim to increase precision and external validity Conclusions: The results show that a structured intervention consisting of a brief advice and a stepwise dose reduction guided by the general practitioner to cease benzodiazepine use is five times more effective than usual care and it seems to be feasible in primary care. Even though there is a substantial relapse rate the intervention remains effective in the long term and we observe a parallel effect over the professionals. Finally, we have designed an ambitious trial to evaluate the effectiveness of two different complexity interventions in which we aim to increase precision and external validity

Evolución de la utilización de antidepresivos, ansiolíticos e hipnóticos en la Comunitat Valenciana. Período 2000-2010

ResumenObjetivoConocer la evolución de la utilización de antidepresivos (AD), ansiolíticos(A) e hipnóticos (H) en la Comunidad Valenciana (CV) entre los años 2000 y2010, su importe y el coste por dosis diaria definida (DDD).DiseñoEstudio observacional retrospectivo.EmplazamientoRecetas dispensadas cargo del sistema público de salud de la CV durante los años 2000 a 2010.MedicionesConsumo de los principios activos pertenecientes a los grupos terapéuticos N05B (A), N05C (H) y N06A (AD) obtenidos a partir de la base de datos de farmacia de la Agencia Valenciana de Salud medido en dosis habitante día.ResultadosDurante el período estudiado, el consumo de AD aumentó el 81,2% y el de A e H el 11,7%. Los inhibidores selectivos de la recaptación de serotonina fueron los AD más prescritos y los inhibidores de la recaptación de serotonina y noradrenalina los de mayor crecimiento (386,8%). Escitalopram aumentó el 1.013%. Lorazepam, alprazolam y diacepam, suman el 80,4% de los ansiolíticos prescritos, y lormetazepam y zolpidem el 88,7% de los hipnóticos. El importe de los AD aumentó el 78,2% y el de los A e H el 14,5%; el coste por DDD de ambos grupo descendió el 29%.ConclusionesLa utilización de AD en la CV ha experimentado un gran incremento entre 2000-2010, mientras que el de A e H ha sido moderado, aunque su consumo todavía está por encima del de AD. A pesar de la reducción en el coste de la DDD en ambos grupos, el importe global de la factura en antidepresivos en la CV sigue en aumento.AbstractObjectiveTo describe the evolution in the use of antidepressants (AD), anxiolytics (A) and hypnotics (H) in the Comunitat Valenciana (CV) between 2000 and 2010, their expenditure, and the cost of the defined daily dose (DDD).DesignRetrospective observational study.SettingPrescriptions covered by the health public service of the CV during the period 2000-2010.MeasurementsConsumption of the therapeutic groups N06A (antidepressants), N05B (anxiolytics) and N05C (hypnotics) from the pharmacy database of the public Valencian Health Agency measured in defined daily dose per 1.000 inhabitants.ResultsDuring the period of study the use of AD increased by 81.2% and A and H, 11.7%. Selective serotonin reuptake inhibitors were the most prescribed AD and Selective serotonin and norepinephrine reuptake inhibitors experienced the higher rise (386.8%). The increase of escitalopram was 1.013%. Lorazepam, alprazolam and diazepam, accounted for the 80.4% of the anxyolitics, and lormetazepam and zolpidem the 88.7% of the hypnotics. The expenditure rise of AD was by 78.2% and that of the A and H was 14.5%; the cost of the DDD of both decreased by 29%.ConclusionsAntidepressant utilization has experienced a remarkable rise between 2000 and 2010 while that of A and H has been mild even though they are still more consumed than AD. In spite of the reduction of the DDD cost in both therapeutic groups, the whole expenditure on AD in the CV is still growing