PREDICT plus PREVENT

DO THE PREDICT RISK CALCULATORS HAVE SCIENTIFIC VALIDITY?

In Spain, “Predict” risk calculators or algorithms predict the occurrence in a certain person of a major depressive episode, an anxiety disorder (generalized anxiety, panic attacks or nonspecific anxiety disorder) and/or at-risk alcohol consumption in next year^1,2,3.

Validation studies of the "Predict" risk algorithms have been carried out in other European countries (UK, Holland, Portugal, Estonia and Slovenia) and Chile ^4,5,6,7. There is also a risk algorithm for depression validated in the United States^8,9 and another Australia¹⁰, in the latter case for the quality of mental life in general and only for the working population.

The validation studies of the risk calculators included in "predictplusprevent" have been carried out specifically in a healthy Spanish population, who during the follow-up throughout one year did or did not develop these health problems^1,2,3

The Spanish risk algorithms for depression (predictD), anxiety (predictA) and at-risk alcohol consumption (predictAL) have shown good discriminant validity and calibration^1,2,3, , similar or even slightly better than risk algorithms for predicting cardiovascular diseases (for example, Framingham or Score algorithms).

Below we will briefly describe the Predict validation studies in Spain:

1. Bellón et al. Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain. Psychological Medicine; 2011, 41(10):2075-2088.

2. Moreno-Peral et al. Predicting the onset of anxiety syndromes at 12 months in primary care attendees. The predictA-Spain study. PloS one. 2014; 9(9):e106370.

3. Bellón JA et al. Predicting the onset of hazardous alcohol drinking in primary care: development and validation of a simple risk algorithm. The British Journal of General Practice. 2017. 67(657): e280-e292.

4. King M et al. Development and validation of an international risk prediction algorithm for episodes of major depression in general practice attendees: the PredictD study. Arch Gen Psychiatry. 2008 Dec;65(12):1368-76

5. King M et al. An international risk prediction algorithm for the onset of generalized anxiety and panic syndromes in general practice attendees: predictA. Psychol Med. 2011 Aug;41(8):1625-39

6. King M et al. Development and validation of a risk model for prediction of hazardous alcohol consumption in general practice attendees: the predictAL study. PLoS One. 2011;6(8):e22175.

7. Saldivia S Development of an algorithm to predict the incidence of major depression among primary care consultants. Rev Med Chil. 2014 Mar;142(3):323-9.

8. Wang J et al. A prediction algorithm for first onset of major depression in the general population: development and validation. J Epidemiol Community Health. 2014;68:418-24.

9. Nigatu YT et al. External validation of the international risk prediction algorithm for major depressive episode in the US general population: the PredictD-US study. BMC Psychiatry. 2016 Jul 22;16:256..

10. Fernández A et al. Development and validation of a prediction algorithm for the onset of common mental disorders in a working population. Aust N Z J Psychiatry. 2017

11. Bellón JA et al. Preventing the onset of major depression based on the level and profile of risk of primary care attendees: protocol of a cluster randomised trial (the predictD-CCRT study). BMC Psychiatry. 2013 Jun 19;13:171.

12. Bellón JA et al. Intervention to Prevent Major Depression in Primary Care: A Cluster Randomized Trial. Ann Intern Med. 2016 May 17;164(10):656-65

WHAT CAN I DO AS A HEALTH PROFESSIONAL IF A PATIENT CONSULTS ME BECAUSE HE OR SHE HAS BEEN INFORMED OF THE POSSIBILITY OF CURRENTLY SUFFERING FROM (NOT IN THE FUTURE) DEPRESSION, ANXIETY AND/OR AT-RISK ALCOHOL CONSUMPTION?

You should know that if the "predict" risk calculators detect that a person may currently suffer (not in the future) a problem of depression, anxiety and/or alcohol abuse, he/she is administered the specific questionnaires that are indicated in each case (PHQ-9, PRIME-MD-anxiety and/or AUDIT-10 for depression, anxiety and alcohol problems, respectively), and if the scores exceed the standard cut-off point, the individual is informed about this in the following way:

“Evaluating your answers, we inform you that you may currently suffer from (depression / generalized anxiety / panic attacks / non-specific anxiety). This diagnosis should be confirmed by a health professional who, if necessary, could indicate the most appropriate treatment for you.”

“Your current alcohol consumption exceeds the recommended limits in healthy and non- pregnant adults, which could have negative consequences for your health.”

“If you are a teenager, pregnant or in treatment for alcohol problems, your alcohol consumption should be NONE. If you have any health problems or are taking any medication, it is possible that your alcohol consumption should be NONE. In other circumstances (certain jobs, driving vehicles, etc.) it is also possible that your alcohol consumption should be NONE.”

“If you have questions about what the appropriate alcohol consumption is for you, you could consult with a health professional.”

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WHAT CAN I DO AS A HEALTH PROFESSIONAL IF A PATIENT CONSULTS ME BECAUSE HE OR SHE HAS A HIGH OR VERY HIGH RISK (IN THE FUTURE: NEXT YEAR) OF DEPRESSION, ANXIETY AND/OR AT-RISK ALCOHOL CONSUMPTION?

The website "predictplusprevent" reports the probability of risk in the next year for depression, anxiety and/or at-risk alcohol consumption, giving a percentage and indicating its interpretation as very low, low, moderate, high or very high risk.

The website also tries to explain the probability of risk with the analogy of a lottery and the number of tickets that each person has. It is also reported that at present the individual does not suffer from depression, anxiety and/or at risk alcohol consumption and that, therefore, at this time, he/she is not a sick person with regard to these health problems, and that he/she is possibly not sick because he/she is already doing things that prevent depression, anxiety and/or at-risk alcohol consumption that are working for him/her.

Finally, users of the "predictplusprevent" website are referred to the tab named “PREVENTION”, which briefly explains those activities and programs that have shown scientific evidence of their effectiveness in preventing these problems. Users are also provided with a series of self-help booklets related to these preventive programs.

If any user, in addition to consulting the “PREVENCIÓN”, tab, decides to consult with their primary care professional, perhaps he/she will do so only to clarify information about prediction or prevention. In this case, our recommendation would be to actively listen to the patient, detect his/her doubts and clarify them if necessary.

If you consider that your patient also expects support or advice from you, we summarize the following recommendations that have been already tested in a depression and anxiety prevention trial with 3,326 Spanish primary care consultants^11,12(an example can be seen in a 5-minute video)

1) Remind the patient that he/she does not currently have depression, anxiety and/or problems with alcohol.

2) Invite the patient to mention the things he/she already does to prevent depression, anxiety and/or at-risk alcohol consumption, and positively reinforce those that are backed by scientific evidence (a list of these can be found in the "PREVENTION" tab).

3) Also invite the patient to think of and mention something else, which he/she still does not do or does insufficiently, that could prevent depression, anxiety, and/or at-risk alcohol consumption, and positively reinforce it if scientific evidence is available (a list of these can be found in the PREVENTION tab).

4) If the patient confides to you any event or problem that "moves" him/her (positively or negatively), actively listen and be empathetic with gestures (nonverbal empathy) and words (verbal empathy).

5) If you detect any physical health problems (e.g., sedentary lifestyle, chronic pain, crippling arthritis, etc.) and you think you can do something about it (physical activity advice, adjust pain medication, prescribe physiotherapy, advise surgery, etc.), do it. Improving the quality of physical life significantly decreases the probability of onset of an anxiety or depression problem.

6) If you detect any associated mental health problems in the patient (e.g., addictions, sexual problems, generalized anxiety problem in patients at risk for depression, etc.), and you can do something, e.g. advise, indicate psychotropic drugs or refer to mental health services, do it. Treatment of these associated mental health problems contributes significantly to the prevention of depression, anxiety and at-risk alcohol consumption.

7) If you detect a social problem in the patient (e.g. loneliness, lack of social support, family dysfunction, etc.) about which you could advise, either with your own resources, from the health center (e.g. social worker, support groups, etc.) or with resources from the neighborhood or the community (self-help groups, workshops and organized leisure activities, gyms, etc.), prescribe this (social prescription) or advise the patient to consult with the social worker from the health center or from the neighborhood.

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