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Objective: Obsessive-compulsive disorder is characterized by a chronic course that can vary between patients. The knowledge on the naturalistic long-term outcome of obsessive-compulsive disorder and its predictors is surprisingly limited. The present research was designed to identify clinical and psychosocial predictors of the long-term outcome of obsessive-compulsive disorder., Methods: We included 377 individuals with a current diagnosis of obsessive-compulsive disorder, who participated in the Netherlands Obsessive Compulsive Disorder Association study, a multicenter naturalistic cohort study. Predictors were measured at baseline using self-report questionnaires and clinical interviews. Outcome was assessed using the Yale-Brown Obsessive Compulsive Scale at 2-, 4- and 6-year follow-up., Results: The overall course of obsessive-compulsive disorder was characterized by two prominent trends: the first reflected an improvement in symptom severity, which was mitigated by the second, worsening trend in the long term. Several determinants affected the course variations of obsessive-compulsive disorder, namely, increased baseline symptom severity, late age of onset, history of childhood trauma and autism traits., Conclusion: The long-term outcome of obsessive-compulsive disorder in naturalistic settings was characterized by an overall improvement in symptom severity, which was gradually halted to the point of increased worsening. However, after 6 years, the severity of symptoms remained below the baseline level. While certain determinants predicted a more favorable course, their effect diminished over time in correspondence to the general worsening trend. The results highlight the importance of a regular and continuous monitoring for symptom exacerbations as part of the management of the obsessive-compulsive disorder, regardless of the presence of putative predictors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objective: Little is known about the course of anxiety disorders in the general population. This study provides insights into the course of anxiety disorders in the general population taking into account transition to residual symptoms and to other diagnostic categories., Methods: Using data from three waves of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2; n  = 6646), subjects with anxiety disorders (T 0; n  = 243) were divided into three mutually exclusive course trajectories according to their diagnostic status at 3-year (T 1 ) and 6-year (T 2 ) follow-up: remission group (no disorder at T 2 ), intermittent course group (no disorder at T 1 and disorder at T 2 ) and chronic course group (disorder at all measurements). Transition to residual symptoms or other psychopathology were studied. In addition, predictors of course trajectories were assessed., Results: During 6-year follow-up, 77.8% of subjects achieved remission, 14.0% followed an intermittent course and 8.2% a chronic course. Of those in remission, residual anxiety symptoms remained in 46.6%, while 7.9% developed another disorder between T 0 and T 2 . Compared with the remitting group, a chronic course was predicted by not living with a partner, multiple negative life events, neuroticism, lower mental functioning, severity of anxiety symptoms, use of mental health care and medication use., Limitations: The intermittent and chronic course groups were small, limiting statistical power. As a result, certain predictors may not have reached significance., Conclusions: In the general population at 6-year follow-up, 77.8% of subjects with anxiety disorders achieved remission. Because of transition to residual symptoms or another diagnostic category, only 52.4% of those subjects had a true favourable outcome.

Background: This study examined the prevalence, course and risk indicators of subthreshold anxiety disorder to determine the necessity and possible risk indicators for interventions., Methods: Data were derived from the 'Netherlands Mental Health Survey and Incidence Study-2' (NEMESIS-2), a psychiatric epidemiological cohort study among the general population (n = 4528). This study assessed prevalence, characteristics, and three-year course of subthreshold anxiety disorder (n = 521) in adults, and compared them to a no anxiety group (n = 3832) and an anxiety disorder group (n = 175). Risk indicators for persistent and progressive subthreshold anxiety disorder were also explored, including socio-demographics, vulnerability factors, psychopathology, physical health and functioning., Results: The three-year prevalence of subthreshold anxiety disorder was 11.4%. At three-year follow-up, 57.3% had improved, 29.0% had persistent subthreshold anxiety disorder and 13.8% had progressed to a full-blown anxiety disorder. Prevalence, characteristics and course of subthreshold anxiety disorder were in between both comparison groups. Risk indicators for persistent course partly overlapped with those for progressive course and included vulnerability and psychopathological factors, and diminished functioning., Limitations: Course analysis were restricted to the development of anxiety disorders, other mental disorders were not assessed. Moreover, due to the naturalistic design of the study the impact of treatment on course cannot be assessed., Conclusions: Subthreshold anxiety disorder is relatively prevalent and at three-year follow-up a substantial part of respondents experienced persistent symptoms or had progressed into an anxiety disorder. Risk indicators like reduced functioning may help to identify these persons for (preventative) treatment and hence reduce functional limitations and disease burden., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Improvement of the quality and safety of care is associated with lower suicide rates among mental healthcare patients. In The Netherlands, about 40% of all people that die by suicide is in specialist mental healthcare. Unfortunately, the degree of implementation of suicide prevention policies and best practices within Dutch mental healthcare services is variable. Sharing and comparing outcome and performance data in confidential networks of professionals working in different organisations can be effective in reducing practice variability within and across organisations and improving quality of care., Methods and Analysis: Using formats of professional networks to improve surgical care (Dutch Initiative for Clinical Auditing) and somatic intensive care (National Intensive Care Evaluation), 113 Suicide Prevention has taken the lead in the formation of a Suicide Prevention Action Network (SUPRANET Care), with at present 13 large Dutch specialist mental health institutions. Data on suicide, suicide attempts and their determinants as well as consumer care policies and practices are collected biannually, after consensus rounds in which key professionals define what data are relevant to collect, how it is operationalised, retrieved and will be analysed. To evaluate the impact of SUPRANET Care, standardised suicide rates will be calculated adjusted for confounding factors. Second, the extent to which suicide attempts are being registered will be analysed with the suicide attempt data. Finally, professionals' knowledge, attitude and adherence to suicide prevention guidelines will be measured with an extended version of the Professionals In Training to STOP suicide survey., Ethics and Dissemination: This study has been approved by the Central Committee on Research Involving Human Subjects, The Netherlands. This study does not fall under the scope of the Medical Research Involving Human Subjects Act (WMO) or the General Data Protection Regulation as stated by the Dutch Data Protection Authority because data are collected on an aggregated level., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The tic-related subtype of obsessive-compulsive disorder (OCD) has a distinct clinical profile. The course of tic-related OCD has previously been investigated in treatment studies, with inconclusive results. This study aimed to compare clinical profiles between tic-related and tic-free OCD patients and to establish the influence of tics on the 2-year natural course in adult OCD patients., Methods: Within the Netherlands OCD Association cohort, 377 patients with a current DSM-IV diagnosis of OCD were divided into a tic-related group (28%) and a tic-free group and compared on clinical variables with t tests or χ² tests. Linear mixed-model analyses were used to compare the 2-year course between the groups, with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) as primary outcome measure. Data were collected from 2005 to 2007 and from 2007 to 2009., Results: Compared to patients with tic-free OCD, those with tic-related OCD reported earlier disease onset (P = .009) and more symmetry/ordering symptoms (P = .002). Overall symptom severity was similar in both groups. Patients with tic-related OCD reported increased traits of attention-deficit hyperactivity (P < .001) and autism (P = .005) compared to the tic-free OCD group. Clinical improvement at 2-year follow-up (mean = 5.3-point decrease on the Y-BOCS, P < .001, 95% CI = 4.3 to 6.3) was not significantly moderated by tic status (P = .24). This remained unchanged after correcting for baseline differences., Conclusions: Tics do not critically affect the 2-year course of adult OCD, but tic-related OCD shows differences from tic-free OCD, such as early onset and increased autism and ADHD traits, that may indicate a neurodevelopmental subtype., (© Copyright 2016 Physicians Postgraduate Press, Inc.)

Objective: This study assesses the feasibility and outcome of the implementation of a screening program for classifying panic disorder (PD) in patients presenting with noncardiac chest pain (NCCP(1)), when integrated in routine cardiac emergency department (CED(2)) care., Methods: Barrier analyses were made during the pilot phase and implementation period. NCCP patients aged 18-70 years presenting at the CED (n=252) were eligible for screening with the Hospital Anxiety and Depression Scale (HADS). Those scoring above cutoff on the HADS were referred to the psychiatric department and received the Composite International Diagnostic Interview., Results: Screening was initiated in 60 patients (23.8%), of whom nine refused participation. Staff adherence remained low despite implementing several improvements in the screening procedure. In total, 39 patients completed the program; 8 were diagnosed with a psychiatric disorder, including 2 patients with PD., Conclusion: Feasibility of implementation of this screening program for PD in NCCP patients in routine CED care was limited because offering screening frequently conflicted with provision of acute care and because patients showed relatively high refusal rates. Contrasting our assumption, various other psychiatric disorders besides PD were classified., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Age of onset is an important epidemiological indicator in characterizing disorders׳ subtypes according to demographic, clinical and psychosocial determinants. While investigated in various psychiatric conditions, age of onset and related characteristics in agoraphobia have yet to be examined. In light of the new diagnostic status in the DSM-5 edition of agoraphobia as independent from panic disorder, research on agoraphobia as a stand-alone disorder is needed., Methods: Admixture analysis was used to determine the best-fitting model for the observed ages at onset of 507 agoraphobia patients participating in the Netherlands Study of Depression and Anxiety (age range 18-65). Associations between agoraphobia age of onset and different demographic, clinical and psychosocial determinants were examined using multivariate logistic regression analysis., Results: Admixture analyses identified two distributions of age of onset, with 27 as the cutoff age (≤27; early onset, >27; late onset). Early onset agoraphobia was only independently associated with family history of anxiety disorders (p<0.01) LIMITATIONS: Age of onset was assessed retrospectively, and analyses were based on cross-sectional data., Conclusion: The best distinguishing age of onset cutoff of agoraphobia was found to be 27. Early onset agoraphobia might constitute of a familial subtype. As opposed to other psychiatric disorders, early onset in agoraphobia does not indicate for increased clinical severity and/or disability., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Psychiatric rehabilitation supports individuals with mental disorders to acquire the skills needed for independent lives in communities. This article assesses the potential of outsourcing psychiatric rehabilitation by analysing care farm services in the Netherlands. Service characteristics were analysed across 214 care farms retrieved from a national database. Qualitative insights were provided by five case descriptions, selected from 34 interviews. Institutional care farms were significantly larger and older than private care farms (comprising 88.8% of all care farms). Private, independent care farms provide real-life work conditions to users who are relatively less impaired. Private, contracted care farms tailor the work activities to their capacities and employ professional supervisors. Institutional care farms accommodate for the most vulnerable users. We conclude that collaborations with independent, contracted and institutional care farms would provide mental health care organizations with a diversity in services, enhanced community integration and a better match with users' rehabilitation needs.

Background: Anxiety disorders are associated with substantial functional limitations but the course of functioning following symptom remission remains largely unknown., Method: Using data from the Netherlands Study of Depression and Anxiety (NESDA), we examined the 2-year trajectories of functioning in participants with chronic (n = 586) or remitting anxiety disorders (n = 385) and in healthy controls (n = 585). In participants with remitting anxiety disorders, we identified predictors of functioning from among sociodemographic, clinical and vulnerability variables. Data were analysed using linear mixed models (LMMs). Functioning was assessed with the World Health Organization Disability Assessment Schedule II (WHO DAS II)., Results: At baseline, participants with remitting anxiety disorders functioned significantly better than those with chronic anxiety disorders, but significantly worse than controls. In both anxiety disorder groups, most impairment was reported in social functioning, occupational functioning and cognition. During the follow-up, functioning improved in both groups, probably due to treatments received. Participants who achieved symptom remission experienced moderate improvements in social functioning and cognition but not in occupational functioning. Of those who remitted, 45.8% reported functioning scores similar to healthy controls whereas 28.5% still functioned at the level of those with chronic anxiety disorders. Worse functioning was predicted by severe anxiety disorders, use of psychological treatment, co-morbid depressive disorders and maladaptive personality traits., Conclusions: In anxiety disorders, symptom remission is accompanied by improvements in functioning but significant functional impairments may persist because of co-morbid disorders, lower functioning prior to the onset of the anxiety disorder or residual subthreshold anxiety symptoms.

Purpose: Mental health services increasingly incorporate the vision of recovery. This qualitative study analysed and compared experiences of recovery on prevocational services, in order to assess if users make progress towards recovery, relative to a staged recovery model., Method: Data were collected through semi-structured interviews with participants on care farms (n = 14), work (n = 7) and creative projects (n = 5)., Results: The transition from past to current lives was described as a progressive, non-linear process, with different stages guided by different goals. Participants on creative projects lacked clear goals, presented less interest in peers and high need for emotional support. Participants on work projects aimed for occupational rehabilitation, but struggled with the patient culture of the peer community. Participants on care farms aimed for daytime occupations and closer contact with society. They experienced care farms as open, real-life work settings where they could exercise responsibility and connect with people., Conclusions: Participants progressed towards recovery, as care farms, work- and creative projects empowered them to leave behind inactive, isolated or disorganized living. In day centres, users focused on self-reflection and personal development (creative projects) or on occupational performance (work projects), whereas on care farms, users fulfilled worker roles in a real-life, open community environment., Implications for Rehabilitation: Organized as open communities in real-life settings, care farms facilitate the reflection on personal and social responsibility, and therefore have the potential to help users internalize worker identities and improve their motivation to progress towards recovery. Supervisors on care farms are regarded by users as close contacts within the social networks they develop on the service, a position that allows supervisors to actively engage and promote users' progress towards recovery. Elements of the farm environment (such as the "normal life", presence of family members and visitors, and nature) can serve as anchors for supporting the progress towards recovery.

Background: While studies into the implementation of clinical practice guidelines for mental health care are scarce, studies on the effectiveness of implementing practice guidelines for anxiety disorders appear to be entirely non-existent., Objective: To examine whether adherence to anxiety disorder clinical practice guidelines in secondary mental health care yields superior treatment results than non-adherence., Method: A closed-cohort study of 181 outpatients with an anxiety disorder or hypochondriasis who were treated in a routine mental health setting. Preceding the inclusion of these 181 patients, a start was made on the implementation of the Dutch national multidisciplinary practice guidelines for anxiety disorders. Patients were asked to complete several questionnaires before the start of treatment and again 1 year later. The medical records of these patients were reviewed to assess guideline adherence. Ultimately, adherence or non-adherence to the different treatment algorithms described in the guidelines was related to changes in the severity of psychiatric symptomatology, psychiatric functioning, general well-being and satisfaction with treatment., Results: Compared with patients whose treatment did not adhere to the guidelines, those whose treatment adhered to the guidelines were found to have greater symptom reduction after 1 year (P < 0.01). The latter group of patients also rated their satisfaction with their treatment significantly higher (P = 0.01). No significant differences were found after 1 year with respect to changes in impairment of functioning and quality of life in the two groups of patients., Conclusions: Adherence to anxiety disorder guidelines yields superior treatment results and increased patient satisfaction with treatment when compared with patients whose treatment did not adhere to the clinical guidelines. These results should encourage a more widespread implementation of such guidelines in mental health care facilities., (© 2012 John Wiley & Sons Ltd.)

Background: This study describes lifetime and current rates of comorbidity, its onset and its consequences in a large clinical sample of patients with obsessive compulsive disorder (OCD). A wide range of risk factors and clinical characteristics were also examined to determine whether pure OCD is different from OCD with current comorbidity. Finally, the temporal sequencing of the disorders was examined., Method: Data were obtained from the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. A sample of 382 participants with current OCD (during the past month) was evaluated., Results: Current comorbidity occurred in 55% of patients with OCD, while 78% suffered from lifetime comorbidity. Comorbidity is associated with more severe OCD, anxiety and depressive symptoms and more negative consequences on daily life. Multiple comorbid disorders often precede OCD and influence both its course and severity. Childhood trauma and neuroticism are vulnerability factors for the development of multiple comorbid disorders in OCD., Limitations: It should be noted that causal inferences about the association between risk factors and OCD are precluded since our results were based on cross-sectional data., Conclusion: (Multiple) comorbidity in OCD is clinically relevant since it is associated with a specific pattern of vulnerability, with greater chronicity, with more severe OCD and more negative consequences on daily life. This indicates that the diagnosis and treatment of all comorbid disorders is clinically relevant, and clinicians should be especially aware of multiple disorders in cases of childhood trauma and high levels of neuroticism. Primary OCD has a different developmental and comorbidity pattern compared to secondary OCD., (© 2013 Elsevier B.V. All rights reserved.)

Background: Questionnaires may help in detecting and diagnosing anxiety disorders in primary care. However, since utility of these questionnaires in target populations is rarely studied, the Patient Health Questionnaire anxiety modules (PHQ) were evaluated for use as: a) a screener in high-risk patients, and/or b) a case finder for general practitioners (GPs) to assist in diagnosing anxiety disorders., Methods: A cross-sectional analysis was performed in 43 primary care practices in the Netherlands. The added value of the PHQ was assessed in two samples: 1) 170 patients at risk of anxiety disorders (or developing them) according to their electronic medical records (high-risk sample); 2) 141 patients identified as a possible 'anxiety case' by a GP (GP-identified sample). All patients completed the PHQ and were interviewed using the Mini International Neuropsychiatric interview to classify DSM-IV anxiety disorders. Psychometric properties were calculated, and a logistic regression analysis was performed to assess the diagnostic value of the PHQ., Results: Using only the screening questions of the PHQ, the area under the curve was 83% in the high-risk sample. In GP-identified patients the official algorithm showed the best characteristics with an area under the curve of 77%. Positive screening questions significantly increased the odds of an anxiety disorder diagnosis in high-risk patients (odds ratio = 23.4; 95% confidence interval 6.9 to 78.8) as did a positive algorithm in GP-identified patients (odds ratio = 13.9; 95% confidence interval 3.8 to 50.6)., Conclusions: The PHQ screening questions can be used to screen for anxiety disorders in high-risk primary care patients. In GP-identified patients, the benefit of the PHQ is less evident.

Admissions for irreversible psychosurgical treatment of obsessive-compulsive disorder (OCD) by the Working Group for Indication Psychosurgery in the Netherlands were analyzed, and the postsurgical effects on symptom severity and quality of life were evaluated. The data were extracted from patient records in the period 2001-2008, and there was a postoperative assessment with a semistructured interview. Fourteen patients applied, having severe OCD with mostly one or more comorbid disorders. The mean Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 32 points. Four of seven patients in whom psychosurgery was deemed useful were operated on. The decrease of the Y-BOCS score from registration to after surgery was 9 points (range, 3-17 points). An improvement in social function was present in three of four patients. In conclusion, psychosurgery can be a valuable treatment option for patients with severe OCD in whom other treatments fail.

In half of Obsessive Compulsive Disorder (OCD) patients the disorder runs a chronic course despite treatment. The factors determining this unfavourable outcome remain unknown. The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study is a multicentre naturalistic cohort study of the biological, psychological and social determinants of chronicity in a clinical sample. Recruitment of OCD patients took place in mental health organizations. Its design is a six-year longitudinal cohort study among a representative clinical sample of 419 OCD patients. All five measurements within this six-year period involved validated semi-structured interviews and self-report questionnaires which gathered information on the severity of OCD and its co-morbidity as well as information on general wellbeing, quality of life, daily activities, medical consumption and key psychological and social factors. The baseline measurements also include DNA and blood sampling and data on demographic and personality variables. The current paper presents the design and rationale of the study, as well as data on baseline sample characteristics. Demographic characteristics and co-morbidity ratings in the NOCDA sample closely resemble other OCD study samples. Lifetime co-morbid Axis I disorders are present in the majority of OCD patients, with high current and lifetime co-morbidity ratings for affective disorders (23.4% and 63.7%, respectively) and anxiety disorders other than OCD (36% current and 46.5% lifetime)., (Copyright © 2012 John Wiley & Sons, Ltd.)

Young immigrant women in the Netherlands demonstrate disproportionate rates of suicidal behavior. This study investigated the origins of suicidal behavior in South Asian-Surinamese, Turkish, and Moroccan immigrant young women in order to identify ethnic- and gender-specific patterns of suicidal behavior. Based on life story interviews of women who had been enrolled in mental health care, we constructed five typical patterns in which social, cultural, and personal factors were interconnected. Suicidal behavior was influenced by the ability and right to act autonomously with regard to strategic life choices, as well as by the questioning of cultural values of self-sacrifice and protection of honor.

Objective: General anxiety symptoms are common in patients with cardiac disease and considered to have an adverse effect on cardiac prognosis. The role of specific cardiac anxiety, however, is still unknown. The aim of this study is to examine the factor structure, reliability, and validity of the Dutch version of the Cardiac Anxiety Questionnaire (CAQ), which was specifically designed to assess heart focused anxiety., Methods: Two hundred thirty-seven patients admitted for an acute coronary syndrome (ACS) and a control group of 49 patients admitted for an exacerbation of rheumatoid arthritis (RA) completed the CAQ, the Agoraphobic Cognitions Questionnaire, Mobility Inventory, Beck Depression Inventory, Beck Anxiety Inventory, and the State-Trait Anxiety Inventory., Results: Although the original three-factor solution (fear, avoidance, and attention) was acceptable (model fit parameters: CFI = 0.89 and TLI = 0.87), our data were best explained by a four-factor model including safety seeking behaviors. Internal consistency and test-retest reliability were good. The CAQ had moderate correlations with the other anxiety and depression questionnaires. Recently admitted ACS patients had significantly higher scores than RA patients, even after controlling for general anxiety and depressive symptoms (p < 0.001)., Conclusion: The CAQ is a reliable and valid instrument to assess cardiac anxiety in patients hospitalized with ACS. These results enable longitudinal studies to examine the relationship of heart-focused anxiety with cardiac prognosis and to evaluate interventions specifically targeted at anxiety in cardiac patients.

Background: Appropriate management of anxiety disorders in primary care requires clinical assessment and monitoring of the severity of the anxiety. This study focuses on the Beck Anxiety Inventory (BAI) as a severity indicator for anxiety in primary care patients with different anxiety disorders (social phobia, panic disorder with or without agoraphobia, agoraphobia or generalized anxiety disorder), depressive disorders or no disorder (controls)., Methods: Participants were 1601 primary care patients participating in the Netherlands Study of Depression and Anxiety (NESDA). Regression analyses were used to compare the mean BAI scores of the different diagnostic groups and to correct for age and gender., Results: Patients with any anxiety disorder had a significantly higher mean score than the controls. A significantly higher score was found for patients with panic disorder and agoraphobia compared to patients with agoraphobia only or social phobia only. BAI scores in patients with an anxiety disorder with a co-morbid anxiety disorder and in patients with an anxiety disorder with a co-morbid depressive disorder were significantly higher than BAI scores in patients with an anxiety disorder alone or patients with a depressive disorder alone. Depressed and anxious patients did not differ significantly in their mean scores., Conclusions: The results suggest that the BAI may be used as a severity indicator of anxiety in primary care patients with different anxiety disorders. However, because the instrument seems to reflect the severity of depression as well, it is not a suitable instrument to discriminate between anxiety and depression in a primary care population.

Background: Comorbidity of depressive and anxiety disorders is common and has been shown to be a consistent predictor of chronicity. Comorbidity patterns among specific depressive and anxiety disorders have not been extensively reported. This study examines comorbidity patterns and temporal sequencing of separate depressive and anxiety disorders using data from a large psychiatric cohort., Method: Baseline data (N = 1,783) of the Netherlands Study of Depression and Anxiety, collected between September 2004 and February 2007, were used. Current and lifetime comorbidity rates for depressive and anxiety disorders (DSM-IV-TR criteria) were calculated. Associations of comorbidity with sociodemographic, vulnerability, and clinical characteristics, and temporal sequencing of disorders were examined., Results: Of those with a depressive disorder, 67% had a current and 75% had a lifetime comorbid anxiety disorder. Of persons with a current anxiety disorder, 63% had a current and 81% had a lifetime depressive disorder. Comorbidity of depressive and anxiety disorders was associated with more childhood trauma (OR = 1.19; 95% CI, 1.06-1.33), higher neuroticism (OR = 1.05; 95% CI, 1.02-1.08), earlier age at onset of first disorder (OR = 1.59; 95% CI, 1.22-2.07), longer duration of depressive and/or anxiety symptoms (OR = 1.01; 95% CI, 1.01-1.01), and higher symptom severity (ORs ranging from 1.01 to 1.03; all P values < .05). In 57% of comorbid cases, anxiety preceded depression, and in 18%, depression preceded anxiety. Comorbidity with preceding depression compared to preceding anxiety was associated with a shorter duration of symptoms of depressive and/or anxiety symptoms (OR = 0.99; 95% CI, 0.98-0.99), earlier age at first onset (OR = 0.46; 95% CI, 0.31-0.68), and fewer fear symptoms (OR = 0.98; 95% CI, 0.97-0.99)., Conclusions: Comorbidity rates in anxiety and depressive disorders were very high, indicating that it is advisable to assess both disorders routinely regardless of the primary reason for consultation. This is especially important since comorbid patients showed a specific vulnerability pattern, with more childhood trauma, neuroticism, and higher severity and duration of symptoms., (© Copyright 2011 Physicians Postgraduate Press, Inc.)

Objective: To avert the public health consequences of anxiety disorders, prevention of their onset and recurrence is necessary. Recent studies have shown that prevention is effective. To maximize the health gain and minimize the effort, preventive strategies should focus on high-risk groups., Method: Using data from a large prospective national survey, high-risk groups were selected for i) the prevention of first ever (n = 4437) and ii) either first-ever or recurrent incident anxiety disorders (n = 4886). Indices used were: exposure rate, odds ratio, population attributable fraction and number needed to be treated. Risk indicators included sociodemographic, psychological and illness-related factors., Results: Recognition of a few patient characteristics enables efficient identification of high-risk groups: (subthreshold) panic attacks; an affective disorder; a history of depressed mood; a prior anxiety disorder; chronic somatic illnesses and low mastery., Conclusion: Preventive efforts should be undertaken in the selected high-risk groups.

Background: Although panic disorder is generally considered to be a chronic condition, little is known about the natural history of panic attacks and the factors predicting the prognosis of panic. It is expected that data derived from the community show more variation in the prognosis of panic and that subjects with less severe, 'subthreshold panic disorder' have a better prognosis., Methods: Using a large, representative population-based study, the 2-year course of panic attacks and its predictors were investigated among 155 subjects with panic disorder and subthreshold panic disorder. Presence and frequency of attacks were studied using structured interviews. Putative risk-indicators of chronicity included socio-demographics, psychobiological, environmental, psychiatric and panic-related factors., Results: Thirty-nine percent of those with panic disorder and 17% of those with subthreshold panic disorder reported panic episodes during more than 75% of the observed time periods in the Life Chart Interview. Forty-three percent of those with panic disorder and 14% of those with subthreshold panic disorder reported over 24 attacks per 3-month period. Male gender, severity of panic and agoraphobia predicted a high proportion of time spent in panic episodes. Low self-esteem, limited positive life events and severity of panic predicted highly frequent attacks., Limitations: The sample size was small, thereby limiting statistical power. The reported outcome may have overestimated chronicity., Conclusions: As was expected, the 2-year prognosis of panic was more varied than is often found in clinical studies. Although subthreshold panic disorder had a more favourable prognosis than full-blown panic disorder, a sizeable proportion of those with subthreshold panic disorder had an unfavourable prognosis., (2009 Elsevier B.V. All rights reserved.)

Background: Panic disorder (PD) is generally considered to be a chronic or intermittent disorder. This view may be biased because of a lack of general population studies investigating panic from the onset of an episode onwards. Data regarding the course of subthreshold panic disorder (sub-PD) and predictors of its course are lacking., Method: Using data from a large community-based survey, the Netherlands Mental Health and Incidence Study (NEMESIS), that retrospectively assessed the 2-year course of panic with a Life Chart Interview (LCI), this study investigated remission, chronicity and recurrence in subjects with new episodes of PD or sub-PD. Predictor variables of remission consisted of sociodemographics, psychobiological, environmental, psychiatric and panic-related factors., Results: In PD, remission of panic attacks occurred in 64.5% of subjects, mean time to remission was 5.7 months, and the remission rate was 5.8/100 person-months. In 43.3% of subjects panic was still present after 1 year. Recurrence of panic attacks occurred in 21.4% of those with PD who had achieved remission and for whom sufficient follow-up time was available. In general, the course of sub-PD was more favourable. Predictors of remission were female gender, the absence of ongoing difficulties, subthreshold panic and a low initial frequency of attacks., Conclusions: These results suggest that the course of panic is diverse in the general population, thereby underlining the need for accurate predictors. This requires further research including biological data and additional psychological data. In addition, given the large proportion with a relapse, relapse prevention should be part of any treatment programme.

Objective: To examine the prevalence rate, impairment, comorbidity, course of illness and determinants of eight specific phobia variants: animals (animal subtype); heights, water, storms (natural environment subtype); flying, enclosed spaces, being alone (situational subtype); and blood/injury (blood/injury subtype)., Method: Data were obtained from the Netherlands Mental Health Survey and Incidence Study, a prospective study in the Dutch general population aged 18-65 (N = 7,076)., Results: The most prevalent condition was specific phobia with a fear of heights (4.9%). On all parameters except duration, specific phobia with a fear of being alone emerged as the most severe condition. Phobias with fear of enclosed spaces and phobias with fear of blood showed a slightly greater likelihood of impairment, comorbidity and personality problems than phobias with fear of animals, heights, water or storms., Conclusion: The situational and blood/injury phobia subtypes appear to be a more significant index for impairments and for comorbid psychiatric disorders than the animal and natural environment phobia subtypes.

It appears from a review of the literature that at present a considerable number of psychiatric patients are being deprived of evidence-based treatment. However, Australian theoretical research has shown that if patients were to be treated entirely in accordance with evidence-based guidelines they would derive considerably more benefit from their treatment. This conclusion has been corroborated by various randomised controlled trials (RCT's) in which the effect of evidence-based treatment according to guidelines is compared with the effect of 'treatment as usual'. Studies carried out under less controlled circumstances than those prevailing in RCT's yield slightly less positive results. The literature stresses the difficulties of improving the quality of patient care. Studies on the implementations of guidelines show that carefully constructed, tailor-made interventions are needed to ensure that professionals adhere to guidelines. More research is required into effective ways of implementing guidelines in an adequate manner.

We investigated the prevalence and explored the vulnerability to suicidal ideation across several ethnic minority versus ethnic majority adolescents in the city of Utrecht in The Netherlands. Exploratory analyses were conducted on a dataset obtained from the Municipal Health Services in Utrecht. We examined whether ethnic minority adolescents are at risk for suicidal ideation because of a family background of migration, social-economic position and certain family factors, which influence psychological constellations. We found that levels of suicidal ideation among adolescents of Turkish background were significantly higher than in both majority and other minority adolescents, The Turkish adolescents at risk for suicidal ideation reported that they do not enjoy being at home with their families. Psychological factors, in particular lack of self-pride and the idea of not becoming successful in life, appeared to be important, as well as feelings of loneliness. Suicidal ideation was not found equally across all ethnic minority groups. A history of migration, ethnic minority status, or low socioeconomic status were not sufficient to explain the variation across ethnicities. Our results suggest that specific social-cultural factors, contextualized in the individual and located in the family environment, are relevant in explaining the disproportionate rates for Turkish adolescents in Utrecht.

Background: Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up., Methods: We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first., Results: Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions., Conclusions: These results suggest that reduction of compulsions is the process through which both ERP and CT affect change., (2008 S. Karger AG, Basel)

Background: Whether long-term benzodiazepine users who participate in a family practice-based benzodiazepine discontinuation programme substitute benzodiazepines by other psychotropics is not clear., Objective: To evaluate the impact of a benzodiazepine discontinuation programme on non-benzodiazepine psychotropic prescription in family practice., Methods: In family practices in the Netherlands, 2425 long-term benzodiazepine users participated in a two-step benzodiazepine discontinuation programme. The programme started with a discontinuation letter (Step 1). Subjects unable to stop (N = 1707) were offered participation in Step 2, a three-group randomized trial with a taper procedure with group psychotherapy, a taper without psychotherapy and usual care. Only 156 subjects agreed to participate. The comparison group consisted of 1821 long-term users from family practices not participating in the programme. The main outcome was the change in prescription of non-benzodiazepine psychotropic medication from baseline (3 months before the start of the programme) till 21 months after the start of the programme. Four logistic regression models were performed concerning antidepressant prescription in the follow-up., Results: Only antidepressants were prescribed in relevant numbers. The prescription of antidepressants was not related to the programme. (P-value of experimental versus control group varied between 0.18 and 0.85 in the four models). The most important predictor of antidepressant prescription in follow-up was baseline antidepressant prescription [odds ratio (OR): 67.2; 95% confidence interval (95% CI): 49.8-90.7]. Subjects, of whom the prescription of benzodiazepines had been discontinued completely, had been prescribed less antidepressants (OR: 0.8; 95% CI: 0.6-1.0)., Conclusion: An effective benzodiazepine reduction programme was not accompanied by a substitute use of other psychotropics.

Objective: To investigate similarities and differences between the symptom profiles of patients with hypochondriasis and those of patients with obsessive-compulsive disorder (OCD) and to compare the contamination/cleaning OCD subtype to other OCD subtypes., Method: Between January 1998 and July 2002, 76 patients diagnosed with hypochondriasis (N = 31) or OCD (N = 45) (DSM-IV criteria) and 25 subjects with no formal DSM-IV diagnosis were compared with regard to the extent of diagnosis-specific symptoms, the number and nature of physical symptoms, and whether these symptoms evoked fear. The analyses were repeated after subdividing the OCD patients into the contamination/cleaning and other OCD subgroups., Results: Patients with hypochondriasis and OCD differed significantly from each other on the extent of diagnosis-specific symptoms (all p < .001). Patients with hypochondriasis reported significantly more obsessive-compulsive symptoms and patients with OCD reported significantly more hypochondriacal symptoms than did the healthy control-group members (all p < .05). Neither group differed significantly from the other on the number and nature of feared physical symptoms. The contamination/cleaning OCD subtype did not differ significantly from other OCD subtypes in either the severity of hypochondriacal symptoms or the number of feared physical symptoms., Conclusion: Hypochondriasis and OCD can be distinguished on the basis of diagnosis-specific symptoms, although they share a number of similarities. In addition, although patients with the contamination/cleaning OCD subtype tend to be afraid of contracting diseases, the differences between the symptom profiles of these patients and those of patients with hypochondriasis exceed the similarities. Our results confirm that the 2 conditions are separable and valid diagnoses.

Background: Predictors of benzodiazepine discontinuation after sending a discontinuation letter by the family practitioner have not been established sufficiently., Objective: To identify predictors of short- and long-term discontinuation of benzodiazepine use and relapse in use after a minimal intervention with a discontinuation letter followed by an offer for an evaluation consultation., Methods: Predictors of benzodiazepine discontinuation and relapse in use were studied by logistic regression analysis and survival analysis within a family practice population of long-term benzodiazepine users (n = 1707) addressed by a discontinuation letter and followed for 21 months., Results: A lower baseline prescription, a shorter duration of use, male gender and use of an agent with a half-life time <24 hours were predictive of complete discontinuation in the short (6 months) and long term (21 months). Multiple agent use at baseline, use of antidepressants at 6 months and benzodiazepine type (anxiolytic/hypnotic) at baseline predicted relapse. Attendance at an evaluation consultation 3 months after the letter was sent was not predictive of discontinuation or relapse., Conclusions: Amount of baseline use and duration of use are the main determinative characteristics of successful discontinuation. The discontinuation letter intervention is suitable for use with a broad group of long-term benzodiazepine users in family practice and can be used as a first step within a stepped care approach to decrease long-term benzodiazepine use.

Objective: The purpose of this study was to examine the comorbidity of and communality of risk factors associated with major depressive disorder and anxiety disorders in later life., Method: A random age- and sex-stratified community-based sample (N=3,056) of the elderly (age 55-85 years) in the Netherlands was studied. A two-stage screening design was used, with the Center for Epidemiologic Studies Depression Scale as a screening instrument and the National Institute of Mental Health Diagnostic Interview Schedule as a criterion instrument. Risk factors were measured with well-validated instruments and represented a broad range of vulnerability and stress-related factors associated with anxiety and depression. Multivariate analyses examined risk factors associated with pure major depressive disorder, pure anxiety disorders, and comorbid conditions., Results: Comorbidity was highly prevalent: 47.5% of those with major depressive disorder also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorder. While the only variables associated with pure major depressive disorder were younger age and external locus of control, risk factors representing a wide range of both vulnerability and stress were associated with pure anxiety disorders. External locus of control was the only common factor. The group with anxiety disorders plus major depressive disorder had a distinct risk factor profile and may represent those with a more severe disorder., Conclusions: Although high levels of comorbidity between major depressive disorder and anxiety disorders were found, comparing risk factors associated with pure major depressive disorder and pure anxiety disorders revealed more differences than similarities. Anxiety disorders in later life merit separate study.

Objective: The aim of the study was to investigate patterns of comorbidity among the anxiety disorders in a community-based older population, and the relationship of these disorders with major depression, use of alcohol and benzodiazepines, cognitive impairment and chronic somatic illnesses., Method: The data were derived from the Longitudinal Aging Study Amsterdam (LASA) study. A two-stage screening design was adopted to identify respondents with anxiety disorders., Results: In total, 10% of the elderly with an anxiety diagnosis suffered from two or more anxiety disorders. Major depression (13% vs. 3%), benzodiazepine use (24% vs. 11%) and chronic somatic diseases (12% vs. 7%) were significantly more prevalent in respondents with an anxiety disorder than in respondents without anxiety disorders. Heavy or excessive alcohol intake (5% vs. 4%) and cognitive impairment (11% vs. 13%) were not significantly associated with any anxiety disorder., Conclusion: When anxiety disorders are diagnosed, in older people there is a relatively high probability of comorbid conditions being present.

Objective: To study the prevalence and risk factors of anxiety disorders in the older (55-85) population of The Netherlands., Method: The Longitudinal Aging Study Amsterdam (LASA) is based on a random sample of 3107 older adults, stratified for age and sex, which was drawn from the community registries of 11 municipalities in three regions in The Netherlands. Anxiety disorders were diagnosed using the Diagnostic Interview Schedule in a two-stage screening design. The risk factors under study comprise vulnerability, stress and network-related variables. Both bivariate and multivariate statistical methods were used to evaluate the risk factors., Results: The overall prevalence of anxiety disorders was estimated at 10.2%. Generalized anxiety disorder was the most common disorder (7.3%), followed by phobic disorders (3.1%). Both panic disorder (1.0%) and obsessive compulsive disorder (0.6%) were rare. These figures are roughly similar to previous findings. Ageing itself did not have any impact on the prevalence in both bivariate and multivariate analyses. The impact of other factors did not change much with age. Vulnerability factors (female sex, lower levels of education, having suffered extreme experiences during World War II and external locus of control) appeared to dominate, while stresses commonly experienced by older people (recent losses in the family and chronic physical illness) also played a part. Of the network-related variables, only a smaller size of the network was associated with anxiety disorders., Conclusions: Anxiety disorders are common in later life. The risk factors support using a vulnerability-stress model to conceptualize anxiety disorders. Although the prevalence of risk factors changes dramatically with age, their impact is not age-dependent. The risk factors indicate which groups of older people are at a high risk for anxiety disorders and in whom active screening and treatment may be warranted.