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OBJECTIVE: Anxiety disorders are the most prevalent psychiatric disorders in primary care and have significant social, economic, and interpersonal costs. Primary care is an ideal setting to prevent the appearance of anxiety disorders. The aim of this study was to evaluate the efficacy and cost-effectiveness of primary prevention interventions in anxiety disorders in the adult population receiving primary health care. METHODS: A literature search was carried out in four databases-PubMed, PsycInfo, Cochrane, and Web of Science-from January 1980 to November 2013. Clinical trials and systematic reviews published in English and non-English languages and that evaluated the efficacy and/or cost-effectiveness of interventions of primary prevention for anxiety in primary care in the general adult population were included. Risk of bias was assessed by the Cochrane Risk Bias Tool and Overview Quality Assessment Questionnaire. RESULTS: No high-quality research was identified that studied primary prevention of anxiety disorders in the adult population in the primary care setting. The few studies that exist focus on the child-adolescent population or on other types of interventions, usually as secondary prevention. CONCLUSION: This study emphasizes the need for the development of high-quality clinical trials on the prevention of anxiety disorders in primary care.
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Trastornos de Ansiedad/prevención & control , Atención Primaria de Salud , Prevención Primaria/métodos , Humanos , Salud Mental , Prevención Primaria/economíaRESUMEN
OBJECTIVE: To evaluate the effectiveness and feasibility of a cognitive-behavioral program for patients in primary care units who were diagnosed as having abridged somatization disorder. METHOD: A multicenter, randomized controlled trial was designed. One hundred sixty-eight patients were recruited from 29 primary care units and randomly assigned to one of three arms: treatment as usual (TAU), individual cognitive-behavioral therapy (CBT), and group CBT. Somatic symptoms were measured using the Screening for Somatoform Disorders and the Severity of Somatic Symptoms scale. The Hamilton Anxiety Rating Scale and the Hamilton Depression Rating Scale were used to assess the severity of anxiety and depression. RESULTS: Individual CBT achieves greater changes in the Screening for Somatoform Disorders posttreatment compared with group CBT (mean [95% confidence interval], 14.17 [11.9-16.3] versus 11.63 [9.4-13.7], p < .001). These improvements were observed at 6 and 12 months (p < .001 and p < .001, respectively). For individual CBT versus TAU, the number-needed-to-treat was 8, whereas for group CBT versus TAU, the number-needed-to-treat was 9. Individual CBT treatment resulted in lower anxiety scores compared with group CBT and TAU (7.33 [5.4-9.2] versus 11.47 [9.4-13.9] versus 13.07 [10.9-15.2], p < .001) posttreatment. Individual CBT and group CBT were associated with sustained benefits at 12-month follow-up compared with TAU (8.6 [6.6-10.6] versus 9.28 [7.2-11.2] versus 16.2 [13.9-18.5], p < .001). Depressive symptoms were lower for individual CBT posttreatment than for TAU (6.96 [5.3-8.6] versus 10.87-12.7], p < .01). CONCLUSIONS: CBT in individual and group settings results in significant improvements in somatic symptoms among patients with somatoform abridged disorder compared with TAU. Individual CBT results in greater posttreatment improvements at 6-month and 12-month follow-ups. TRIAL REGISTRATION: current controlled trials identifier ISRCTN69944771.
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Terapia Cognitivo-Conductual/métodos , Psicoterapia de Grupo/métodos , Trastornos Somatomorfos/terapia , Adulto , Ansiedad/psicología , Ansiedad/terapia , Depresión/psicología , Depresión/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Trastornos Somatomorfos/psicología , Resultado del TratamientoRESUMEN
INTRODUCTION: No randomised, controlled trials have been conducted to date on the efficacy of psychological and pharmacological treatments of pain catastrophising (PC) in patients with fibromyalgia. Our aim in this study was to assess the effectiveness of cognitive-behaviour therapy (CBT) and the recommended pharmacological treatment (RPT) compared with treatment as usual (TAU) at the primary care level for the treatment of PC in fibromyalgia patients. METHODS: We conducted a six-month, multicenter, randomized, blinded, parallel group, controlled trial in which patients were randomly assigned to one of three study arms: CBT (n = 57), RPT (n = 56) and TAU at the primary care level (n = 56). The major outcome of this study was PC in patients with fibromyalgia. The secondary variables were pain acceptance, depression, anxiety, pain, global function and quality of life. RESULTS: CBT significantly decreased global PC at the six-month follow-up examination with effect sizes of Cohen's d = 0.73 and 1.01 compared with RPT and TAU, respectively. CBT was also more effective than RPT and TAU at increasing pain acceptance at the six-month follow-up examination (effect sizes of Cohen's d = 0.77 and 0.80, respectively). Compared with RPT and TAU, CBT was more effective at improving global function based on the Fibromyalgia Impact Questionnaire (six-month effect sizes Cohen's d = 0.44 and 0.53, respectively) and quality of life based on the European Quality of Life Scale (six-month effect sizes Cohen's d = 0.11 and 0.40, respectively). There were no differences among the three treatments with regard to pain and depression. CONCLUSIONS: CBT shows higher efficacy than RPT and TAU not only in key outcomes in FM, such as function and quality of life, but also in relevant mediators of treatment effects, such as pain catastrophising and pain acceptance. TRIAL REGISTRATION: ISRCTN: ISRCTN10804772.
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Catastrofización/psicología , Catastrofización/terapia , Terapia Cognitivo-Conductual/métodos , Fibromialgia/psicología , Fibromialgia/terapia , Adulto , Catastrofización/epidemiología , Femenino , Fibromialgia/epidemiología , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor/métodos , Pregabalina , Método Simple Ciego , Resultado del Tratamiento , Ácido gamma-Aminobutírico/análogos & derivados , Ácido gamma-Aminobutírico/uso terapéuticoRESUMEN
BACKGROUND: Pharmacists can play a decisive role in the management of ambulatory patients with depression who have poor adherence to antidepressant drugs. OBJECTIVE: To systematically evaluate the effectiveness of pharmacist care in improving adherence of depressed outpatients to antidepressants. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. RCTs were identified through electronic databases (MEDLINE, Cochrane Central Register of Controlled Trials, Institute for Scientific Information Web of Knowledge, and Spanish National Research Council) from inception to April 2010, reference lists were checked, and experts were consulted. RCTs that evaluated the impact of pharmacist interventions on improving adherence to antidepressants in depressed patients in an outpatient setting (community pharmacy or pharmacy service) were included. Methodologic quality was assessed and methodologic details and outcomes were extracted in duplicate. RESULTS: Six RCTs were identified. A total of 887 patients with an established diagnosis of depression who were initiating or maintaining pharmacologic treatment with antidepressant drugs and who received pharmacist care (459 patients) or usual care (428 patients) were included in the review. The most commonly reported interventions were patient education and monitoring, monitoring and management of toxicity and adverse effects, adherence promotion, provision of written or visual information, and recommendation or implementation of changes or adjustments in medication. Overall, no statistical heterogeneity or publication bias was detected. The pooled odds ratio, using a random effects model, was 1.64 (95% CI 1.24 to 2.17). Subgroup analysis showed no statistically significant differences in results by type of pharmacist involved, adherence measure, diagnostic tool, or analysis strategy. CONCLUSIONS: These results suggest that pharmacist intervention is effective in the improvement of patient adherence to antidepressants. However, data are still limited and we would recommend more research in this area, specifically outside of the US.
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Antidepresivos/uso terapéutico , Depresión/tratamiento farmacológico , Cumplimiento de la Medicación/estadística & datos numéricos , Servicios Farmacéuticos , Atención Ambulatoria , Antidepresivos/efectos adversos , Humanos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Fibromyalgia (FM) is a prevalent and disabling disorder characterised by widespread pain and other symptoms such as insomnia, fatigue and depression. Catastrophisation is considered to be a key clinical symptom in FM; however, few studies have investigated how contextual factors, such as catastrophisation, might contribute to the duration of the pain. The present research examined the relationship among pain, catastrophic thinking and FM impact, as a function of stage of chronicity. METHODS: In this cross-sectional study, the sample of 328 patients diagnosed with FM was divided into 3 groups based on level of chronicity: Group A (6 months to 2 years, N = 46); Group B (2-4 years, N = 59); and Group C (more than 4 years, N = 223). The three subscales of the Pain Catastrophising Scale (PCS), rumination, magnification, and helplessness, were used as predictors of dysfunction. The Fibromyalgia Impact Questionnaire and the McGill Pain Questionnaire were also administered. A hierarchical regression analysis was performed on the entire sample and, subsequently, for each group to determine the effect of the continuous process variables (castastrophising and pain) on the stages of chronicity. RESULTS: Total score and PCS subscales were strongly associated with pain and impact in all the stages of chronicity in FM patients (r = 0.27-0.73, p < 0.05). For Group A, a regression analysis revealed that rumination predicted FM impact beyond the variance accounted for by age and pain. Both magnification and helplessness predicted impact in Group B, and helplessness was a significant predictor of impact in Group C. CONCLUSION: These findings provide preliminary evidence that stage of chronicity is an important moderator of psychological vulnerability for FM impact and should be taken into account by tailoring psychological interventions.
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Catastrofización/psicología , Fibromialgia/psicología , Trastornos del Humor/psicología , Dolor/psicología , Adolescente , Adulto , Anciano , Catastrofización/diagnóstico , Catastrofización/epidemiología , Enfermedad Crónica , Comorbilidad , Estudios Transversales , Femenino , Fibromialgia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Trastornos del Humor/diagnóstico , Trastornos del Humor/epidemiología , Dolor/diagnóstico , Dolor/epidemiología , Adulto JovenRESUMEN
BACKGROUND: The aim of this study was to validate a Spanish version of the Chronic Pain Acceptance Questionnaire (CPAQ). Pain acceptance is the process of giving up the struggle with pain and learning to live a worthwhile life despite it. The Chronic Pain Acceptance Questionnaire (CPAQ) is the questionnaire most often used to measure pain acceptance in chronic pain populations. METHODS: A total of 205 Spanish patients diagnosed with fibromyalgia syndrome who attended our pain clinic were asked to complete a battery of psychometric instruments: the Pain Visual Analogue Scale (PVAS) for pain intensity, the Hospital Anxiety and Depression Scale (HADS), the Medical Outcome Study Short Form 36 (SF-36), the Pain Catastrophising Scale (PCS) and the Fibromyalgia Impact Questionnaire (FIQ). RESULTS: Analysis of results showed that the Spanish CPAQ had good test-retest reliability (intraclass correlation coefficient 0.83) and internal consistency reliability (Cronbach's alpha: 0.83). The Spanish CPAQ score significantly correlated with pain intensity, anxiety, depression, pain catastrophising, health status and physical and psychosocial disability. The Scree plot and a Principal Components Factor analysis confirmed the same two-factor construct as the original English CPAQ. CONCLUSION: The Spanish CPAQ is a reliable clinical assessment tool with valid construct validity for the acceptance measurement among a sample of Spanish fibromyalgia patients. This study will make it easier to assess pain acceptance in Spanish populations with fibromyalgia.
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Fibromialgia/psicología , Psicometría , Encuestas y Cuestionarios , Adulto , Anciano , Ansiedad/diagnóstico , Ansiedad/etiología , Enfermedad Crónica , Depresión/diagnóstico , Depresión/etiología , Femenino , Humanos , Lenguaje , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Reproducibilidad de los Resultados , EspañaRESUMEN
BACKGROUND: Fibromyalgia is a prevalent and disabling disorder characterized by widespread pain and other symptoms such as insomnia, fatigue or depression. Catastrophization is considered a key clinical symptom in fibromyalgia; however, there are no studies on the pharmacological or psychological treatment of catastrophizing. The general aim of this study is to assess the effectiveness of cognitive-behaviour therapy and recommended pharmacological treatment for fibromyalgia (pregabalin, with duloxetine added where there is a comorbid depression), compared with usual treatment at primary care level. DESIGN: A multi-centre, randomized controlled trial involving three groups: the control group, consisting of usual treatment at primary care level, and two intervention groups, one consisting of cognitive-behaviour therapy, and the other consisting of the recommended pharmacological treatment for fibromyalgia. SETTING: 29 primary care health centres in the city of Zaragoza, Spain. SAMPLE: 180 patients, aged 18-65 years, able to understand and read Spanish, who fulfil criteria for primary fibromyalgia, with no previous psychological treatment, and no pharmacological treatment or their acceptance to discontinue it two weeks before the onset of the study. INTERVENTION: Psychological treatment is based on the manualized protocol developed by Prof. Escobar et al, from the University of New Jersey, for the treatment of somatoform disorders, which has been adapted by our group for the treatment of fibromyalgia. It includes 10 weekly sessions of cognitive-behaviour therapy. Pharmacological therapy consists of the recommended pharmacological treatment for fibromyalgia: pregabalin (300-600 mg/day), with duloxetine (60-120 mg/day) added where there is a comorbid depression). MEASUREMENTS: The following socio-demographic data will be collected: sex, age, marital status, education, occupation and social class. The diagnosis of psychiatric disorders will be made with the Structured Polyvalent Psychiatric Interview. Other instruments to be administered are the Pain Catastrophizing Scale, the Hamilton tests for Anxiety and for Depression, the Fibromyalgia Impact Questionnaire (FIQ), the EuroQuol-5 domains (EQ-5D), and the use of health and social services (CSRI). Assessments will be carried out at baseline, 1, 3, and 6 months. MAIN VARIABLE: Pain catastrophizing. ANALYSIS: The analysis will be per intent to treat. We will use the general linear models of the SPSS version 15 statistical package, to analyse the effect of the treatment on the result variable (pain catastrophizing). DISCUSSION: It is necessary to assess the effectiveness of pharmacological and psychological treatments for pain catastrophizing in fibromyalgia. This randomized clinical trial will determine whether both treatments are effective for this important prognostic variable in patients with fibromyalgia. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10804772.