Department of Psychiatry School of Medicine University of La Laguna Campus de Ofra s/n San Cristóbal de La Laguna Canary Islands, Spain
cdelascuevas@gmail.com
Carlos de las Cuevas, MD, Ph.D. is Professor of Psychiatry at the School of Medicine in the University of La Laguna, Canary Islands, Spain. Dr. De las Cuevas' research interests focus on issues involving pharmacoepidemiology of psychiatric drugs and telepsychiatry, and have been supported by grants from Spain and Canary Islands government agencies and foundations.
Abstract: AIM: To assess the relationship between mental health and health-related quality of life (HRQL) in the general population, and to map GHQ-12 as a screening test for population psychological distress to a generic health state measure (EQ-5D) in order to estimate health state values and allow deriving quality-adjusted life years. METHODS: Relationship between mental health and HRQL was examined from the 2004 Canary Islands' Health Survey. Participants were classified as probable psychiatric cases according to GHQ-12. HRQL was measured by the EQ-5D index. Multivariate lineal regression analysis was used to examine the association between mental health and HRQL adjusting by socio-demographic variables and comorbidities. A multivariate regression model was built from EQ-5D to estimate health states values using GHQ-12 as exposure. RESULTS: EQ-5D index scores decreased as the GHQ-12 scores increased. Clinical and socio-demographic factors influenced HRQL without changing the overall trend for this negative relationship. The regression equation explained 43% of the variance. For estimation of utility scores, the model showed a high predictive capacity, with a mean forecast errors of 16%. CONCLUSIONS: HRQL progressively decreased when the probability of being a psychiatric case increased. Findings enable health state values to be derived from GHQ-12 scores for populations where utilities has not or cannot be measured directly.
Abstract: BACKGROUND: Driving a motor vehicle could be central to the functional autonomy of patients with psychiatric illnesses. For patients, a driver's license could mean independence, the ability to care for themselves, and the freedom to travel when they wish. However, both psychiatric disorders and psychiatric drug treatments can produce changes in perception, information processing and integration, and psychomotor activity that can disturb and/or interfere with the ability to drive safely. OBJECTIVE: To assess the fitness to drive of psychiatric outpatients in a sample representative of current clinical practice. METHOD: Cognitive functioning and psychomotor performance of 208 consecutive psychiatric outpatients treated in a community mental health center in the Canary Islands (Spain) were assessed in different clinical situations. The LNDETER 100 battery, an electronic assessment unit-based measurement that consists of 5 screenbased tests, was used to assess concentrated attention and resistance to monotony, multiple discriminative reactions and their correctness, anticipation of speed, bimanual coordination, and the decision making process and tendency to assume risk. The study was conducted from July 2007 to September 2007. RESULTS: Of 208 patients, only 33 had scores compatible with the requirements of a driver's license, and 84% failed at least 1 of the required tests. Of patients with a driver's license who drive almost every day, 79.5% registered scores that would not allow obtaining or renewal of the license. None of the driving patients studied notified the traffic authorities that they had a psychiatric condition that may affect safe driving. No patient stopped driving, although 10% of them recognized that their ability to drive was somehow damaged. CONCLUSION: Guidance on how best to formulate and deliver recommendations on driving fitness in stable psychiatric patients is lacking and much needed.
Abstract: Introduction. Psychiatric disorders, either due to their psychopathology or the drug treatments required, may lead to changes in perception, information processing and integration, and psychomotor activity which may disturb and/or interfere with the ability to drive safely. Method. This study assesses competence to drive in a sample of psychiatric outpatients, with a driver's license, who drove regularly. This ability was assessed with the accredited LNDETER 100 battery, an electronic assessment unit measurement, in different clinical situations. Results. Only 24 of the 120 patients passed the four tests required to obtain or renew a driver's license, and 80% failed in at least one of the required tests. None of the patients studied had notified the traffic authorities or the examination centers that they had a psychiatric condition that could affect safe driving. No patient stopped driving, although 10% of them admitted that their ability to drive was somewhat deteriorated. Conclusions. Psychiatric patients with altered psychomotor performance should be a concern for psychiatrists and general practitioners regarding their competence to drive vehicles. Clinical, ethical and legal aspects of our findings are discussed. Key words: Filtness to drive. Psychiatric disorders. Drug treatment. Behavior toxicity. Actas Esp Psiquiatr 2008;36(0):00-00.
Abstract: PURPOSE: To assess the prevalence and characteristics of psychiatric drug use in pregnancy. METHODS: A prospective observational study was performed on a total of 1332 consecutive women admitted for delivery, during a 3 months period, in the public obstetric services of Tenerife Island (covering a population of 1 000 000 inhabitants). RESULTS: Less than 4% (3.6%) of the women recognised having a psychiatric disorder, and only 2.5% were receiving psychiatric drug treatment at the moment they knew they were pregnant; of those, 68.7% introduced substantial modifications in their treatment at that moment, 47.9% did not report any change with respect to the period before pregnancy and 35.4% recognised that their mood was worse than previously. Although patients affected by a psychiatric disorder registered a higher rate of abdominal delivery, no differences in delivery or obstetric complications were found between women with and without psychiatric illness or in relation to psychiatric drug treatment. CONCLUSIONS: Compared to the literature, the studied population shows a lower rate of psychiatric problems and pharmacological treatment. This might reflect underrecognition or undertreatment.
Abstract: BACKGROUND: Effectiveness and tolerability of psychiatric medications are not only determined by the drug's pharmacological profile but through the interaction of different factors, including patients' attitudes toward their prescribed medications. Increased knowledge about those attitudes may help prescribers to improve patient concordance and thereby the effectiveness of the pharmacological therapy. OBJECTIVE: The goal of this study was to assess stable psychiatric outpatients' attitudes toward psychiatric drug treatment and to what extent patients and public opinions on this subject diverge as a consequence of being on this type of medication. METHODS: Two anonymous self-reported questionnaires [Drug Attitude Inventory (DAI)-10 and an abridge version of Beliefs about Medicines Questionnaire (BMQ)] were administered to 270 stable psychiatric outpatients under treatment and 292 citizens naïve to psychotropic medication. RESULTS: Psychiatric patients showed a more positive attitude toward medication (DAI score 3.6 vs. -0.7; range -10 to +10; negative to positive). Up to 77% of patients showed positive scores compared with only 36% in the general population. Multiple regression analysis showed that none of the variables in the analysis have a predictive value with regard to the attitude toward psychiatric drugs used. CONCLUSION: The continuous use of psychotropic medication shapes the opinion of the users toward a more beneficial perception of medications, but the opinion on the general population, where stigmatizing attitudes are born, is more negative toward them. For psychiatrists and their patients, trying to achieve a better understanding of each other's expectations and reaching concordance is mandatory.
Abstract: Psychiatric treatment with selective serotonin reuptake inhibitors (SSRIs) may be desirable or necessary during pregnancy; however, the benefit of these treatments must balance the benefits to the mother with any risk to the developing foetus. At the present time, the role of serotonin in normal central nervous system development, as well as the effects of altering serotonin transmission at critical periods of embryo development, remains to be further clarified. Depression has a high prevalence in pregnant women (around 10%) and approximately one-half of the pregnancies are unplanned, making necessary that physicians have to know the risks associated with the decision to use this kind of antidepressants during pregnancy. The effects of antidepressants in pregnancy could be classified in several main categories: the teratogenic possible effects; the effects on the normal development of the brain and neuropsychological functions; the effects on birth weight and/or early delivery; the risk of increased bleeding on the mother during delivery; the neuropsychological behaviour and adaptation after delivery, including not only neonatal withdrawal syndromes but also pain reactivity and increased parasympathetic cardiac modulation during recovery after an acute noxious event and in a wide range of neurobehavioural outcomes; and medium- to long-term effects in neurocognitive functions in those children. These areas are reviewed according to the most recent published cohort-controlled studies and prospective surveys regarding SSRIs use in pregnancy. The review tries to clarify the blurred aspects of the use of SSRI during pregnancy and to give sensible and up-to-dated guidelines for the treatment of psychiatric disorders with SSRI during pregnancy.
Abstract: Although telepsychiatry in the form of videoconferencing has been well received in terms of increasing access to care and user satisfaction, few data on treatment outcomes and efficacy from telepsychiatry applications are available at the present time. This paper evaluates the efficacy of telepsychiatry through videoconference in the treatment of mental disorders by comparing to face-to-face conventional (F2FC) treatment. We carried out a randomized clinical trial where 140 psychiatric outpatients were randomized to either F2FC treatment or videoconference telepsychiatry (VCTP) treatment. Patients were diagnosed according to International Classification of Diseases, 10th edition (ICD-10) criteria using the Composite International Diagnostic Interview. Treatment involves eight consultations lasting 30 minutes over the 24-week study period. Patients received pertinent psychotropic medication plus cognitive- behavioral therapy during sessions. The same psychiatrist diagnosed and treated all the patients that were recruited from the Community Mental Health Centre of San Sebastian de la Gomera, in the Canary Islands. Change in psychiatric test scores served as the primary efficacy criterion. Efficacy was determined by comparing baseline (visit 1) Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales as well as Global Indexes (GSI, PSDI, and PST) from SCL-90R with scores obtained at the end of the study period (week 24). Response was defined as a CGI-I score of 1 or 2. Reliable Change Indexes were computed in SCL-90R Global Indexes scores. Of 140 patients randomized, 130 completed 24 weeks of treatment. Only 4 patients dropped out prematurely from the study in VCTP and 6 in F2FC. The study involves 534 teleconsultations, 522 F2FC consultations, and more than 500 hours of clinical practice. Significant improvements were found on the CGI and SCL-90- R Global Indexes scores of both treatment groups, showing clear clinical state improvement. No statistically significant differences were observed when the efficacy of VCTP treatment was compared to F2FC psychiatric treatment efficacy. This study demonstrated that telepsychiatry treatment through videoconference has equivalent efficacy to F2FC psychiatric treatment. Telepsychiatry showed to be an effective mean of delivering mental health services to psychiatric outpatients living in remote areas with limited resources.
Abstract: BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) have been associated with withdrawal symptoms. We investigated whether use of these drugs in pregnant women might cause neonatal withdrawal syndrome. METHODS: An association between paroxetine and neonatal convulsions was identified in December, 2001, by the data mining method routinely used to screen the WHO database of adverse drug reactions. An information component (IC) measure was used to screen for unexpected adverse reactions relative to the information in the database. We then assessed cases of neonatal convulsions and neonatal withdrawal syndrome associated with drugs included in the anatomical therapeutic chemical groups N06AB and N06AX. FINDINGS: By November, 2003, a total of 93 suspected cases of SSRI-induced neonatal withdrawal syndrome had been reported, and were regarded as enough information to confirm a possible causal relation. 64 of the cases were associated with paroxetine, 14 with fluoxetine, nine with sertraline, and seven with citalopram. The IC-2 SD for the group became greater than 0 in the first quarter of 1991, and the IC increased to 2.68 (IC-2 SD 0.32) by the second quarter of 2003. For each individual compound, the IC-2 SD was greater than 0. INTERPRETATION: SSRIs, especially paroxetine, should be cautiously managed in the treatment of pregnant women with a psychiatric disorder.
Abstract: INTRODUCTION: Polypharmacy with psychoactive drugs is an increasingly common and debatable contemporary practice in clinical psychiatry more probably based on experience than evidence. The objective of this study was to evaluate the prevalence and estimators of polypharmacy in psychiatric patients living in an area with very limited mental health resources. METHOD: All patients (n = 352) with mental disorders receiving psychotropic medication living in La Gomera were studied through an audit of case records and a second phase confirmation strategy through personal interviews. RESULTS: The mean number of psychoactive drugs prescribed was 2.22 +/- 0.70 (range: 1-6). The rate of polypharmacy was 67 %, with 34.1 % of patients receiving two drugs, 20.5 % receiving three drugs and 12.5 % of the patients receiving four or more psychotropic drugs at the same time. Multiple regression analysis shows that none of the variables considered (age, sex, marital status, educational level, work activity and diagnosis) had predictive value in regards to the number of psychotropic drug used. Benzodiazepines were the most prevalent drugs in single drug therapy, while antidepressants and antipsychotics were the most used in combination with other treatment. A questionably very high degree of same-class polypharmacy was observed, while multiclass, adjunctive and augmentation polypharmacy seems to be more appropriate. CONCLUSION: The psychiatric clinical practice needs to develop indicators for an appropriate polypharmacy of mental disorders. More research is still needed to identify patients at risk of polypharmacy in order to develop interventions that minimize the risks associated to this treatment alternative.
Abstract: BACKGROUND: Polypharmacy with psychoactive drugs is an increasingly common and debatable contemporary practice in clinical psychiatry based more upon experience than evidence. The objective of this study was to evaluate the prevalence and conditioners of polypharmacy in psychiatric patients. METHOD: A cross-sectional survey was carried out using the Canary Islands Health Service Clinical Records Database. A representative sample (n = 2,647) of patients with mental disorders receiving psychotropic medication was studied. RESULTS: The mean number of psychoactive drugs prescribed was 1.63 +/- 0.93 (range 1-7). The rate of polypharmacy was 41.9%, with 27.8% of patients receiving two drugs, 9.1% receiving three, 3.2% receiving four, and 1.8% of the patients receiving five or more psychotropic drugs. Multiple regression analysis shows that variables sex and diagnosis have a predictive value with regard to the number of psychotropic drug used, being men and schizophrenic patients the most predisposed. Benzodiazepines were the more prevalent drugs in monotherapy, while anticonvulsants and antipsychotics were the more used in combination with other treatment. A questionable very high degree of same-class polypharmacy was evidenced, while multi-class, adjunctive and augmentation polypharmacy seem to be more appropriate. CONCLUSIONS: Almost half of the psychiatric patients are treated with several psychotropics. Polypharmacy is common and seems to be problematic, especially when same class of drugs are prescribed together. Some diagnoses, such as schizophrenia, are associated with an increase risk of Polypharmacy but there is a lack of evidence based indicators that allows for quality evaluation on this practice.
Abstract: PURPOSE: To analyse and describe the pattern of prescriptions for antidepressants by all psychiatrists working for the Canary Islands Health Service (CIHS) during the 4-year period from 1999 to 2002. METHODS: All prescriptions for antidepressants by the ten psychiatrists who worked continuously for the CIHS during the period 1999-2002 in the island of Tenerife (700,000 inhabitants) were collected from the CIHS central database. Global prescription of antidepressant medication for the entire region (1.8 million inhabitants) by any physician working for the public sector was counted and converted into defined daily doses (DDDs). RESULTS: The intensity of prescribing antidepressants increased from 22.1 DDD/1000 inhabitants/day in 1999 to 29.1 DDD/1000 inhabitants/day in 2002, with the five top selective serotonine reuptake inhibitors (SSRIs) being responsible for 83.6% of all the antidepressant prescriptions in the year 2002. A wide variation in individual prescription pattern was evident both between and within each psychiatrist during these years. Working in the same conditions, and with a similar morbidity pattern, one psychiatrist prescribed up to 32,000 DDDs in one year, whereas another colleague only prescribed 600 DDDs in the same period and to the same covered population. The amount of individual variation in prescription pattern highly correlated with the intensity of drug prescribing. CONCLUSIONS: The high inter- and intra-individual variation in antidepressant prescribing could not be linked with personal, structural or morbidity patterns, and the heavy influence of pharmaceutical industry could not be ruled out.
Abstract: BACKGROUND: Benzodiazepines are commonly used psychotropics frequently applied in ways not fully supported by the present state of scientific knowledge. These departures are usually based on considerations of clinical practice characteristics seldom fully acknowledged by Evidence Based Medicine. MATERIAL/METHODS: To assess the basic knowledge that sustains the prescription of benzodiazepines, a questionnaire about its use composed of twelve statements which are either "right" or "wrong" was given to a representative sample of 194 general practitioners and 34 psychiatrists working for the Canary Islands Health Service. The correctness of the statements were evaluated against literature sources and the answers were analyzed according to those results. RESULTS: None of the participants answered all statements correctly. Six statements were incorrectly answered by more than 50%, another three by more than 40%, and only the remaining three were failed by less than 20% of the sample. If a score had been developed for each professional, general practitioners would have achieved a mean score of 4.9 points out of 10, whereas psychiatrists would have had a mean score of 6.1 out of 10. CONCLUSIONS: Benzodiazepines are commonly used, safe and efficacious drugs, but the knowledge shown by health professionals with ample experience is not in agreement with the current state of knowledge on the matter. To better use these useful and old drugs, up-to-date knowledge is needed. Along the same line, the scientific knowledge related to an adequate psychoactive drug prescription should be revised, giving more importance to real circumstances from clinical practice.
Abstract: A telepsychiatry service, using ISDN videoconferencing, was established to provide psychiatric consultations for the population of El Hierro, the most westerly of the Canary Islands. During the first year of routine operation, a total of 40 patients had 40 initial and 126 follow-up teleconsultations. The main reason for the consultation identified in the general practitioner's referral form was to establish a diagnosis (60% of patients); the second most common reason was the management of a patient previously diagnosed (20% of patients). According to the results of a questionnaire survey, patients' acceptance of and satisfaction with the technology were high. In their first teleconsultation, about a third of them said that they experienced some initial inconvenience, but this disappeared after a few minutes. Ninety per cent of the patients considered that they received the follow-up care they required. Telepsychiatry was considered by physicians and patients as an adequate vehicle for mental health-care.
Abstract: AIMS: To estimate the prevalence, characteristics and risk factors associated with the development of benzodiazepine dependence in the users of these active ingredients. DESIGN: A representative sample of patients currently receiving benzodiazepine treatment for 1 month or longer (mean 38.2+/-52 months, range 1-360 months) was studied. PARTICIPANTS: One thousand and forty eight (1048) consecutive patients attending 20 primary-care health centres of the Canary Islands Health Service participated in this study during 2002. MEASUREMENTS: The severity of dependence scale (SDS) was used as a screening test of benzodiazepine dependence among patients using benzodiazepines. FINDINGS: Of patients using benzodiazepines for more than 1 month, 47% developed dependence to these compounds. Benzodiazepine dependence was more prevalent among women who were middle aged, separated, of low educational background, unemployed or housewives. Patients using short half-life benzodiazepines registered higher rates of dependence as well as those using higher doses or the patients with longer use. However, multivariate logistic regression analysis shows that benzodiazepine dependence was closely related only to three of the variables considered: the benzodiazepine dose used, the duration of this use and to the concomitant use of antidepressants. CONCLUSIONS: The distribution of dose and length of treatment shows no evidence of pharmacological tolerance, neither in the whole sample nor in those patients with addiction (SDS+), reinforcing the idea that psychological dependence (addiction) is more relevant than pharmacological or physiological dependence in benzodiazepine chronic use.
Abstract: OBJECTIVE: To assess the antidepressant prescribing patterns of community psychiatrists, and the prescriptions issued by general practitioners and private physicians during 1999 in order to analyse and discuss the intensity and sources of variations between doctors. METHODS: All reimbursed prescriptions for antidepressants written in 1999 by community psychiatrists and general practitioners working for the Canary Islands Health Service at Santa Cruz de Tenerife were collected from official sources. Prescriptions were available individualized for each psychiatrist but were collected globally for the others. Drugs were classified according to the Anatomic Therapeutic Chemical (ATC-1999 edition) System and use was quantified in terms of defined daily doses (DDDs). As an indicator of the quality of drug prescribing, the DU90% was used. RESULTS: The total use of antidepressant in Tenerife was 21.4 DDD/1000 inhabitants/day. The most frequently prescribed substances were fluoxetine, paroxetine and sertraline, which accounted for 58% of all prescriptions. Each psychiatrist used between 10 and 20 different substances and between 15 and 26 different trade names. Prescribing by general practitioners mirrored that of psychiatrist, and private doctors (mainly psychiatrist) were found to have a different pattern of prescribing with higher use of new and uncommon antidepressants. Psychiatrists acknowledge the pressures of promotion by the pharmaceutical industry and half of them recognize a personal relationship with some 'company representatives'. CONCLUSION: There is a remarkable degree of variation in antidepressant prescribing by psychiatrists and general practitioners, this is due to economic and social factors as much as to morbidity differences.
Abstract: AIMS: To assess the validity of the Severity of Dependence Scale (SDS) as a screening test to detect benzodiazepine dependence in regular benzodiazepine users. METHOD: One hundred regular benzodiazepine users, recruited from neurotic benzodiazepine users attending the Mental Health Outpatient Services of the Canary Islands Health Service, were administered the SDS and responses were compared with the Composite International Diagnostic Interview (CIDI) diagnosis of benzodiazepine dependence. Receiver Operating Characteristic (ROC) analysis was used to determine which cut-off score on SDS allowed the best trade-off between sensitivity and specificity. RESULTS: SDS was shown to have high diagnostic utility, and a score higher than six on the scale appears to be an appropriate threshold for problematic benzodiazepine use. The SDS had a specificity of 94.2% and a sensitivity of 97.9%, and the area under the curve was of 0.991. CONCLUSION: The SDS was found to be a valid brief self-report questionnaire for the assessment of benzodiazepine dependence in patients using benzodiazepines.
Abstract: OBJECTIVE: To assess the extent, characteristics and determinants of benzodiazepine prescription in outpatient Primary Health Care. METHODS: A clinical audit of a stratified random sample of Primary Health Care Centres in the seven islands and 1.6 million inhabitants region of 'Canarias' in Spain was carried out. From those centres, a random sample of 1045 clinical records was reviewed and information on diagnosis, prescription and prescribed dosages was collected in a structured questionnaire. A multivariate logistic regression analysis was performed in order to determine the 'risk factors' for the use of benzodiazepines. RESULTS: Benzodiazepine prescription was recorded in 23.4% of all clinical records; 87.7% of these were for benzodiazepines classified as anxiolytics (N05B) and 12.3% for hypnotics (N05C2). Benzodiazepine prescription was more common for women, elderly, widowed, divorced, low educational background, housewives and retired people. Using multivariate logistic regression, the probability of benzodiazepine prescription was found to be closely related to age, gender and employment status, but not with educational level. Prescribed Daily Doses were lower than Defined Daily Doses (DDD) in 77.1% of all anxiolytic prescriptions, but were in agreement with DDD in 90% of hypnotic prescriptions. The duration of treatment recorded in the clinical records was 25+/-21 months, with a range of 1 and 144 months. General Practitioners were responsible for 67% of all benzodiazepine prescription. Anxiolytics were prescribed as a single daily dose in 57% of the cases, and only 'at supper' in 48.6%. CONCLUSION: In the general population attending Primary Health Care Centres of the Canary Islands Health System the prescription of benzodiazepines is higher for women and the elderly, and the most common use is chronic, with a duration of over 2 years in most cases. Anxiolytics are prescribed in doses which are much lower than those used as DDD and were used only 'at night' in almost half of the cases. This could represent an overlapping of the indications with hypnotics, and explain part of the huge difference in the use of anxiolytics in Spain compared with other figures in Europe. This fact must also be taken into account when making inferences of benzodiazepine use from sales statistics, which are very imprecise measures of drug use.
Abstract: INTRODUCTION: This work seeks to know the state of the Burnout syndrome among Spanish psychiatrists' with the purpose of having some national reference values. It also sought to elucidate the sociodemographic and work-related variables which can influence the burnout syndrome. METHODS: A survey (which includes sociodemographic, work-related variables and the Maslach Burnout Inventory) is applied to a sample of psychiatrists assisting at the National Congress of Psychiatry held in Valencia. The statistical analysis comprises parametric, non parametric and multivariate methods. RESULTS: The results of the three subscales included in the Maslach Burnout Inventory is offered along their relationship with the sociodemographic and work-related variables studied. The multivariate analysis shows that only the variable sex can influence the probability of obtaining high scores in the depersonalization subscale. CONCLUSIONS: The scores obtained in the three subscales of the of Maslach Burnout Inventory are higher than those published to date. These prior studies were carried out with autonomous samples. The possible relationship of these high scores with the current spanish situation is considered.
