[The integrated management software of primary care,a tool for analysing indicators of use]. / El software de gestión integral de la atención primaria, una herramienta de análisis de los indicadores de utilización.

OBJECTIVES: To analyse the indicators of use in the Gran Canaria Health Area. To characterise over-users so that the primary care team can take corrective measures. To design a computer tool giving appropriate useful information to the management, that can be directly put into practice in primary care. DESIGN: Retrospective descriptive study. SATTING: Gran Canaria Health Area. Hierarchical descent in the analysis of data in the base health area and family care unit, in the year 2000. PARTICIPANTS: Users of the Canaries Health Service registered on the individual health card data base. MAIN MEASUREMENTS AND RESULTS: The activity generated by 636 270 users with 2 876 394 appointments was studied. Mean frequency of attendance in the Gran Canaria Health Area was 4.52, with a 67.3% use rate. The user causing 11 or more visits per year was defined as an over-user. 13.4% of users were over-users and caused among them 52.3% of visits. 32.7% of users registered made no visit. CONCLUSIONS: A small section of the population causes over half the consultations. The characteristics of these users need to be analysed so that programmes can be worked out to decrease their frequency of use. The integrated management software for primary care enables this information to be analysed and serves as a support for the primary care teams. Special attention needs to be paid to the population that does not use the health centres.

El software de gestión integral de la atención primaria, una herramienta de análisis de los indicadores de utilización / The comprehensive management software primary care, an analysis tool utilization indicators

Objetivo. Analizar los indicadores de utilización del Área de Salud de Gran Canaria. Caracterizar al grupo hiperfrecuentador con el fin de emprender medidas correctoras desde el equipo de atención primaria. Diseñar una herramienta informática que aporte información adecuada y útil a la gestión y que sea de aplicación directa en los equipos de atención primaria. Diseño. Estudio descriptivo, retrospectivo. Emplazamiento. Área de Salud de Gran Canaria. Descenso jerárquico en el análisis de los datos a zona básica de salud y unidad de atención familiar. Año 2000.Participantes. Usuarios del Servicio Canario de la Salud registrados en la base de datos de la tarjeta sanitaria individual. Mediciones y resultados principales. Se estudió la actividad creada por 636.270 usuarios que generaron 2.876.394 citas. La frecuentación media del Área de Salud de Gran Canaria fue de 4,52, con una tasa de utilización del 67,3 por ciento. Se definió como hiperfrecuentador al usuario que genera 11 o más citas en un año. El 13,4 por ciento de los usuarios fue hiperfrecuentador, y generó el 52,3 por ciento de las visitas. Un 32,7 por ciento de los usuarios no generó ninguna visita. Conclusiones. Una pequeña parte de la población genera más de la mitad de la consulta. Se hace preciso analizar las características de estos usuarios con el fin de elaborar programas destinados a disminuir su frecuentación. El software de gestión integral de la atención primaria permite analizar esta información, y sirve como apoyo a los equipos de atención primaria. Es necesario prestar atención especial a la población no frecuentadora. (AU)

Whither psychiatric diagnosis.

OBJECTIVE: The aim of this paper is to describe the development of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), its purposes and limitations, and the psychiatric nosologies which may emerge from advances in psychiatric research and which may supersede the current classification system. METHOD: A review of the methodology used to develop DSM-IV, considered in the context of current and future psychiatric, neurobiological, and genetic research, was undertaken. RESULTS: The DSM-IV is a descriptive nosology that has shaped psychiatric research and clinical practice by providing agreed-upon definitions of psychiatric disorders based on the current state of empirical data. Despite the critical importance of the DSM system of classification, this complex yet limited nosology will eventually be replaced by simpler, more incisive explanatory models of psychiatric illness that reflect the interplay of biological, psychological, environmental and social variables affecting the expression and treatment of psychiatric disorders. CONCLUSIONS: As we continue to understand the pathophysiology of brain disorders, as well as the biological effects of psychiatric interventions, we will be able to move from a descriptive model to an integrative, explanatory model of psychiatric illness.

Treatment of depressive symptoms in human immunodeficiency virus-positive patients.

BACKGROUND: This randomized clinical trial compared 16-week interventions with interpersonal psychotherapy, cognitive behavioral therapy, supportive psychotherapy, and supportive psychotherapy with imipramine for human immunodeficiency virus (HIV)-positive patients with depressive symptoms. METHODS: Subjects (N = 101; 85 male, 16 female) with known HIV seropositivity for at least 6 months were randomized to 16 weeks of treatment. Inclusion criteria were 24-item Hamilton Depression Rating Scale score of 15 or higher, clinical judgment of depression, and physical health sufficient to attend outpatient sessions. Therapists were trained in manualized therapies specific for HIV-positive patients. Treatment adherence was monitored. RESULTS: Subjects randomized to interpersonal psychotherapy (n = 24) and supportive psychotherapy with imipramine (n = 26) had significantly greater improvement on depressive measures than those receiving supportive psychotherapy (n = 24) or cognitive behavioral therapy (n = 27). Similar results appeared in the completer subsample. CONCLUSIONS: Depressive symptoms appear treatable in HIV-positive patients. Interpersonal psychotherapy may have particular advantages as a psychotherapy for patients who have experienced the significant life events of HIV infection.

The Expert Consensus Guidelines for treating depression in bipolar disorder.

We present expert consensus guideline recommendations for the treatment of bipolar depression. These were arrived at through the statistical aggregation of the survey responses of 61 leading clinical researchers to eight questions about the key decision points in the management of bipolar depression. The experts' first-line recommendation for treating psychotic depression in bipolar disorder is to provide a combination of mood stabilizer, antidepressant, and neuroleptic medication. For severe, but nonpsychotic bipolar depression, the experts recommend the combination of a mood stabilizer and an antidepressant. For milder bipolar depression, a mood stabilizer and an antidepressant together or a mood stabilizer alone would be first line. The experts' antidepressant dose and dosing schedule recommendations are equivalent for unipolar and bipolar depression, but the experts recommend a faster discontinuation of antidepressants during the maintenance phase in bipolar patients--probably to reduce the risk of rapid cycling. Among the antidepressants, the experts prefer bupropion and the serotonin reuptake inhibitors as first line. They also believe that bupropion is least likely among antidepressants to cause switches to mania. Among mood stabilizers, the experts rate lithium as most likely to have a direct antidepressant effect.

Individual psychotherapies for depressed HIV-positive patients.

OBJECTIVE: The authors present preliminary data from two treatment modalities of a randomized clinical trial in which they compared 16-week interventions of interpersonal psychotherapy to supportive psychotherapy. METHOD: HIV-positive patients who were not acutely medically ill and had scores of 15 or higher on the Hamilton Depression Rating Scale were randomly assigned to one of four treatment modalities. They were assessed by the Hamilton scale and Beck Depression Inventory at 8 and 16 weeks. Most subjects who underwent either interpersonal psychotherapy (N = 16) or supportive psychotherapy (N = 16) were male, gay or bisexual, white, and college educated. RESULTS: Results of last-observation-carried-forward and completer analyses showed that scores on the Hamilton scale and Beck Depression Inventory decreased significantly for both treatments. Differential improvement for interpersonal psychotherapy appeared by midtreatment (week 8) and persisted at termination. CONCLUSIONS: This is the first controlled study of individual psychotherapies for depressed HIV-positive patients. Results suggest that a specific antidepressant psychotherapy, interpersonal psychotherapy, has advantages over a supportive therapy.

Clinical correlates of self-mutilation in borderline personality disorder.

OBJECTIVE: This exploratory study sought demographic and clinical correlates of self-mutilation (self-injury without suicidal intent) in borderline personality disorder. METHOD: Among 124 consecutively admitted inpatients with borderline personality disorder, there were 62 who did not mutilate themselves, 23 who mutilated themselves infrequently (fewer than five lifetime events), and 39 who mutilated themselves frequently (five or more lifetime events); each received ratings on numerous measures of psychopathology. RESULTS: Compared to nonmutilators, frequent mutilators were significantly more likely to be in outpatient treatment at the time of admission and had more weeks of prior outpatient and inpatient treatment; they were also more likely to receive comorbid diagnoses of current major depression, anorexia nervosa, and bulimia nervosa. Frequent mutilators had significantly higher group means on the Beck Scale for Suicidal Ideation, were more likely to have attempted suicide, and were more likely to have attempted suicide more often than both infrequent mutilators and nonmutilators. The adjusted odds ratios from logistic regression analyses demonstrated that major depression, bulimia nervosa, number of prior suicide attempts, and acute suicidal ideation were each associated with greater risk of frequent mutilation. CONCLUSIONS: Borderline patients who frequently mutilate themselves may represent a subgroup of especially high utilizers of psychiatric treatment who are at particularly high risk for suicidal behavior and for comorbid major depression and eating disorders. Clinicians should consider aggressive treatment of comorbid axis I disorders and careful assessment of suicide risk in these patients.

Desipramine for the treatment of "pure" dysthymia versus "double" depression.

The authors report results of an 8-week, open trial of desipramine in 42 patients with DSM-III-R dysthymia with a concurrent diagnosis of major depression ("double" depression) and 33 patients with dysthymia who had no other depressive diagnosis ("pure" dysthymia). Either complete or partial remission was achieved by 70% of the patients with "pure" dysthymia. This compared favorably with but was not significantly different from results in the "double" depression group.

Eye tracking dysfunction in schizophrenia: characterization of component eye movement abnormalities, diagnostic specificity, and the role of attention.

To characterize oculomotor components and diagnostic specificity of eye tracking abnormalities in schizophrenia, we examined a large consecutively admitted series of psychotic patients and matched controls. The most common abnormality in schizophrenic patients was low gain (slow) pursuit eye movements (47% of cases). Pursuit and saccadic eye movement abnormalities were no more severe in schizophrenic Ss than in those with affective psychoses, except that high rates of catch-up saccades were unique to schizophrenic Ss (17% of cases). These findings indicate that impaired pursuit eye movements are a major cause of eye tracking impairments in schizophrenia, that tracking dysfunctions commonly occur in affective psychoses, and that markedly high rates of catch-up saccades during eye tracking may be specific to schizophrenia.

Crisis intervention response and long-term outcome: a pilot study.

We investigated whether process variables (therapeutic alliance and insight) measured at the termination of crisis intervention predict long-term treatment compliance and 2-year outcome. Thirty-seven consecutive depressed psychiatric patients assigned to outpatient crisis intervention (CCI) were assessed with both questionnaires and standardized instruments at intake, 1 week, and CCI termination (mean, 6 weeks). Thirty-one subjects (84%) were also evaluated at 1-year and 2-year follow-up. We found that working alliance and development of insight predicted positive global change and symptom improvement at 1 and 2 years' follow-up. Furthermore, the observed correlation between process measures and 2-year outcome was found to be independent of age, sex, symptoms severity at intake, improvement of symptoms at CCI termination, premorbid adjustment, DSM-III-R axis I/axis II diagnosis, and therapeutic alliance at intake.

Predictors of posttraumatic stress disorder after burn injury.

OBJECTIVE: The authors' goal was to examine subjective and objective predictors of posttraumatic stress disorder (PTSD). METHOD: Hospitalized burn patients were assessed 1 week after injury with both objective predictors (percent of burned area and facial disfigurement) and subjective predictors (emotional distress and perceived social support). The patients were then assessed 2, 6, and 12 months later for development of PTSD. RESULTS: Among 51 patients, 18 (35.3%) met PTSD criteria at 2 months. High rates of PTSD were also found at 6 months (N = 16, 40.0% of the 40 available patients) and 12 months (N = 14, 45.2% of the 31 available patients). PTSD was predicted by subjective variables assessed at baseline, but patients with more severe burns were not more likely to develop PTSD. CONCLUSIONS: The DSM-III-R diagnosis of PTSD relies on an objective evaluation of the stressor's severity. The prospective data in this study support those who argue that evaluations of the severity of the stressor might also take into account subjective factors.

Bizarre delusions and DSM-III-R schizophrenia.

OBJECTIVE: Bizarre delusions are assigned greater weight relative to other delusions in the DSM-III-R diagnosis of schizophrenia. The decision to emphasize bizarre delusions was based largely on historical tradition rather than empirical evidence. This study examined 1) the extent to which a history of bizarre delusions contributes to the diagnosis of schizophrenia and 2) whether schizophrenic patients with bizarre delusions constitute a clinically distinguishable subgroup. METHOD: Two hundred fourteen consecutively admitted psychotic inpatients were assessed for bizarre delusions according to the DSM-III-R criteria. Clinical and demographic correlates of bizarre delusions were examined in subsets of patients diagnosed as schizophrenic according to DSM-III-R who also received CT scans and neuropsychological testing. RESULTS: With the base prevalence rate for schizophrenia of 0.71, bizarre delusions had a sensitivity of 0.79, a specificity of 0.56, and a positive predictive power of 0.82 for the diagnosis of schizophrenia (N = 152) relative to other psychotic disorders (N = 62). Clinical, neurobehavioral, CT scan, and premorbid adjustment data on the schizophrenic patients indicated that beyond manifesting more severe positive symptoms, patients with bizarre delusions did not otherwise constitute a clinically distinguishable subgroup. CONCLUSIONS: The data suggest that criterion A for the diagnosis of schizophrenia in DSM-IV could be improved by removing the special emphasis that was placed on bizarre delusions in DSM-III-R.

Increased tardive dyskinesia in alcohol-abusing schizophrenic patients.

Many schizophrenics have a diagnosis of substance abuse or dependence. We evaluated whether drug or alcohol abuse is an independent risk factor for tardive dyskinesia (TD) in schizophrenia. In a consecutive admission, clinical study of 75 hospitalized schizophrenics, drug or alcohol abusers had significantly higher TD scores than nonabusers. The association of alcohol abuse or dependence with TD seemed independent from other risk factors for TD.

Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients.

We investigated prevalence and comorbidity of DSM-III dysthymic disorder in a psychiatric outpatient clinic. Seventy-five consecutive outpatients received structured interviews. Prevalence of dysthymic disorder was 36% in the consecutive sample. Thirty-four dysthymic and 56 non-dysthymic patients were compared for comorbidity. Dysthymic subjects were more likely to meet criteria for major depression, social phobia, and avoidant, self-defeating, dependent, and borderline personality disorders. Dysthymic disorder was usually of early onset, predating comorbid disorders, and had often not received adequate antidepressant treatment. These results help define dysthymic disorder as prevalent, usually predating axis I comorbidity, and associated with particular axis II diagnoses.