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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

Background and Aims: 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., Method: 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., Results: 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., Conclusion: 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., Implications: 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., Competing Interests: EA has received honoraria as a speaker or consultant from Lundbeck and Esteve. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Tomé-Pires, Aragonès, Rambla, López-Cortacans, Sánchez-Rodríguez, Caballero and Miró.)

Background: 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., Objective: 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., Methods: 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., Results: 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., Conclusion: 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., Trial Registration: ClinicalTrials.gov (NCT02605278), registered 16/11/2015., (© 2023. The Author(s).)

Background: 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., Methods: 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., Results: 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., Conclusions: 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., Trial Registration: ClinicalTrials.gov identifier: NCT03285659 ; Registered 18th September, 2017., (© 2022. The Author(s).)

Objective: The aims of this study were twofold: 1) to better understand the associations between pain-related cognitions and pain severity, and psychological and physical function, and 2) to determine the extent to which these cognitions function as mediators in the association between pain severity and depression in a sample of primary care adult patients with chronic pain and depression., Design: Cross-sectional design., Methods: Three hundred twenty-eight patients with both depression and chronic pain from primary care centers responded to measures of pain severity, pain interference, depression severity, and pain-related cognitions (including measures of catastrophizing and other pain-related beliefs). We performed three hierarchical regression analyses and two multiple regression analyses., Results: The helplessness domain of pain catastrophizing was positively associated with pain severity, depression severity, and pain interference and mediated the relationship between depression and pain severity and vice versa. Beliefs about disability showed a positive association with pain severity, pain interference, and depression severity, and also mediated the relationship between pain severity and depression. Believing in a medical cure was positively associated with pain interference and negatively associated with depression; emotion beliefs were positively associated with pain severity., Conclusions: These findings provide important new information about the associations between several pain-related cognitions and pain severity, depression, and pain interference and the potential mediating roles that these cognitions play in the associations between pain severity and depression in patients with both chronic pain and depression in the primary care setting., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: We designed a collaborative care program for the integrated management of chronic musculoskeletal pain and depression, which frequently coexist in primary care patients. The aim of this study was to evaluate the cost-effectiveness of this program compared with care as usual., Methods: We performed a cost-effectiveness analysis alongside a randomized clinical trial. Results were monitored over a 12-month period. The primary outcome was the incremental cost-effectiveness ratio (ICER). We performed cost-effectiveness analyses from the perspectives of the healthcare system and society using an intention-to-treat approach with imputation of missing values., Results: We evaluated 328 patients (167 in the intervention group and 161 in the control group) with chronic musculoskeletal pain and major depression at baseline. From the healthcare system perspective, the mean incremental cost was €234 (p = .17) and the mean incremental effectiveness was 0.009 QALYs (p = .66), resulting in an ICER of €23,989/QALY. Costs from the societal perspective were €235 (p = .16), yielding an ICER of €24,102/QALY. These estimates were associated with a high degree of uncertainty illustrated on the cost-effectiveness plane., Conclusions: Contrary to our expectations, the collaborative care program had no significant effects on health status, and although the additional costs of implementing the program compared with care as usual were not high, we were unable to demonstrate a favorable cost-effectiveness ratio, largely due to the high degree of uncertainty surrounding the estimates., Competing Interests: Declaration of Competing Interest E. Aragonès has received speaker/consultancy fees from Schwabe, Lündbeck, Grünental, and Pfizer. E. Sánchez-Iriso has received honoraria as a speaker from Pfizer. All authors declare that they have no other relationships, interests, or activities that could appear to have influenced the submitted work., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: 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., Methods: 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)., Results: 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]., Limitations: This is a pragmatic study, and poor adherence to the programme by patients and physicians was a main limitation., Conclusion: The programme improves clinical outcomes for depression, although no clinical benefits were seen for pain., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice., Methods: Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care., Design: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system., Participants: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia)., Intervention: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework., Measures: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact., Discussion: This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society., Trial Registration: ClinicalTrials.gov identifier: NCT03285659 ; Registered 12th September, 2017.

Background: Chronic musculoskeletal pain and depression are very common in primary care patients. Furthermore, they often appear as comorbid conditions, resulting in additive effect on adverse health outcomes. On the basis of previous studies, we hypothesise that depression and chronic musculoskeletal pain may benefit from an integrated management programme at primary care level. We expect positive effects on both physical and psychological distress of patients., Objective: To determine whether a new programme for an integrated approach to chronic musculoskeletal pain and depression leads to better outcomes than usual care., Design: Cluster-randomised controlled trial involving two arms: a) control arm (usual care); and b) intervention arm, where patients participate in a programme for an integrated approach to the pain-depression dyad., Settings: Primary care centres in the province of Tarragona, Catalonia, Spain, Participants: We will recruit 330 patients aged 18-80 with moderate or severe musculoskeletal pain (Brief Pain Inventory, average pain subscale ≥5) for at least 3 months, and with criteria for major depression (DSM-IV)., Intervention: A multicomponent programme according to the chronic care model. The main components are care management, optimised antidepressant treatment, and a psychoeducational group action. Blind measurements: The patients will be monitored through blind telephone interviews held at 0, 3, 6 and 12 months., Outcomes: Severity of pain and depressive symptoms, pain and depression treatment response rates, and depression remission rates., Analysis: The outcomes will be analysed on an intent-to-treat basis and the analysis units will be the individual patients. This analysis will consider the effect of the study design on any potential lack of independence between observations made within the same cluster., Ethics: The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAP), Barcelona, (P14/142)., Discussion: This project strengthens and improves treatment approaches for a major comorbidity in primary care. The design of the intervention takes into account its applicability under typical primary care conditions, so that if the programme is found to be effective it will be feasible to apply it in a generalised manner., Trial Registration: ClinicalTrials.gov: NCT02605278 ; Registered 28 September, 2015.

Objective: To describe nurse attitudes toward depression, using a standardized questionnaire and to evaluate how a training workshop can modify or influence these attitudes., Methods: A prospective study based on the application of the Depression Attitude Questionnaire, before and six months after, participating in a training day on the nursing role in the management of depression in Primary Care. The sample consisted of 40 Primary Care nurses from 10 health centers in the province of Tarragona., Results: Nurses are in a neutral position when considering the management of depressed patients as a difficult task, or to feel comfortable in this task, but there is a high degree of acceptance of the claim that the time spent caring for depressed patients is rewarding. In general, there was little significant difference in the mean scores for the different items of the Depression Attitude Questionnaire, before and six months, after the training intervention., Conclusions: The attitude towards the management of depression in Primary Care and to the role that nurses can play in this task is generally favorable. Fruitful training and organizational initiatives can be established in order to define and structure the nursing role in the management of depression in Primary Care., (Copyright © 2015 Elsevier España, S.L.U. All rights reserved.)

Background: A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring., Methods: Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life., Trial Registration: ISRCTN16384353., Results: A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance., Limitations: The number of patients lost (31%) before follow-up may have introduced a bias., Conclusions: Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: 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., Methods: This is a cluster-randomized controlled trial, conducted between June 2007 and June 2010. Twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a multi-component programme with clinical, educational and organizational procedures including primary care nurses working as case-managers. Outcomes were monitored by a blinded interviewer at 0, 3, 6 and 12 months., Trial Registration: ISRCTN16384353, at http://isrctn.org., Results: In total, 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 12 months, 302 patients were assessed, 172 in the intervention group and 130 in the control group. The severity of depression (mean Patient Health Questionnaire-9 score) was 1.76 points lower in the intervention group [7.15 vs. 8.78, 95% CI=-3.53 to 0.02, p=0.053]. The treatment response rate was 15.4% higher in the intervention group than in the controls [66.9% vs. 51.5%, odds ratio 1.9, 95% CI=1.2 to 3.1, p=0.011)], and the remission rate was 13.4% higher [48.8% vs. 35.4%, odds ratio 1.8, 95% CI=1.1 to 2.9, p=0.026)]., Limitations: Unblinded physicians diagnosed depression in their patients and decided whether to include them in the study, so we cannot discount a hidden selection bias., Conclusions: The programme for managing depression leads to better clinical outcomes in patients with major depression in primary care settings., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Aim: To describe the attitudes of General Practitioners (GPs) towards depression in Primary Health Care Centres., Design: Cross-sectional study based on the application of a standard questionnaire., Setting and Participants: A total of 112 GPs from all of the 20 Primary Health Care Centres in the Tarragona-Reus Primary Care Area (Catalan Health Institute)., Measurements: A Spanish adaptation of Depression Attitudes Questionnaire was used., Results: A total of 88.4% of doctors agreed there was an increase in the number of depressive patients in recent years. Around half of the GPs thought that depression in Primary Health Care Centres are due to the adversities of life, but 72.3% considers that there is a biological root in severe depressions. A large majority (81.2%) of doctors believed that antidepressants used in Primary Care are efficient and the majority values psychotherapy as a useful therapeutic option. There is an agreement in the role of nursing staff when attending depressed patients. The role of psychiatric referral when a satisfactory result is not obtained in Primary Care is recognised. Although 64.3% of doctors consider that dealing with depressed patients is hard work, but 57.1% feel comfortable and only 19.7% think it is an unpleasant job., Conclusions: In general, there is a favourable predisposition to deal with depression in Primary Care where training and organisational initiatives can be introduced to improve clinical outcomes of depression in Primary Care., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

Background: ADHD in adults is not uncommon and, according to recent epidemiological data, has a population prevalence of 3-4%. However, there is major unawareness of this disorder among doctors, particularly in primary care. The aim of this study is to determine the prevalence of the diagnosis of ADHD recorded in adults and the proportion of patients with drug prescriptions for this disorder in primary care., Methods: This is a cross-sectional study on databases of computerised primary care medical records. The target population is adults (18-44 years) assigned to primary care centres of the Catalan Health Institute (n = 2,452,107). We obtained the proportion of patients with ADHD (F90/ICD- 10 code) registered as active problem, and the proportion of patients with a specific prescription for ADHD in adults: methylphenidate, methylphenidate extended release or atomoxetine., Results: The prevalence of recorded ADHD is 0.04% (0.07% in men, 0.02% in women). The percentage of patients with a specific prescription for ADHD is 0.07% (0.08% in men, 0.05% in women). 32.05% of ADHD patients had specific prescription., Conclusion: The diagnosis of ADHD in adults and specific treatment are extremely low in primary care. These results contrast with population data: registered ADHD is 1/85 of the population prevalence.

Purpose: We describe a multicomponent program for the systematic evaluation and treatment of depression in primary care., Conclusion: Primary-care nurses trained in clinical and therapeutic aspects of depression play a central role in care management, patient education, treatment adherence, and clinical monitoring., Practice Implications: Diverse interventions, including organizational changes and the enhancement of the role of nurses, have been effective in improving depression outcomes in primary-care settings.

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., 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.

This article deals with the impact dementia can cause in a family in our modern society, an impact which often leads to a crisis or a rupture in a family. Due to the evolution in family structure in Spain over the last few decades, as evidenced by separations, divorces, reconstructed families, a descent in birth rate, and especially by women joining the work force, the possibilities for traditional family care of the elderly have become complicated and have been reduced, which leads to a tremendous physical and psychological wear on the person who takes on the largest part of this care, the so-called main caretaker, usually a woman. In consequence to this situation, dysfunctional behaviors may develop in this caretaker which, if not treated, may early or later on develop into the caretaker syndrome. The effects of this syndrome include subjective ones such as emotional suffering and objective ones such as a loss of health. This article presents a proposal for action by nurses acting out of primary health care centers which leads to a series of measures providing containing methods and formal support structures, in other words prevention, for the family and especially for the main caretaker of patients suffering from dementia.