Abstract: Borderline personality disorder (BPD) is a common personality disorder, with a population prevalence of 1.4-5.9%, although the epidemiology of this disorder in primary care is insufficiently known. Our objective was to determine the registered prevalence of BPD in primary care databases and to study the demographic and clinical characteristics of these patients.
Abstract: Objective: Borderline personality disorder (BPD) is a common personality disorder, with a population prevalence of 1.4–5.9%, although the epidemiology of this disorder in primary care is insufficiently known.
Our objective was to determine the registered prevalence of BPD in primary care databases and to study the demographic and clinical characteristics of these patients.
Methods: We performed a cross-sectional study of the computerized databases of primary care clinical records. The target population consisted of all adults (≥ 16 years old) registered in the Catalan Health Institute (n = 4,764,729).
Results: The prevalence of recorded BPD was 0.017%, and was higher in patients with other mental disorders, particularly substance-abuse disorders (0.161%). These patients had twice as many appointments with the general practitioner as the general population (8.1 vs. 4.4).
Conclusion: The number of diagnoses of BPD recorded in primary care is extremely low, which contrasts with the available population-based data.
Abstract: There are significant shortcomings in the management and clinical outcomes of depressed patients. The objective is to assess the effectiveness of a multi-component programme to improve the management of depression in primary care.
Abstract: La depresión es el trastorno mental más frecuente y relevante en Atención Primaria. Sin embargo, existen dificultades en su manejo y los resultados clÃnicos que se obtienen no son a menudo satisfactorios. En el marco del desarrollo de un modelo multifactorial para mejorar los resultados de la depresión en Atención Primaria (el proyecto INDI) se ha diseñado un programa psicoeducativo dirigido a los pacientes deprimidos, asà como a sus allegados. En el modelo INDI, la implementación de las actividades psicoeducativas recae principalmente en la enfermera de Atención Primaria. Los contenidos del programa incluyen formación sobre la propia enfermedad, especialmente orientada a combatir el estigma y los prejuicios sobre la misma, sobre el tratamiento antidepresivo y la importancia de la adherencia al mismo, sobre el automanejo de las dificultades asociadas, asà como orientaciones sobre el importante papel que pueden/deben desempeñar las personas próximas al paciente deprimido.
Abstract: BACKGROUND: Somatic symptoms (SS) tend to dominate clinical symptomatology in patients with depression in primary care. OBJECTIVE: The authors performed a cross-sectional nationwide epidemiological study on 1,150 primary-care patients with major depression and evaluated the prevalence of SS and physicians’ attribution of their origin. METHOD: Patients were administered the Structured Polyvalent Psychiatric Interview. RESULTS: Ninety-three percent of patients had at least one SS fully or partially attributed to depression, and 45% of patients had four to nine. Painful symptoms, despite being the most frequent, were the least often attributed to depression (fewer than 25% of patients with pain) and significantly more often attributed to a combined origin. CONCLUSION: Results suggest that primary-care physicians tend to associate pain with depression to a significantly lesser extent than any other somatic symptom (e.g., cardiopulmonary or gastrointestinal). Therefore, special attention should be given to painful symptoms in order to ensure efficient management of depression in primary care.
Abstract: OBJECTIVE: To analyse how clinical characteristics in depressed patients, as well as the management of their depression, are related to the presence of significant physical comorbidity. METHODS: This is a two-phase cross-sectional study that took place in 10 primary care centres in Tarragona (Spain). A total of 906 consecutive patients were screened for depression with a self-rating questionnaire and 306 were subject to a structured interview that contained the diagnoses of major depression and dysthymia (DSM-IV), and the severity of the physical comorbidity (Duke Severity of Illness Scale: DUSOI). The association of several clinical variables with the presence of physical comorbidity was evaluated. RESULTS: The comorbidity was of moderate to extreme severity (DUSOI >50) in 31.7% of cases. The patients with comorbidity visited the physician more often. There were no differences in the consumption of antidepressants, reason for the consultation (psychological/somatic), or the probability of being detected as depressed. Neither were there any differences in the severity or disability between both groups. CONCLUSION: Physical comorbidity is frequent in primary care depressed patients. In general, the characteristics of depression and the handling by the doctor are similar in patients with and without comorbidity.
Abstract: BACKGROUND: Most depressed patients are attended at primary care. However, there are significant shortcomings in the diagnosis, management and outcomes of these patients. The aim of this study is to determine whether the implementation of a structured programme for managing depression will provide better health outcomes than usual management. METHODS/DESIGN: DESIGN: A cluster-randomized controlled trial involving two groups, one of which is the control group consisting of patients who are treated for depression in the usual way and the other is the intervention group consisting of patients on a structured programme for treating depression. SETTING: 20 primary care centres in the province of Tarragona (Spain) SAMPLE: 400 patients over 18 years of age who have experienced an episode of major depression (DSM-IV) and who need to initiate antidepressant treatment INTERVENTION: A multi-component programme with clinical, educational and organisational procedures that includes training for the health care provider and evidence-based clinical guidelines. It also includes primary care nurses working as care-managers who provide educational and emotional support for the patients and who are responsible for active and systematic clinical monitoring. The programme aims to improve the primary care/specialized level interface. MEASUREMENTS: The patients will be monitored by telephone interviews. The interviewer will not know which group the patient belongs to (blind trial). These interviews will be given at 0, 3, 6 and 12 months. MAIN VARIABLES: Severity of the depressive symptoms, response rate and remission rate. ANALYSIS: Outcomes will be analyzed on an intent-to-treat basis and the unit of analysis will be the individual patient. This analysis will take into account the effect of study design on potential lack of independence between observations within the same cluster. DISCUSSION: The effectiveness of caring for depression in primary care can be improved by various strategies. The most effective models involve organisational changes and a greater role of nurses. However, these models are almost exclusively from the USA, and this randomized clinical trial will determine if this approach could be effective to improve the outcomes of depression in primary care in the Spanish health care system. TRIAL REGISTRATION: ISRCTN16384353.
Abstract: BACKGROUND: The underdiagnosis of depression is an important research topic. Nevertheless, overdiagnosis has not been given the importance it deserves by research into the ability of family physicians to diagnose depression correctly. OBJECTIVES: To identify the factors that determine the overdiagnosis of depression by family physicians and to evaluate the clinical significance of this error. DESIGN: Two-phase cross-sectional study. SETTING: Primary care centres in Tarragona (Spain). METHODS: In the first phase, we screened 906 consecutive patients using Zung's self-rating depression scale (SDS). In the second phase, all the 209 patients with a positive screening and 97 patients with a negative screening (1 out of 7 randomly) were given the Structured Clinical Interview for DSM-IV Disorders, a series of questionnaires, and the family physician judged whether depression was present. In the 186 patients for whom there were no criteria of major depression or dysthymia, the association of various variables with the physicians' overdiagnosis of depression was analysed. RESULTS: The rate of diagnosis of depression in non-depressed patients was 26.5% (95% CI: 19.0-33.9). The factors associated independently with overdiagnosis were the SDS score (OR: 1.05; 95% CI: 1.01-1.10), the Global Assessment of Functioning score (OR: 0.95; 95% CI: 0.90-0.99), previous history of depression (OR: 2.66; 95% CI: 1.12-6.30) and presence of generalized anxiety (OR: 0.42; 95% CI: 0.18-0.97). CONCLUSION: Family physicians classify as depressed those patients who do not have the formal signs of depression but who do have antecedents of this disorder or a psychological distress that may be prodromal of future depressive episodes.
Abstract: OBJECTIVE: The aim of this study is to determine, within the context of primary care, the frequency of the various ways in which depression is presented with respect to somatic symptoms and to compare depressed patients who present their distress somatically with those with psychological complaints. METHOD: In the two-phase cross-sectional study, first, we screened 906 consecutive patients, and second, we interviewed in detail 306 selected patients. RESULTS: The prevalence of depression was 16.8% (CI 95%: 13.4-20.2). There were 59 cases with psychological presentation, 45 somatizers and 16 had organic disorders with depressive comorbidity. Somatizers had lower level of education, and somatized depression was less serious and caused less repercussion. Detection, antidepressive treatment and psychiatric care were lower for somatizers than for psychologizers. CONCLUSIONS: Somatization is a frequent way to present depression in primary care. For somatizers, depression is less severe and is associated with less repercussion. Somatization is associated with the under-detection of the underlying psychiatric process.
Abstract: OBJECTIVE: Depressive disorders are considered to be a public health problem. Primary health care plays an important role in the treatment of such disorders. Our aim is to determine the prevalence and determinant factors of major depression and dysthymia in consecutive primary care attenders. METHOD: The study took place in medical consultations in 10 Primary Care Centers in Tarragona (Spain). It was designed as a two-phase cross-sectional study. In the first phase we screened 906 consecutive patients according to Zung's Self-Rating Depression Scale. In the second phase the 209 patients whose results were positive and 97 patients whose results were negative (1/7 chosen at random) were given the Structured Clinical Interview for DSM-IV Axis I Disorders, plus a series of questionnaires. We evaluated the link between major depression and dysthymia and several sociodemographic and clinical variables using non-conditional logistic regression. RESULTS: Weighted prevalence was 14.3% (CI 95%: 11.2-17.4) for major depression and 4.8% (CI 95%: 2.8-6.8) for dysthymia. Independently linked to the presence of major depression were female sex, panic disorder, generalized anxiety disorder, frequency of primary care visits, and clinical presentation in the form of explicitly psychosocial symptoms as opposed to exclusively somatic symptoms. Independently linked to the presence of dysthymia were age, generalized anxiety disorder and psychosocial symptoms. CONCLUSION: In our area, depressive disorders in primary care attenders are very common. General practitioners should be aware of this fact so that these disorders can be detected and treated correctly.
Abstract: OBJECTIVE: Many patients with depression who attend primary care are not detected and are unaware of the benefits of therapeutic intervention. Our aim is to evaluate the recognition and management of depressed patients presenting in primary care in Spain. METHODS: This was a two-phase cross-sectional study in primary care centers in Tarragona (Spain). In the first phase, we screened 906 consecutive patients using the Zung's Self-Rating Depression Scale. In the second phase, all 209 patients whose results were positive and 97 patients whose results were negative (1/7 at random) were given the Structured Clinical Interview for DSM-IV Disorders, a series of questionnaires, and the judgment of the physician about the presence of depression was determined. In the 120 patients with major depression and/or dysthymia, predictors of detection and treatment of depression were determined. RESULTS: Seventy-two percent of depressed patients were detected. The detection was associated with educational level, severity of the depression, level of impairment, and the complaint of explicit psychological symptoms. Thirty-four percent were receiving treatment with antidepressants. Antidepressant treatment was associated with marital status, severity of and impairment from the depression, frequency of visits to the family physician, and the patients' complaint of psychological symptoms. CONCLUSION: Many depressed patients are not detected, but these are often the patients who present with the mildest forms of depression and for whom the benefits of detection are far from clear. Although treatment was associated with the severity of depression, most depressed patients, at any level of seriousness, do not receive appropriate treatment.
Abstract: OBJECTIVE: To determine the prevalence and forms of clinical expression of depressive disorders in primary care patients. To analyse the under-detection of depression by primary care doctors. DESIGN: Descriptive and transversal study, with two-stage sampling. Setting. Primary care consultations in the Camp de Tarragona area. PARTICIPANTS: 1000 consecutive patients visiting their doctor for any reason will make up the first-stage sample. Of these 350 go on to the second stage (all the positive results in the screening for depression test plus a random one-seventh of the negative results). MAIN MEASUREMENTS: The first stage will consist of the screening of the sample for depressive disorders with Zung's Self-Rating Depression Scale. In the sub-sample that will go on to the second stage, the Structured Clinical Interview for DSM-IV Disorders will be used to establish diagnoses of depressive disorders and other co-morbid psychiatric disorders. There will also be a range of specific questionnaires to find reasons for consultation and the form of presentation of an eventual depressive disorder, medical co-morbidity, medication taken, use of health services, the functional and vital repercussions of depression. A questionnaire for the patient's G.P. will assess and detect depression. DISCUSSION: The study will enable us to check the validity for our patients of pre-suppositions on depression in primary care obtained from studies in other countries with different health structures and social and cultural conditioners, and to find diverse information extrapolated from specialist studies.
Abstract: OBJECTIVE: To find the prevalence and characteristics of depressive disorders in patients consulting in primary care.Design. Cross-sectional descriptive study. Two stages: screening, then structured psychiatric interview.Setting. Eight clinics at four primary care centres. PATIENTS AND METHODS: A sample of 350 consecutive patients aged between 18 and 70 filled out Zung's Self-Rating Depression Scale (SDS). The diagnoses of major depressive episode and dysthymia for the 138 with positive result and the 67 with negative result were investigated through the Structured Clinical Interview for DSM-IV Axis I Disorders.Measurements and main results. We found a weighted prevalence of 14.7% (95% CI: 10.7-18.7) for major depression and 4.6% (95% CI: 2.4-6.8) for dysthymia. Mean score on the SDS was 65.6 (SD 11.6) in the group with major depression and 63.3 (SD 8.7) in the group with dysthymia. Mean score in the not-depressed group was 44.2 (SD 8.7), lower than the scores for both groups with depression (p < 0.0001). Being female distinguished the depressed groups from the not-depressed group. Lower educational level and the amount of over-users distinguished the group with major depression from the not-depressed group. The symptom profiles were virtually identical for the two depressed groups, whereas the frequency of occurrence of most of the symptoms explored differed significantly between those with and without depression. CONCLUSIONS: Prevalence of major depression and dysthymia are high in primary care patients in our area. Both disorders have common characteristics of demographic variables and symptom profile.
Abstract: INTRODUCTION: Although the Spanish version of the Zung's Self-Rating Depression Scale (SDS) is widely used, there are no studies about its validity as a diagnostic test in primary health care patients. METHODS: In a first phase, a sample of 350 consecutive primary care patients was assessed with the SDS. In a second phase, a subsample composed by all the positive test results and 1/3 of the negatives selected at random, was assessed with the modules of current Major Depressive Episode and Dysthymia of the Structured Clinical Interview for DSM-IV. Specific methods to avoid verification bias were used. Prevalence, sensitivity and specificity, predictive values, Receiver Operating Characteristic (ROC) curve, and Stratum Specific Likelihood Ratios (SSLR) were calculated. RESULTS: Prevalence estimations of major depression and dysthymia were 14,7% (IC95%: 10,7-18,7%) and 4,6% (IC95%: 2,4%-6,8%) respectively. Sensitivity and specificity to detect both diagnoses were 0,95 (IC95%: 0.87-1) and 0,74 (IC95%: 0,68-0,79). Area under ROC curve was 0,93. SSLR for scoring < 50 led to a post-test probability of 0.01. In the stratum with scoring > 69 the SSLR generated a post-test probability of 0.96. Less conclusive results were obtained by intermediate strata. CONCLUSIONS: The SDS is effective in primary care patients and shows operating characteristics comparable to other depression assessment scales. SSLR provides practical information to estimate the probability of suffer a depressive disorder in individual patients.
Abstract: We have evaluated serum cholesterol in a primary care center with a recently introduced portable analyzer: Reflotron (Boehringer Mannheim). The linearity and exactitude were investigated with Hitachi 704 (Boehringer Mannheim) used in the reference laboratory. Accuracy was also tested. We found a good accuracy after repeated analysis (n = 30) of two control sera with a variation coefficient of 2.77% in the first (mean = 125.14 mg/dl, SD 3.47) and 2.94% (mean = 254.53 mg/dl, SD 7.49) in the second. We found an overall lack of accuracy of Reflotron with a more pronounced negative bias in capillary blood (mean d = 30.93 mg/dl, dSE 3.25) than in serum (mean d = dSE 1.12). We found a positive linear correlation both using serum (r = 0.9845; n = 45) and capillary blood (r = 0.9094; n = 30). We feel that Reflotron is useful for primary care due to its good accuracy and linearity regarding the reference method, but its inexactitud should be taken into account. We emphasize the need for quality control to investigate its limitations when the results are analyzed.
