Low intensity vs. self-guided internet-delivered psychotherapy for major depression: a multicenter, controlled, randomized study.

BACKGROUND Major depression will become the second most important cause of disability in 2020. Computerized cognitive-behaviour therapy could be an efficacious and cost-effective option for its treatment. No studies on cost-effectiveness of low intensity vs self-guided psychotherapy has been carried out. The aim of this study is to assess the efficacy of low intensity vs self-guided psychotherapy for major depression in the Spanish health system. METHODS The study is made up of 3 phases: 1.- Development of a computerized cognitive-behaviour therapy for depression tailored to Spanish health system. 2.- Multicenter controlled, randomized study: A sample (N=450 patients) with mild/moderate depression recruited in primary care. They should have internet availability at home, not receive any previous psychological treatment, and not suffer from any other severe somatic or psychological disorder. They will be allocated to one of 3 treatments: a) Low intensity Internet-delivered psychotherapy + improved treatment as usual (ITAU) by GP, b) Self-guided Internet-delivered psychotherapy + ITAU or c) ITAU. Patients will be diagnosed with MINI psychiatric interview. Main outcome variable will be Beck Depression Inventory. It will be also administered EuroQol 5D (quality of life) and Client Service Receipt Inventory (consume of health and social services). Patients will be assessed at baseline, 3 and 12 months. An intention to treat and a per protocol analysis will be performed. DISCUSSION The comparisons between low intensity and self-guided are infrequent, and also a comparative economic evaluation between them and compared with usual treatment in primary. The strength of the study is that it is a multicenter, randomized, controlled trial of low intensity and self-guided Internet-delivered psychotherapy for depression in primary care, being the treatment completely integrated in primary care setting. TRIAL REGISTRATION Clinical Trials NCT01611818.

Adolescent survivors of childhood cancer: are they vulnerable for psychological distress?

OBJECTIVES: We aimed to (i) evaluate psychological distress in adolescent survivors of childhood cancer and compare them to siblings and a norm population; (ii) compare the severity of distress of distressed survivors and siblings with that of psychotherapy patients; and (iii) determine risk factors for psychological distress in survivors. METHODS: We sent a questionnaire to all childhood cancer survivors aged <16 years when diagnosed, who had survived ≥ 5 years and were aged 16-19 years at the time of study. Our control groups were same-aged siblings, a norm population, and psychotherapy patients. Psychological distress was measured with the Brief Symptom Inventory-18 (BSI-18) assessing somatization, depression, anxiety, and a global severity index (GSI). Participants with a T-score ≥ 57 were defined as distressed. We used logistic regression to determine risk factors. RESULTS: We evaluated the BSI-18 in 407 survivors and 102 siblings. Fifty-two survivors (13%) and 11 siblings (11%) had scores above the distress threshold (T ≥ 57). Distressed survivors scored significantly higher in somatization (p=0.027) and GSI (p=0.016) than distressed siblings, and also scored higher in somatization (p ≤ 0.001) and anxiety (p=0.002) than psychotherapy patients. In the multivariable regression, psychological distress was associated with female sex, self-reported late effects, and low perceived parental support. CONCLUSIONS: The majority of survivors did not report psychological distress. However, the severity of distress of distressed survivors exceeded that of distressed siblings and psychotherapy patients. Systematic psychological follow-up can help to identify survivors at risk and support them during the challenging period of adolescence.

The predictive value of psychological assessment of candidates for gastric bypass: A medical chart review

Background and Objectives: Guidelines for bariatric surgery demand a psychological evaluation of applicants. The aim of this study was to evaluate if the presence of "psychological risk factors" predicts postoperative weight loss after gastric bypass. Methods: Medical records of obese women who underwent bariatric surgery between 2000 and 2004 were reviewed. Psychological assessment consisted of a one-hour semi-structured interview, summarized in a written report. Anthropometric assessment at baseline and 6,12,18 and 24 months after surgery included body weight, height and body mass index. Results: The mean BMI of included patients (N = 92) was 46.2 + 6,3 kg/m(2) (range 38.4-69.7). Based on the psychological assessment, 27% (N = 25) of the patients were classified as having "psychological risk factors" and 28% (N = 26) were diagnosed with a psychiatric diagnosis, most often major depression. Two years after gastric bypass, 16% of patients with "psychological risk factors" achieved an excellent result (%EWL > 75) versus 39% of those without (p < 0.05). About 1 out of 4 patients was in postoperative psychiatric treatment, but only half of them were identified as having "psychological risk factors" at baseline. Weight loss of patients initiating a psychiatric treatment only after surgery was less than of patients who continued psychiatric treatment already initiated before surgery (55.7 + 14.8 versus 66.5 + 14.2 %EWL). Conclusions: A single semi-structured psychological interview may identify patients who are at risk for diminished postoperative weight loss; however, psychological assessment did not identify those patients who were in need of a psychiatric postoperative treatment.

Differential effect of Charlson index and its components on in-hospital mortality and health costs

Introduction: The Charlson index (Charlson, 1987) is a commonly used comorbidity index in outcome studies. Still, the use of different weights makes its calculation cumbersome, while the sum of its components (comorbidities) is easier to compute. In this study, we assessed the effects of 1) the Charlson index adapted for the Swiss population and 2) the sum of its components (number of comorbidities, maximum 15) on a) in-hospital deaths and b) cost of hospitalization. Methods: Anonymous data was obtained from the administrative database of the department of internal medicine of the Lausanne University Hospital (CHUV). All hospitalizations of adult (>=18 years) patients occurring between 2003 and 2011 were included. For each hospitalization, the Charlson index and the number of comorbidities were calculated. Analyses were conducted using Stata. Results: Data from 32,741 hospitalizations occurring between 2003 and 2011 was analyzed. On bivariate analysis, both the Charlson index and the number of comorbidities were significantly and positively associated with in hospital death. Conversely, multivariate adjustment for age, gender and calendar year using Cox regression showed that the association was no longer significant for the number of comorbidities (table). On bivariate analysis, hospitalization costs increased both with Charlson index and with number of comorbidities, but the increase was much steeper for the number of comorbidities (figure). Robust regression after adjusting for age, gender, calendar year and duration of hospital stay showed that the increase in one comorbidity led to an average increase in hospital costs of 321 CHF (95% CI: 272 to 370), while the increase in one score point of the Charlson index led to a decrease in hospital costs of 49 CHF (95% CI: 31 to 67). Conclusion: Charlson index is better than the number of comorbidities in predicting in-hospital death. Conversely, the number of comorbidities significantly increases hospital costs.

Using the costs of drug therapy to screen patients for a community pharmacy-based medication review program

Objectives: To measure the positive predictive value (PPV) of the cost of drug therapy (threshold = 2000 Swiss francs [CHF], US$1440, <euro>1360) as a screening criterion for identifying patients who may benefit from medication review (MR). To describe identified drug-related problems (DRPs) and expense problems (EPs), and to estimate potential savings if all recommendations were accepted. Setting Five voluntary Swiss community pharmacies. Methods: Of 12,680 patients, 592 (4.7%) had drug therapy costs exceeding 2000 CHF over a six-month period from July 1 to December 31, 2002. This threshold limit was set to identify high-risk patients for DRPs and EPs. Three pharmacists consecutively conducted a medication review based on the pharmaceutical charts of 125 sampled patients who met the inclusion criterion. Main outcome measure: The PPV of a threshold of 2000 CHF for identifying patients who might benefit from a MR: true positives were patients with at least one DRP, while false positives were patients with no DRP. Results: The selection based on this criterion had a PPV of 86% for detecting patients with at least one DRP and 95% if EPs were also considered. There was a mean of 2.64 (SD = 2.20) DRPs per patient and a mean of 2.14 (SD = 1.39) EPs per patient. Of these patients, 90% were over 65 years old or were treated with at least five chronic medications, two common criteria for identifying patients at risk of DRPs. The main types of DRPs were drug-drug interactions, compliance problems and duplicate drugs. Mean daily drug cost per patient was CHF 14.87 (US$10.70, <euro>10.10). A potential savings of CHF 1.67 (US$1.20, <euro>1.14) per day (11%) was estimated if all recommendations to solve DRPs and EPs suggested herein were implemented. Conclusion: Further studies should investigate whether the potential benefit of medication reviews in preventing DRPs and containing costs in this patient group can be confirmed in a real practice environment. [Authors]

The energetic grooming costs imposed by a parasitic mite (Spinturnix myoti) upon its bat host (Myotis myotis).

Parasites often exert severe negative effects upon their host's fitness. Natural selection has therefore prompted the evolution of anti-parasite mechanisms such as grooming. Grooming is efficient at reducing parasitic loads in both birds and mammals, but the energetic costs it entails have not been properly quantified. We measured both the energetic metabolism and behaviour of greater mouse-eared bats submitted to three different parasite loads (no, 20 and 40 mites) during whole daily cycles. Mites greatly affected their time and energy budgets. They caused increased grooming activity, reduced the overall time devoted to resting and provoked a dramatic shortening of resting bout duration. Correspondingly, the bats' overall metabolism (oxygen consumption) increased drastically with parasite intensity and, during the course of experiments, the bats lost more weight when infested with 40 rather than 20 or no parasites. The short-term energetic constraints induced by anti-parasite grooming are probably associated with long-term detrimental effects such as a decrease in survival and overall reproductive value.

Psychological correlates of childhood obesity.

To enhance the prevention and intervention efforts of childhood obesity, there is a strong need for the early detection of psychological factors contributing to its development and maintenance. Rather than a stable condition, childhood obesity represents a dynamic process, in which behavior, cognition and emotional regulation interact mutually with each other. Family structure and context, that is, parental and familial attitudes, activity, nutritional patterns as well as familial stress, have an important role with respect to the onset and maintenance of overweight and obesity. Behavioral and emotional problems are found in many, though not all, obese children, with a higher prevalence in clinical, treatment-seeking samples. The interrelatedness between obesity and psychological problems seems to be twofold, in that clinically meaningful psychological distress might foster weight gain and obesity may lead to psychosocial problems. The most frequently implicated psychosocial factors are externalizing (impulsivity and attention-deficit hyperactivity disorder) and internalizing (depression and anxiety) behavioral problems and uncontrolled eating behavior. These findings strengthen the need to further explore the interrelatedness between psychological problems and childhood obesity.

Cuestiones controvertidas en evaluación económica (III). Intervenciones sanitarias en tres situaciones especiales: enfermedades raras, tratamientos al final de la vida y externalidades en las evaluaciones.

The development of the economic evaluation of health care interventions has become a support tool in making decisions on pricing and reimbursement of new health interventions. The increasingly extensive application of these techniques has led to the identification of particular situations in which, for various reasons, it may be reasonable to take into account special considerations when applying the general principles of economic evaluation. In this article, which closes a series of three, we will discuss, using the Metaplan technique, about the economic evaluation of health interventions in special situations such as rare diseases and end of life treatments, as well as consideration of externalities in assessments, finally pointing out some research areas to solve the main problems identified in these fields.

Developmental, metabolic and immunological costs of flea infestation in the common vole

Parasites use resources from their hosts, which can indirectly affect a number of host functions because of trade-offs in resource allocation. In order to get a comprehensive view of the costs imposed by blood sucking parasites to their hosts, it is important to monitor multiple components of the development and physiology of parasitized hosts over long time periods. The effect of infestation by fleas on body mass, body length growth, haematocrit, resistance to oxidative stress, resting metabolic rate and humoral immune response were experimentally evaluated. During a 3-month period, male common voles, Microtus arvalis, were either parasitized by rat fleas (Nosopsyllus fasciatus), which are naturally occurring generalist ectoparasites of voles, or reared without fleas. Then voles were challenged twice by injecting Keyhole Limpet Haemocyanin (KLH) to assess whether the presence of fleas affects the ability of voles to produce antibodies against a novel antigen. During the immune challenge we measured the evolution of body mass, haematocrit, resistance to oxidative stress and antibody production. Flea infestation negatively influenced the growth of voles. Moreover, parasitized voles had reduced haematocrit, higher resting metabolic rate and lower production of antibodies against the KLH. Resistance to oxidative stress was not influenced by the presence of fleas. During the immune challenge with KLH, body mass decreased in both groups, while the resistance to oxidative stress remained stable. In contrast, the haematocrit decreased only in parasitized voles. Our experiment shows that infestation by a haematophageous parasite negatively affects multiple traits like growth, energy consumption and immune response. Fleas may severely reduce the survival probability and reproductive success of their host in natural conditions.

Bayesian nash equilibrium in ''linear'' cournot models with private information about costs

Calculating explicit closed form solutions of Cournot models where firms have private information about their costs is, in general, very cumbersome. Most authors consider therefore linear demands and constant marginal costs. However, within this framework, the nonnegativity constraint on prices (and quantities) has been ignored or not properly dealt with and the correct calculation of all Bayesian Nash equilibria is more complicated than expected. Moreover, multiple symmetric and interior Bayesianf equilibria may exist for an open set of parameters. The reason for this is that linear demand is not really linear, since there is a kink at zero price: the general ''linear'' inverse demand function is P (Q) = max{a - bQ, 0} rather than P (Q) = a - bQ.

Anxiety and Psychological Stress Before Prenatal Screening in First-Time Mothers Who Conceived Through IVF/ICSI or Spontaneously.

Mothers' general anxiety, anxiety about the well-being of the child and psychological stress before prenatal testing was studied by comparing women who conceived through in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) with women who conceived naturally. Before the first trimester screening test for Down's syndrome, a group of 51 women who conceived through IVF/ICSI and a group of 54 women who conceived spontaneously completed the State Scale of the State-Trait Anxiety Inventory (S-Anxiety; Spielberger, 1983), the Fear of Bearing a Physically or Mentally Handicapped Child Subscale of the Pregnancy-related Anxiety Questionnaire (PRAQ-R; Huizink et al., 2004), the Psychological Stress Measure (PSM; Lemyre & Tessier, 1988), and the Prenatal Psychosocial Profile (PPP; Curry, Campbell, & Christian, 1994). Women who conceived through IVF/ICSI had more elevated levels of general anxiety and psychological stress than the women who conceived naturally; however, no difference was observed between the two groups for anxiety specifically related to the health of the child. These results underline the need to monitor women's emotional state after conception via IVF/ICSI-when counseling usually ends-and around the time of the first trimester screening. Counseling might thus be extended.

"S'il vous plaît docteur, mettez-moi en arrêt"! Certificats médicaux pour raisons psychologiques ["Doctor please, give me a sick leave"!: medical certificates for psychological reasons].

General practitioners are regularly called to evaluate the psychological work capacity of patients. The implicit motivation behind the explicit reason for requesting a sick leave is linked to the subject's history and the way he transfers it in his professional life. An incapacity to work harbours a variety of challenges for the patient, the physician and their relationship. In order to get a better understanding of all the issues at stake, the doctor should understand the significances that represents the work to the patient and the consequences of a sick leave and its associated transference and countertransference issues.