Search

Background: Stress experienced during childhood or adulthood has been associated with cardiovascular disease (CVD), but it is not clear whether associations are already prevalent on a subclinical cardiovascular level. This study investigates associations between indicators of life stress and subclinical CVD, and whether these are mediated by depression and anxiety., Methods: Subjects were 650 participants of the Netherlands Study of Depression and Anxiety, aged 20-66 years, with or without (27.5%) depressive and anxiety disorders. Life stress included childhood trauma, negative life events and recently experienced daily hassles or job strain. Subclinical CVD was measured as 1) carotid atherosclerosis (intima-media thickness and the presence of plaques) using B-mode ultrasonography, and 2) central arterial stiffness (heart rate normalized augmentation index) using calibrated radial applanation tonometry., Results: Increased central arterial stiffness was shown in subjects who had experienced childhood trauma (per SD increase: β=.07; p=.01), or reported recently experienced daily hassles (per SD increase: β=.06; p=.02), negative life events (per SD increase: β=.05; p=.03), or job strain (high versus low: β=.09; p=.01). Associations between life stress and arterial stiffness appeared to be partly mediated by severity of depressive and anxiety symptoms. No significant associations were found for childhood life events, nor between indicators of life stress and carotid atherosclerosis., Conclusions: Childhood trauma and recent life stress were associated with increased central arterial stiffness. This suggests that life stress - partly via depression and anxiety - might enhance the development and progression of CVD., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Dementia imposes a heavy burden on health and social care systems as well as on family caregivers who provide a substantial portion of the care. Interventions that effectively support caregivers may prevent or delay patient institutionalization and hence be cost-effective. However, evidence about the cost-effectiveness of such interventions is scarce. The aim of this study was to evaluate the cost-effectiveness of a family meetings intervention for family caregivers of dementia patients in comparison with usual care over a period of 12 months., Methods: The economic evaluation was conducted from a societal perspective alongside a randomized trial of 192 primary caregivers with community-dwelling dementia patients. Outcome measures included the Quality Adjusted Life-Years (QALY) of caregivers and patients and the incidence of depression and anxiety disorders in caregivers. Missing cost and effect data were imputed using multiple imputations. Bootstrapping was used to estimate uncertainty around the cost-differences and the incremental cost-effectiveness ratio (ICER). The bootstrapped cost-effect pairs were plotted on a cost-effectiveness plane and used to estimate cost-effectiveness curves., Results: No significant differences in costs and effects between the groups were found. At 12 months, total costs per patient and primary caregiver dyad were substantial: €77,832 for the intervention group and €75,201 for the usual care group (adjusted mean difference per dyad €4,149, 95% CI -13,371 to 21,956, ICER 157,534). The main cost driver was informal care (66% of total costs), followed by patients' day treatment and costs of hospital and long-term care facility admissions (23%). Based on the cost-effectiveness acceptability curves, the maximum probability that the intervention was considered cost-effective in comparison with usual care reached 0.4 for the outcome QALY per patient-caregiver dyad and 0.6 for the caregivers' incidence of depression and/or anxiety disorders regardless of the willingness to pay., Conclusions: The annual costs of caring for a person with dementia were substantial with informal care being by far the largest contributor to the total societal costs. Based on this study, family meetings cannot be considered a cost-effective intervention strategy in comparison with usual care., Trial Registration: ISRCTN register, ISRCTN90163486.

Objective: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient and FP characteristics were related to recognition., Method: A cross-sectional comparison was made between FPs' registration and a structured diagnostic interview, the Composite International Diagnostic Interview, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Seven definitions of recognition were tested using diagnostic codes, medication data, referral data and free text in medical records. Data were derived from the Netherlands Study of Depression and Anxiety. A total of 816 patients were included., Results: Recognition ranged between 9.1% and 85.8%. A broader definition was associated with a higher recognition rate, but led to more false positives. The best definition comprised diagnostic codes for anxiety disorders and symptoms, strong free-text indications, medication and referral to mental health care. Generalized anxiety disorder was best recognized by this definition. Recognition was better among patients with increased severity, comorbid depression and older age., Conclusion: FPs recognized anxiety disorders better than previously reported when all medical record data were taken into account. However, most patients were nonspecifically labeled as having a mental health problem., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Depression in informal caregivers of persons with dementia is a major, costly and growing problem. However, it is not yet clear which caregivers are at increased risk of developing depression. With this knowledge preventive strategies could focus on these groups to maximize health gain and minimize effort., Methods: The onset of clinically relevant depression was measured with the Center for Epidemiologic Studies - Depression Scale in 725 caregivers who were not depressed at baseline and who were providing care for a relative with dementia. Caregivers were followed over 18 months. The indices calculated to identify the most important risk indicators were: odds ratio, attributable fraction, exposure rate and number needing to be treated., Results: The following significant indicators of depression onset were identified: increased initial depressive symptoms, poor self-rated health status and white or Hispanic race/ethnicity. The incidence of depression would decrease by 72.3% (attributive fraction) if these risk indicators together are targeted by a completely effective intervention. Race/ethnicity was not a significant predictor if caregivers of patients who died or were institutionalized were left out of the analyses., Conclusion: Detection of only a few characteristics makes it possible to identify high-risk groups in an efficient way. Focusing on these easy-to-assess characteristics might contribute to a cost-effective prevention of depression in caregivers.

Background: Family caregivers of dementia patients are at increased risk of developing depression or anxiety. A multi-component program designed to mobilize support of family networks demonstrated effectiveness in decreasing depressive symptoms in caregivers. However, the impact of an intervention consisting solely of family meetings on depression and anxiety has not yet been evaluated. This study examines the preventive effects of family meetings for primary caregivers of community-dwelling dementia patients., Methods: A randomized multicenter trial was conducted among 192 primary caregivers of community dwelling dementia patients. Caregivers did not meet the diagnostic criteria for depressive or anxiety disorder at baseline. Participants were randomized to the family meetings intervention (n = 96) or usual care (n = 96) condition. The intervention consisted of two individual sessions and four family meetings which occurred once every 2 to 3 months for a year. Outcome measures after 12 months were the incidence of a clinical depressive or anxiety disorder and change in depressive and anxiety symptoms (primary outcomes), caregiver burden and quality of life (secondary outcomes). Intention-to-treat as well as per protocol analyses were performed., Results: A substantial number of caregivers (72/192) developed a depressive or anxiety disorder within 12 months. The intervention was not superior to usual care either in reducing the risk of disorder onset (adjusted IRR 0.98; 95% CI 0.69 to 1.38) or in reducing depressive (randomization-by-time interaction coefficient = -1.40; 95% CI -3.91 to 1.10) or anxiety symptoms (randomization-by-time interaction coefficient = -0.55; 95% CI -1.59 to 0.49). The intervention did not reduce caregiver burden or their health related quality of life., Conclusion: This study did not demonstrate preventive effects of family meetings on the mental health of family caregivers. Further research should determine whether this intervention might be more beneficial if provided in a more concentrated dose, when applied for therapeutic purposes or targeted towards subgroups of caregivers., Trial Registration: Controlled-Trials.com ISRCTN90163486.

Background: Previous estimates of depression recognition in primary care are low and inconsistent. This may be due to registration artifacts and limited extraction efforts. This study investigated a) whether GPs' medical records demonstrate an accurate recognition of depression and b) which combinations of indications within the record most accurately reflect a diagnosis of depression., Methods: GPs' registrations were compared with a reference standard, the Composite International Diagnostic Interview (CIDI), according to DSM-IV criteria. Six definitions of GPs' recognition of depression were tested using diagnostic codes, medication data, referral data and free text in the medical records. The Youden-index was used to select the optimal definition of recognition. Data were derived from the Netherlands Study of Depression and Anxiety. 816 primary care patients from 33 general practitioners were included in the vicinities of Amsterdam and Leiden, The Netherlands., Results: Registration of antidepressant prescriptions was the best single indicator of GPs' recognition of CIDI depression with a recognition rate of 0.43. The best combination of indicators increased the recognition rate to 0.69. All indications except the specific diagnostic codes for 'depressive disorder' and 'depressive feelings' were included in this definition., Limitations: Potential bias due to the selection of participating GPs might have influenced our recognition rates., Conclusion: GPs are aware of mental health problems in most depressed patients, but labeling with specific diagnostic codes is weak. Researchers should consider that diagnostic coding alone is not an accurate measure of the diagnostic ability of depression and strongly underestimates the accuracy of the GP., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objectives: Depressive symptoms are common among elderly primary care patients, and because they encounter considerable barriers in seeking help and they often resist referral to specialized mental health facilities, it is important to look for easily accessible interventions within the primary care setting. Bibliotherapy, which has been found to be effective among younger populations, might be an attractive option. In this study, the authors investigated the effectiveness of bibliotherapy for depressive symptomatology in very old adults., Design: Randomized controlled trial. After a 3-month period of "watchful waiting," the participants were randomly assigned to a bibliotherapy group or a usual care group., Setting: Thirty-three general practices in the north-western region of the Netherlands., Participants: One hundred seventy community-dwelling adults, aged 75 and older, with subthreshold depression., Intervention: The bibliotherapy intervention consisted of an information leaflet and a self-help manual "Coping with Depression" adapted for the elderly., Measurements: Outcome measures after 3 months were a) change in depressive symptoms according to the Center for Epidemiologic Studies Depression Scale (CES-D) and b) the proportion of participants who scored a significant improvement on the CES-D., Results: One hundred forty-six (85.9%) of the 170 participants completed the baseline and follow-up measurements. The authors did not find any clinically relevant and statistically significant differences between the intervention group and the control group in the severity of the depressive symptoms., Conclusion: Bibliotherapy as a stand-alone intervention for the elderly (aged 75 years and older) did not reduce depressive symptoms more than usual care. This might indicate that bibliotherapy can only be effective for patients who are motivated and acknowledge their depression.

Objectives: Clinically relevant depressive symptoms are highly prevalent in people who are 75 years of age or older. However, very old people with a vulnerable health status are under-represented in studies focussing on incidence and risk factors, while the risk of developing depressive symptoms is expected to be very high in this group. The incidence rates of clinically relevant depressive symptoms and their predictors were investigated in a vulnerable elderly population., Methods: In a community-based cohort, 651 vulnerable elderly (75+) people were identified by means of the COOP-WONCA charts (Dartmouth Coop Functional Health Assessment Charts/World Organisation of Family Doctors). To study the incidence of clinically relevant symptoms of depression and their predictors, 266 people with no symptoms (Centre for Epidemiologic Studies Depression Scale, CES-D score <16 at baseline) were selected and measured again at six and 18 months. The incidence of clinically relevant symptoms of depression was defined as a CES-D score > or =16, in combination with at least a five-point change between measurements. Logistic regression analyses were applied to determine risk indicators., Results: After 18 months, the incidence rate of all clinically relevant symptoms of depression was 48% (95% confidence interval, CI 44.2-51.8). No specific risk factors were identified within this population., Conclusion: Our estimates of the incidence of depressive symptoms were considerably higher than those previously found in elderly populations living in the community. A vulnerable health status is associated with a high risk of depressive symptoms.

Objective: Living with a demented person has been associated with high levels of clinical depression and anxiety. However, there are no prospective studies that allow good estimates of the incidence of depression and anxiety. In this study, the authors assess the long-term incidence of depression and anxiety in the spouses of patients with dementia as recorded by general practitioners., Design: Prospective naturalistic cohort study with a comparison group. Data from medical records in 2001-2007 were analyzed., Participants: Two hundred eighteen spouses of patients with dementia and 353 age and gender-matched spouses of nondemented persons., Setting: Seventy-one general practices in the Netherlands with a listed source population of 320,309 patients., Measurements: Incidence rates (IRs) per 1,000 person-years and hazard ratios (HRs) of depression and anxiety; prescription rates (per 1,000 person-years) for antidepressants and anxiolytics., Results: A new episode of depression was diagnosed in 18 spouses and 7 comparison spouses (IRs of 18.8/1,000 person-years and 4.4/1,000 person-years, respectively). Spouses of patients with dementia were far more likely to be diagnosed with depression than the comparison spouses (HR, 4.16; 95% CI: 1.73-9.98). Spouses did not have a higher incidence of anxiety than the comparison group (HR, 1.26; 95% CI: 0.58-2.71). The prescription rates for both antidepressants and anxiolytics were significantly higher for spouses than for the comparison group., Conclusion: The spouses of patients with dementia have a fourfold higher risk of a diagnosis of depression than the spouses of nondemented persons. The authors could not establish this for anxiety.

Background: Minor and mild-major depression are highly prevalent in primary care. There is insufficient evidence for the effectiveness of antidepressants in the treatment of minor and mild-major depression. We compared the effectiveness of usual primary care treatment, with or without antidepressants, in minor and mild-major depression., Methods: A pragmatic patient-randomized equivalence trial with 52 weeks follow-up was conducted in The Netherlands. In total, 59 primary care physicians (PCPs) recruited and treated 181 adult patients with minor or mild-major depression. Patients were randomized to four consultations within 3 months of usual care plus antidepressants (UCandAD) or usual care alone (UCnoAD). The Montgomery Asberg Depression Rating Scale (MADRS) was used to assess changes in severity of depressive symptoms. The predefined equivalence margin was set at five points. Multilevel analysis was used to analyze the data. Secondary outcome measures were the Short-Form 36 (SF-36), and the Client Satisfaction Questionnaire (CSQ-8)., Results: Patients received on average 3.0 (SD 1.4) 15-min consultations within 3 months with (n = 85) or without paroxetine (n = 96). Equivalence of UCandAD and UCnoAD was demonstrated in the intention-to-treat analyses as well as the per-protocol analysis after 6 weeks, but not at 13, 26 and 52 weeks follow-up. No statistical differences in effectiveness between treatment groups were found in the intention-to-treat analysis. No differences in the physical and mental functioning (SF-36) were found between the treatment groups. Patients allocated to UCandAD were slightly more satisfied with their treatment at 13 weeks follow-up (but not at 52 weeks follow-up) than patients allocated to UCnoAD. Preliminary analyses suggested that subgroups such as patients with mild-major (instead of a minor) depression might benefit from antidepressant treatment. Patients who were assigned to their preferred treatment (in particular to UCnoAD) were more often compliant and had better clinical outcomes., Conclusion: UCandAD was as effective as UCnoAD over the first 6 weeks, but not at 13, 26, and 52 weeks. However, superiority of either treatment could not be demonstrated either. The question whether antidepressants add any clinical effect to usual care remains unresolved. We recommend future studies to look for subgroups of patients who may benefit from antidepressants., Trial Registration: Dutch Trial Registry ISRCN03007807.

Introduction: The efficacy of antidepressants in the treatment of depression has been convincingly demonstrated in randomised trials. However, non-adherence to antidepressant treatment is common., Objective: To evaluate, from a societal perspective, the cost effectiveness of a pharmacy-based intervention to improve adherence to antidepressant therapy in adult patients receiving treatment in primary care., Methods: An economic evaluation was performed alongside a 6-month randomised controlled trial in The Netherlands. Patients who came to 19 pharmacies with a new prescription for a non-tricyclic antidepressant, i.e. those who had not received any prescription for an antidepressant in the past 6 months, were invited to participate. They were then randomly allocated to education and coaching by the pharmacist or to usual care. The coaching programme consisted of three contacts with the pharmacist, with a mean duration of between 13 and 20 minutes, and a take-home video reviewing important facts on depression and antidepressant treatment. The clinical outcome measures were adherence to antidepressant treatment measured using an electronic pill container (eDEM) and improvement in depressive symptoms measured using the Hopkins Symptom Checklist (SCL). Resource use was measured by means of questionnaires. The uncertainty around differences in costs and cost effectiveness between the treatment groups was evaluated using bootstrapping., Results: Seventy patients were randomised to the intervention group and 81 to the usual care group; of these, 40 in the intervention group and 48 in the control group completed all of the follow-up questionnaires. There were no significant differences in adherence, improvements in the SCL depression mean item score and costs over 6 months between the two treatment groups. Mean total costs (2002 values) were 3275 euros in the intervention group and 2961 euros in the control group (mean difference 315 euros; 95% CI -1922, 2416). The incremental cost-effectiveness ratio associated with the pharmacist intervention was 149 euros per 1% improvement in adherence and 2550 euros per point improvement in the SCL depression mean item score. Cost-effectiveness planes and acceptability curves indicated that the pharmacist intervention was not likely to be cost effective compared with usual care., Conclusion: In patients starting treatment with antidepressants, there were no significant differences in adherence, severity of depression, costs and cost effectiveness between patients receiving coaching by a pharmacist and patients receiving usual care after 6 months. Considering the resources needed to implement an intervention like this in clinical practice, based on these results, the continuation of usual care is recommended.

According to professionals, medication nonadherence is often attributed to adverse effects or early remission. There is, however, little evidence to support these attributions. Our aim was to study the predictors of nonadherence in primary care patients with a new antidepressant (AD) prescription. We used a prospective cohort study with 6-month follow-up among 147 primary care patients who were newly prescribed with a nontricyclic AD for depression. They were recruited in 19 community pharmacies in the Netherlands that were linked to 85 general practitioners. An electronic pill container (medication event monitoring system; Aardex Ltd, Untermüli, Switzerland) registered the adherence for 6 months. The predictive values of patient, prescriber, pharmacist, and drug-related characteristics were expressed in univariate and multivariate odds ratios with 95% confidence intervals. Outcome measures showed nonadherence, as expressed in these factors (all dichotomous): (1) incorrect intakes (<80% period coverage); (2) extra pill intakes (>1 per day); (3) drug holidays (>or=1). We found that not only a positive drug attitude, the most important predictor, but also adverse effects, early treatment response, longer onset of depression, and a higher educational level predicted the correct intake of ADs. Extra intakes were predicted by ADs with a shorter half-life and by experience of adverse effects. Drug holidays were predicted by patients with less social support and a negative drug attitude. In conclusion, the predictors of adherence were multifactorial and varied across the 3 adherence types. A positive drug attitude emerged as the most important predictor for correct intakes and drug holidays.

Background: Little is known about the prevalence of depression in older patients consulting their general practitioner., Aim: To estimate the prevalence of major and minor depression in older GP attendees., Design: Cross sectional two-stage screening design., Setting: Seventeen GPs in urban and 41 GPs in rural settings., Methods: Data of The West Friesland Study were used. Five thousand, six hundred and eight-six GP attendees of 55 years and older filled in the Geriatric Depression Scale-15 items as a screening instrument for depression (response 62%). Of those screened positive on the GDS-15, 846 (77.5%) were interviewed using the Primary Care Evaluation of Mental Disorders (PRIME-MD). A random sample (n = 102) scoring below the threshold of the GDS-15 was interviewed to estimate the proportion of false negatives., Results: Major depression was prevalent in 13.7% and minor depression in 10.2% of the patients. Depressed patients were older (mean difference 0.7 years; p = 0.037), more often female (OR 1.3; p < 0.001) and lived more often in urban districts (OR 1.5; p < 0.001). Patients with major depression were younger (mean difference 1.9 years; p < 0.001) and more often female (OR 1.4; p = 0.026) than those with a minor depression. Only 22.9% of the patients with a major depression were treated with antidepressants., Conclusion: Depression in older GP attendees is a very common health problem. Further research should focus on identifying those groups of patients with high risk of persistence of depression. This could help to focus the limited resources available in general practice to those patients in whom treatment is most urgently needed., (Copyright (c) 2005 John Wiley & Sons, Ltd.)

The article reports on research which was conducted to investigate the incidence of depression and anxiety in spousal caregivers who cared for patients with dementia. Researchers evaluated 181 caregivers. They found that caregivers of dementia patients have a high risk of developing a mental disorder, including anxiety and depression.

The present study compared blood pressure levels between subjects with clinical anxiety and depressive disorders with healthy controls. Cross-sectional data were obtained in a large cohort study, the Netherlands Study of Depression and Anxiety (N=2981). Participants were classified as controls (N=590) or currently or remittedly depressed or anxious subjects (N=2028), of which 1384 were not and 644 were using antidepressants. Regression analyses calculated the contributions of anxiety and depressive disorders and antidepressant use to diastolic and systolic blood pressures, after controlling for multiple covariates. Heart rate and heart rate variability measures were subsequently added to test whether effects of anxiety/depression or medication were mediated by vagal control over the heart. Higher mean diastolic blood pressure was found among the current anxious subjects (beta=0.932; P=0.03), although anxiety was not significantly related to hypertension risk. Remitted and current depressed subjects had a lower mean systolic blood pressure (beta=-1.74, P=0.04 and beta=-2.35, P=0.004, respectively) and were significantly less likely to have isolated systolic hypertension than controls. Users of tricyclic antidepressants had higher mean systolic and diastolic blood pressures and were more likely to have hypertension stage 1 (odds ratio: 1.90; 95% CI: 0.94 to 3.84; P=0.07) and stage 2 (odds ratio: 3.19; 95% CI: 1.35 to 7.59; P=0.008). Users of noradrenergic and serotonergic working antidepressants were more likely to have hypertension stage 1. This study shows that depressive disorder is associated with low systolic blood pressure and less hypertension, whereas the use of certain antidepressants is associated with both high diastolic and systolic blood pressures and hypertension. [ABSTRACT FROM AUTHOR]

An effective treatment already exists for many diseases. In these cases the effectiveness of a new treatment may be established by showing that the new treatment is as effective as (i.e., equivalent to) or at least as effective as (i.e., noninferior to) the old treatment. For an economic evaluation accompanying a clinical equivalence or noninferiority trial it is important to decide before the start of the study on the appropriate research question. In many cases the objective of the economic evaluation will be to show equivalence or noninferiority of the cost-effectiveness of the treatments. This has major implications for the design and analysis of the economic evaluation. In this article we propose methods for the analysis of economic equivalence and noninferiority studies that are similar to the methods applied to clinical equivalence and noninferiority trials. Furthermore, cost-effectiveness planes prove to be a valuable tool in the interpretation of the results in an economic equivalence or noninferiority trial. The concepts described in the article are illustrated using the results from an economic noninferiority trial. [ABSTRACT FROM AUTHOR]