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BACKGROUND: Most prescriptions for sedative-hypnotics are written by family physicians. Given the influence of preceptors on residents' prescribing, this study explored how family physician preceptors manage sleeping problems. METHODS: Family physician preceptors affiliated with a postgraduate training program in Alberta were invited to participate in this mixed-methods study, conducted from January to October 2021. It included a quantitative survey of preceptors' attitudes to treatment options for sleep disorder, perceptions of patient expectations and self-efficacy beliefs. Participants indicated their responses on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Respondents were then asked whether they were interested in participating in a semistructured qualitative interview that elicited preceptors' management of sleep disorder in response to a series of vignettes. We analyzed the quantitative data using descriptive statistics and the qualitative interviews using thematic analysis. RESULTS: Of the 76 preceptors invited to participate, 47 (62%) completed the survey, and 10 were interviewed. Thirty-two survey respondents (68%) were in academic teaching clinics, and 15 (32%) were from community clinics. The majority of participants (34 [72%]) agreed they had sufficient expertise to use nondrug treatment. Most (43 [91%]) had made efforts to reduce prescribing, and 45 (96%) felt able to support patients empathically when not using sleeping medication. The qualitative data showed that management of sleeping disorder was emotionally challenging. Participants hesitated to prescribe sedatives and reported "exceptions" to prescribing, many of which included indications within guideline recommendations. Participants were reluctant to change a colleague's management. INTERPRETATION: Preceptors were confident using nonpharmacologic management to treat sleep disorder and hesitant to use sedative-hypnotics, presenting legitimate use of sedatives as exceptional behaviour. Acknowledging social norms and affective aspects involved in prescribing may support balanced prescribing of sedative-hypnotics for sleep disorder and reduce physician anxiety.
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OBJECTIF: Présenter un outil visuel d'aide à la décision clinique dans le but d'aider à personnaliser la pharmacothérapie par antidépresseurs de première intention pour les adultes souffrant d'un trouble dépressif caractérisé (TDC) dans un contexte canadien. SOURCES DE L'INFORMATION: Une recherche documentaire a été effectuée au moyen de Google Scholar, PubMed, la base de données Cochrane des revues systématiques et Trip Pro à l'aide des vedettes MeSH en anglais depression, antidepressive agents, primary care, practice patterns, medication adherence et decision making, shared. MESSAGE PRINCIPAL: Le trouble dépressif caractérisé touche chaque année environ 4,7 % des Canadiens, et il est fréquemment observé et diagnostiqué en soins primaires. La dépression non traitée est liée à une moins bonne qualité de vie, à un risque accru de suicide, de même qu'à une détérioration de la santé physique lorsque la dépression se produit simultanément avec d'autres problèmes chroniques de santé. Dans une méta-analyse en réseau, des médicaments antidépresseurs (comme les inhibiteurs sélectifs de la recapture de la sérotonine, les inhibiteurs de la recapture de la sérotonine-norépinéphrine, le bupropion et la vortioxétine) ont réduit de 50 % ou plus les symptômes de dépression par rapport à un placebo dans le traitement aigu d'adultes souffrant d'un TDC d'une intensité modérée à sévère. Une mauvaise adhésion au traitement et des taux élevés de discontinuation limitent la réussite du traitement du TDC. Il a été démontré que des facteurs comme des alliances thérapeutiques solides entre les patients et les prescripteurs, des soins en collaboration, l'éducation des patients et une autogestion soutenue accroissent l'adhésion au traitement. Les plus récentes lignes directrices sur le traitement de la dépression du CANMAT (Canadian Network for Mood and Anxiety Treatments), publiées en 2016, proposent 15 options différentes d'antidépresseurs de première intention pour le traitement du TDC. Des aides à la décision fondée sur des données probantes sont nécessaires pour personnaliser le traitement aux antidépresseurs dans le cas des patients ayant reçu un diagnostic de TDC. CONCLUSION: De récentes études sur les antidépresseurs ont indiqué qu'aucun antidépresseur n'est supérieur à un autre dans le traitement des patients souffrant d'un TDC. Cela donne à croire qu'il pourrait être possible d'améliorer l'adhésion au traitement et sa réussite en personnalisant le traitement par antidépresseurs en fonction des préférences de chaque patient. L'Outil d'aide au choix d'un antidépresseur a été élaboré pour aider les prescripteurs et les patients adultes à entreprendre une prise de décision partagée pour choisir un antidépresseur de première intention personnalisé et optimal pour le traitement d'un TDC aigu.
Subject(s)
Depressive Disorder, Major , Humans , Depressive Disorder, Major/drug therapy , Antidepressive Agents/therapeutic useABSTRACT
OBJECTIVE: To introduce a visual clinical decision support tool to assist with individualizing first-line antidepressant pharmacotherapy for adults with major depressive disorder (MDD) in a Canadian context. SOURCES OF INFORMATION: A literature review was conducted with Google Scholar, PubMed, the Cochrane Database of Systematic Reviews, and Trip Pro using the MeSH headings depression, antidepressive agents, primary care, practice patterns, medication adherence, and decision making, shared. MAIN MESSAGE: Major depressive disorder affects about 4.7% of Canadians annually and is a prevalent condition encountered and diagnosed in primary care. Untreated depression is associated with decreased quality of life, increased risk of suicide, and worsening physical health outcomes when depression co-occurs with other chronic medical conditions. In a network meta-analysis, antidepressant medications (such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, and vortioxetine) reduced depressive symptoms by 50% or more when compared with placebo in acute treatment of adults with moderate to severe MDD. Poor treatment adherence and high discontinuation rates limit MDD treatment success. Factors such as strong therapeutic alliances between patients and prescribers, collaborative care, patient education, and supportive self-management have been shown to enhance treatment adherence. The most recent Canadian Network for Mood and Anxiety Treatments depression treatment guidelines (published in 2016) suggest 15 different first-line antidepressant medication options for the treatment of MDD. There is a need for evidence-informed decision support aids to individualize antidepressant therapy to treat patients diagnosed with MDD. CONCLUSION: Recent studies on antidepressants have indicated no single antidepressant is superior to others in treating patients with MDD. This suggests there may be opportunities to enhance treatment adherence and success by tailoring antidepressant therapy to align with each patient's preferences. The Antidepressant Decision Support Tool was developed to help prescribers and adult patients engage in shared decision making to select an individualized and optimal first-line antidepressant for the treatment of acute MDD.
Subject(s)
Depressive Disorder, Major , Humans , Adult , Depressive Disorder, Major/drug therapy , Quality of Life , Canada , Systematic Reviews as Topic , Antidepressive Agents/therapeutic use , Selective Serotonin Reuptake Inhibitors/adverse effectsABSTRACT
OBJECTIVES: The effects of switching Canadians from other basal insulins to degludec (IDeg) in an outpatient setting are unknown. Our aim in this study was to evaluate the clinical effectiveness and safety of switching insulin-treated adults with either type 1 (T1DM) or type 2 (T2DM) diabetes mellitus to IDeg. METHODS: This was a retrospective observational cohort study of Albertans who were switched to IDeg between December 1, 2018, and December 1, 2019, and followed until March 1, 2020. We used administrative databases (provincial cohort) and electronic medical records (clinic cohort) to gather data and interrupted time series for the primary outcome analysis. RESULTS: We analyzed a provincial cohort of 5,294 patients, 287 of whom were also included in the clinic cohort (T1DM, n=80; T2DM, n=207). After switching to IDeg, glycated hemoglobin (A1C) decreased by -0.3 (95% confidence interval [CI], -0.4% to -0.2%) and the reduction in A1C was maintained throughout the follow-up period. Rates of all-cause hospitalizations/emergency department visits per patient were not affected (hospitalizations pre-switch 0.07 [95% CI, 0.07 to 0.08], post-switch 0.08 [95% CI, 0.06 to 0.09], p=0.45; ED visits pre-switch 0.25 [95% CI, 0.23 to 0.27], post-switch 0.26 [95% CI, 0.23 to 0.29], p=0.27). In the clinic cohort, at switch, there was an average basal insulin dose reduction of 11.2% (T1DM), 12.3% (T2DM) and 16.3% (patients with insulin resistance). CONCLUSIONS: Patients with inadequate glycemic control or who find their basal insulin dosing inconvenient may benefit from switching to Ideg, with the potential for small improvementa in A1C at lower basal insulin doses.