ATDOM is the Catalan home healthcare program at primary care level. Patients in the home care program are usually frail, elderly people with multiple comorbidities. They are often polymedicated, ...leading to a high risk of drug-related problems (DRPs). Our hypothesis is that the pharmacist-led individualized review of the pharmacotherapeutic plans of ATDOM patients will be effective in improving the quality of treatments by reducing DRPs in terms of indication, adequacy, effectiveness, and safety.
Aim: To compare the effectiveness of a standardized pharmaceutical intervention for the review and optimization of pharmacological treatments in ATDOM patients with usual management practice.
Pragmatic randomized clinical trial with a comparable control group, with prospective follow-up regarding the intervention on the adequacy of the pharmacological treatment of patients in the ATDOM program.
Primary care teams in the Camp de Tarragona Primary Care Area, Tarragona, Spain.
Four hundred and thirty-two ATDOM patients will be recruited, those who are over 65 years old and who are currently undergoing pharmacological treatment.
Effectiveness of a six-month long intervention in reducing DRPs per patient and polypharmacy. Additionally, in the intervention group we will evaluate the implementation of the proposals for change or improvement made by the responsible physician.
The outcomes will be analyzed on an intent-to-treat basis and the analysis units will be the individual patients. Logistic regression and linear regression models will be used to evaluate the effects of the intervention on dichotomous and continuous variables versus the control arm.
The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAPJGol), Barcelona, (19/141-P).
If the results of the pharmaceutical intervention are favorable, widespread implementation of the program could be possible. It could be extended to all ATDOM patients or outpatients in general. Interdisciplinary teamwork could be strengthened as a result, which would improve the healthcare continuum.
Retrospectively registered.
gov Identifier NCT05820945; Registered 21 March, 2023.
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.
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.
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.
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 (β = 0.53; 95% CI = 0.37-0.68) and at 12 months (β = 0.48; 95% CI = 0.29-0.67). Also, pain > 2 years of evolution predicted long term pain severity (β = 0.91; CI95%=0.11-1.71). Baseline pain interference predicted interference at 3 and 12 months (β = 0.27; 95%CI = 0.11-0.43 and β = 0.21; 95%CI = 0.03-0.40, respectively). Baseline pain severity predicted interference at 3 and 12 months (β = 0.26; 95%CI = 0.10-0.42 and β = 0.20; 95%CI = 0.02-0.39, respectively). Pain > 2 years predicted greater severity and greater interference at 12 months (β = 0.91; CI95%=0.11-1.71, and β = 1.23; CI95%=0.41-2.04). Depression severity predicted more interference at 12 months (β = 0.58; CI95%=0.04-1.11). Occupational status as active worker predicted less interference throughout the follow-up (β=-0.74; CI95%=-1.36 to -0.13 and β=-0.96; CI95%=-1.71 to -0.21, at 3 and 12 months). Currently working also predicts less pain severity at 12 months (β=-0.77; CI95%=1.52 - 0.02). With regard to the psychological variables, pain catastrophizing predicted pain severity and interference at three months (β = 0.03; 95% CI = 0.00-0.05 and β = 0.03; 95% CI = 0.00-0.05), but not at long term.
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.
ClinicalTrials.gov (NCT02605278), registered 16/11/2015.
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.
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.
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.
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.
ClinicalTrials.gov identifier: NCT03285659 ; Registered 18th September, 2017.
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.
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.
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.
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.
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.
The COVID-19 pandemic has had a major impact on the mental health of healthcare workers, yet studies in primary care workers are scarce.
To investigate the prevalence of and associated factors for ...psychological distress in primary care workers during the first COVID-19 outbreak.
This was a multicentre, cross-sectional, web-based survey conducted in primary healthcare workers in Spain, between May and September 2020.
Healthcare workers were invited to complete a survey to evaluate sociodemographic and work-related characteristics, COVID-19 infection status, exposure to patients with COVID-19, and resilience (using the Connor-Davidson Resilience Scale), in addition to being screened for common mental disorders (depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder). Positive screening for any of these disorders was analysed globally using the term 'any current mental disorder'.
A total of 2928 primary care professionals participated in the survey. Of them, 43.7% (95% confidence interval CI = 41.9 to 45.4) tested positive for a current mental disorder. Female sex (odds ratio OR 1.61, 95% CI = 1.25 to 2.06), having previous mental disorders (OR 2.58, 95% CI = 2.15 to 3.10), greater occupational exposure to patients with COVID-19 (OR 2.63, 95% CI = 1.98 to 3.51), having children or dependents (OR 1.35, 95% CI = 1.04 to 1.76 and OR 1.59, 95% CI = 1.20 to 2.11, respectively), or having an administrative job (OR 2.24, 95% CI = 1.66 to 3.03) were associated with a higher risk of any current mental disorder. Personal resilience was shown to be a protective factor.
Almost half of primary care workers showed significant psychological distress. Strategies to support the mental health of primary care workers are necessary, including designing psychological support and resilience-building interventions based on risk factors identified.
The Covid-19 pandemic has increased stress levels in GPs, who have resorted to different coping strategies to deal with this crisis. Gender differences in coping styles may be contributing factors in ...the development of psychological distress.
To identify differences by gender and by stress level in coping strategies of GPs during the Covid-19 pandemic.
A cross-sectional, web-based survey conducted with GPs in Catalonia (Spain), in June-July 2021. via the institution's email distribution list, all GPs members of the Catalan Society of Family and Community Medicine were invited to complete a survey assessing sociodemographic, health and work-related characteristics, experienced stress (Stress scale of the Depression, Anxiety and Stress Scales-DASS 21) and the frequency of use of a range of coping strategies (Brief-COPE) classified as problem-focused, emotion-focused and avoidant strategies, some of which are adaptive and others maladaptive. We compared the scores of each strategy by gender and stress level using Student's t-test.
Of 4739 members, 522 GPs participated in the study (response rate 11%; 79.1% women; mean age = 46.9 years, SD = 10.5). Of these, 41.9% reported moderate-severe stress levels. The most common coping strategies were acceptance, active coping, planning, positive reframing and venting. More frequently than men, women resorted to emotional and instrumental support, venting, distraction and self-blame, whereas men used acceptance and humour more commonly than women. Moderate-severe stress levels were associated with non-adaptive coping, with increased use of avoidance strategies, self-blame, religion and venting, and decreased use of positive reframing and acceptance.
The most common coping strategies were adaptive and differed by gender. However, highly stressful situations caused maladaptive strategies to emerge.
•Depression and chronic musculoskeletal pain often exist as comorbid conditions in primary care.•The DROP programme provides an integrated approach to this comorbidity.•The DROP programme was ...observed to have clinical benefits in terms of depression outcomes.•The implementation of the DROP programme did not result in improved outcomes for pain.•The programme must be further refined in order to improve adherence and enhance effectiveness.
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.
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).
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.
This is a pragmatic study, and poor adherence to the programme by patients and physicians was a main limitation.
The programme improves clinical outcomes for depression, although no clinical benefits were seen for pain.
Benzodiazepines are extensively used in primary care, but their long-term use is associated with adverse health outcomes and dependence.
To analyse the efficacy of two structured interventions in ...primary care to enable patients to discontinue long-term benzodiazepine use.
A multicentre three-arm cluster randomised controlled trial was conducted, with randomisation at general practitioner level (trial registration ISRCTN13024375). A total of 532 patients taking benzodiazepines for at least 6 months participated. After all patients were included, general practitioners were randomly allocated (1:1:1) to usual care, a structured intervention with follow-up visits (SIF) or a structured intervention with written instructions (SIW). The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription claims at 12 months.
At 12 months, 76 of 168 (45%) patients in the SIW group and 86 of 191 (45%) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 (15%) in the control group. After adjusting by cluster, the relative risks for benzodiazepine discontinuation were 3.01 (95% CI 2.03-4.46, P<0.0001) in the SIW and 3.00 (95% CI 2.04-4.40, P<0.0001) in the SIF group. The most frequently reported withdrawal symptoms were insomnia, anxiety and irritability.
Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity. A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits.
Healthcare workers are vulnerable to adverse mental health impacts of the COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during the first wave of the pandemic ...among healthcare professionals in Spain.
All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental health status (May 5 – September 7, 2020). We report: probable current mental disorders (Major Depressive Disorder-MDD- PHQ-8≥10, Generalized Anxiety Disorder-GAD- GAD-7≥10, Panic attacks, Posttraumatic Stress Disorder –PTSD- PCL-5≥7; and Substance Use Disorder –SUD-CAGE-AID≥2. Severe disability assessed by the Sheehan Disability Scale was used to identify probable “disabling” current mental disorders.
9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53-13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18-29 years (OR=1.36; 95%CI:1.02-1.82), caring “all of the time” for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95).
One in seven Spanish healthcare workers screened positive for a disabling mental disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quarantined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support.
Los profesionales sanitarios son vulnerables al impacto negativo en salud mental de la pandemia COVID-19. Evaluamos la prevalencia de trastornos mentales y factores asociados durante la primera oleada de la pandemia en sanitarios españoles.
Se invitó a todos los trabajadores de 18 instituciones sanitarias españolas (6 CCAA) a encuestas en línea evaluando características individuales, estado de infección y exposición a COVID-19 y salud mental (5 Mayo – 7 Septiembre, 2020). Reportamos: probables trastornos mentales actuales (Trastorno depresivo mayor TDD PHQ-8≥10, Trastorno de ansiedad generalizada TAG GAD-7≥10, Ataques de pánico, Trastorno de estrés postraumático TEP PCL-5≥7; y Trastorno por uso de sustancias TUS CAGE-AID≥2. La interferencia funcional grave (Escala de Discapacidad de Sheehan) identificó los probables trastornos “discapacitantes”.
Participaron 9.138 sanitarios. Prevalencia de cribado positivo: 28,1% TDD; 22,5% TAG, 24,0% Pánico; 22,2% PTE; y 6,2% TUS. En general, el 45,7% presentó algún trastorno mental actual y el 14,5% algún trastorno discapacitante. Los sanitarios con trastornos mentales previos tuvieron el doble de prevalencia que aquellos sin patología mental previa. Ajustando por todas las variables, el trastorno mental incapacitante se asoció positivamente con: trastornos previos (TUS: OR=5.74; 95%CI 2.53-13.03; Ánimo: OR=3.23; 95%CI:2.27-4.60; Ansiedad: OR=3,03; IC 95%: 2,53-3,62); edad 18-29 años (OR=1,36; IC 95%: 1,02-1,82); atender “siempre” a pacientes COVID-19 (OR=5,19; IC 95%: 3,61-7,46), género femenino (OR=1,58; IC 95%: 1,27-1,96) y haber estado en cuarentena o aislado (OR=1,60; IC 95%: 1,31-1,95).
Uno de cada 7 sanitarios españoles presentaron un probable trastorno mental discapacitante durante la primera oleada de COVID-19. Aquéllos con trastornos mentales alguna vez antes de la pandemia, los que están expuestos con frecuencia a pacientes con COVID-19, los infectados o en cuarentena / aislados, las mujeres y las enfermeras auxiliares deben considerarse grupos que necesitan seguimiento y apoyo de su salud mental.
Background
Healthcare workers are a key occupational group at risk for suicidal thoughts and behaviors (STB). We investigated the prevalence and correlates of STB among hospital workers during the ...first wave of the Spain COVID‐19 outbreak (March–July 2020).
Methods
Data come from the baseline assessment of a cohort of Spanish hospital workers (n = 5450), recruited from 10 hospitals just after the height of the coronavirus disease 2019 (COVID‐19) outbreak (May 5–July 23, 2020). Web‐based self‐report surveys assessed 30‐day STB, individual characteristics, and potentially modifiable contextual factors related to hospital workers' work and financial situation.
Results
Thirty‐day STB prevalence was estimated at 8.4% (4.9% passive ideation only, 3.5% active ideation with or without a plan or attempt). A total of n = 6 professionals attempted suicide in the past 30 days. In adjusted models, 30‐day STB remained significantly associated with pre‐pandemic lifetime mood (odds ratio OR = 2.92) and anxiety disorder (OR = 1.90). Significant modifiable factors included a perceived lack of coordination, communication, personnel, or supervision at work (population‐attributable risk proportion PARP = 50.5%), and financial stress (PARP = 44.1%).
Conclusions and Relevance
Thirty‐day STB among hospital workers during the first wave of the Spain COVID‐19 outbreak was high. Hospital preparedness for virus outbreaks should be increased, and strong governmental policy response is needed to increase financial security among hospital workers.
PDF
