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Background: Depressive symptoms and decreased physical functioning are interrelated conditions and common in older persons, causing significant individual and societal burden. Evidence suggests that vitamin D supplementation may be. beneficial for both mental and physical functioning. However, previous randomized controlled trials have yielded inconsistent results and often had suboptimal designs. This study examines the effect of vitamin D supplementation on both depressive symptoms and physical functioning in a high-risk population of older persons with low vitamin D status. Methods/design: The D-Vitaal study is a randomized, double-blind, placebo-controlled trial investigating the effects of a daily dose of 1200 IU vitamin D3 versus placebo for one year on depressive symptoms and physical functioning (primary outcomes) in older adults. Participants (N = 155, age 60-80 years) were recruited from the general population. Eligibility criteria included the presence of depressive symptoms, =1 functional limitation and serum 25-hydroxyvitamin D levels between 15 and 50/70 nmol/L (depending on season). Secondary outcomes include incidence of major depressive disorder, anxiety symptoms, health-related quality of life, cognitive function and cost-effectiveness of the intervention. Discussion: With this study, we aim to elucidate the effects of vitamin D supplementation on depressive symptoms and physical functioning in older persons who are at high risk of developing more substantial mental and physical problems. If effective, vitamin D supplementation can be a preventive intervention strategy that is easy to implement in the primary care setting. [ABSTRACT FROM AUTHOR]

Background: Panic disorder (PD) and generalized anxiety disorder (GAD) are two of the most disabling and costly anxiety disorders seen in primary care. However, treatment quality of these disorders in primary care generally falls beneath the standard of international guidelines. Collaborative stepped care is recommended for improving treatment of anxiety disorders, but cost-effectiveness of such an intervention has not yet been assessed in primary care. This article describes the aims and design of a study that is currently underway. The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual.Methods/design: The study is a two armed, cluster randomized controlled trial. Care managers and their primary care practices will be randomized to deliver either collaborative stepped care (CSC) or care as usual (CAU). In the CSC group a general practitioner, care manager and psychiatrist work together in a collaborative care framework. Stepped care is provided in three steps: 1) guided self-help, 2) cognitive behavioral therapy and 3) antidepressant medication. Primary care patients with a DSM-IV diagnosis of PD and/or GAD will be included. 134 completers are needed to attain sufficient power to show a clinically significant effect of 1/2 SD on the primary outcome measure, the Beck Anxiety Inventory (BAI). Data on anxiety symptoms, mental and physical health, quality of life, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months.Discussion: It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual. The pragmatic design of this study will enable the researchers to evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options for GAD and PD in the primary care setting. Results will become available in 2011.Trial Registration: NTR1071. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about an article discussing selective serotonin reuptake inhibitors that appeared in a previous issue of the "British Medical Journal."

Objective: The aim of this review is to critically appraise the evidence on measurement properties of self-report questionnaires measuring somatization in adult primary care patients and to provide recommendations about which questionnaires are most useful for this purpose.Methods: We assessed the methodological quality of included studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. To draw overall conclusions about the quality of the questionnaires, we conducted an evidence synthesis using predefined criteria for judging the measurement properties.Results: We found 24 articles on 9 questionnaires. Studies on the Patient Health Questionnaire-15 (PHQ-15) and the Four-Dimensional Symptom Questionnaire (4DSQ) somatization subscale prevailed and covered the broadest range of measurement properties. These questionnaires had the best internal consistency, test-retest reliability, structural validity, and construct validity. The PHQ-15 also had good criterion validity, whereas the 4DSQ somatization subscale was validated in several languages. The Bodily Distress Syndrome (BDS) checklist had good internal consistency and structural validity. Some evidence was found for good construct validity and criterion validity of the Physical Symptom Checklist (PSC-51) and good construct validity of the Symptom Check-List (SCL-90-R) somatization subscale. However, these three questionnaires were only studied in a small number of primary care studies.Conclusion: Based on our findings, we recommend the use of either the PHQ-15 or 4DSQ somatization subscale for somatization in primary care. Other questionnaires, such as the BDS checklist, PSC-51 and the SCL-90-R somatization subscale show promising results but have not been studied extensively in primary care. [ABSTRACT FROM AUTHOR]

Background: Comorbid depression is common in patients with type 2 diabetes (DM2) and/or coronary heart disease (CHD) and is associated with poor quality of life and adverse health outcomes. However, little is known about patients' and practice nurses' (PNs) perceptions of depression. Tailoring care to these perceptions may affect depression detection and patient engagement with treatment and prevention programs. This study aimed to explore patients' and PNs' perceptions of depression in patients with DM2/CHD screened for subthreshold depression. Methods: A qualitative study was conducted as part of a Dutch stepped-care prevention project. Using a purposive sampling strategy, data were collected through semi-structured interviews with 15 patients and 9 PNs. After consent, all interviews were recorded, transcribed verbatim and analyzed independently by two researchers with Atlas.ti.5.7.1 software. The patient and PN datasets were inspected for commonalities using a constant comparative method, from which a final thematic framework was generated. Results: Main themes were: illness perception, need for care and causes of depression. Patients generally considered themselves at least mildly depressed, but perceived severity levels were not always congruent with Patient Health Questionnaire 9 scores at inclusion. Initially recognizing or naming their mental state as a (subthreshold) depression was difficult for some. Having trouble sleeping was frequently experienced as the most burdensome symptom. Most experienced a need for care; psycho-educational advice and talking therapy were preferred. Perceived symptom severity corresponded with perceived need for care, but did not necessarily match help-seeking behaviour. Main named barriers to help-seeking were experienced stigma and lack of awareness of depression and mental health care possibilities. PNs frequently perceived patients as not depressed and with minimal need for specific care except for attention. Participants pointed to a mix of causes of depression, most related to negative life events and circumstances and perceived indirect links with DM2/CHD. Conclusion: Data of the interviewed patients and PNs suggest that they have different perceptions about (subthreshold) depressive illness and the need for care, although views on its causes seem to overlap more. [ABSTRACT FROM AUTHOR]

Background: In 2013 the Dutch guideline for management of medically unexplained symptoms (MUS) was published. The aim of this study is to assess medical care for patients with persistent MUS as recorded in their electronic medical records, to investigate if this is in line with the national guideline for persistent MUS and whether there are changes in care over time. Methods: We conducted an observational study of adult primary care patients with MUS. Routinely recorded health care data were extracted from electronic medical records of patients participating in an ongoing randomised controlled trial in 30 general practices in the Netherlands. Data on general practitioners' (GPs') management strategies during MUS consultations were collected in a 5-year period for each patient prior. Management strategies were categorised according to the options offered in the Dutch guideline. Changes in management over time were analysed. Results: Data were collected from 1035 MUS consultations (77 patients). Beside history-taking, the most frequently used diagnostic strategies were physical examination (24.5%) and additional investigations by the GP (11.1%). Frequently used therapeutic strategies were prescribing medication (24.6%) and providing explanations (11.2%). As MUS symptoms persisted, GPs adjusted medication, discussed progress and scheduled follow-up appointments more frequently. The least frequently used strategies were exploration of all complaint dimensions (i.e. somatic, cognitive, emotional, behavioural and social) (3.5%) and referral to a psychologist (0.5%) or psychiatrist (0.1%). Conclusions: Management of Dutch GPs is partly in line with the Dutch guideline. Medication was possibly prescribed more frequently than recommended, whereas exploration of all complaint dimensions, shared problem definition and referral to mental health care were used less. [ABSTRACT FROM AUTHOR]

Purpose: To assess the impact of EQ-5D country-specific value sets on cost-utility outcomes., Methods: Data from 2 randomized controlled trials on low back pain (LBP) and depression were used. 3L value sets were identified from the EuroQol Web site. A nonparametric crosswalk was employed for each tariff to obtain the likely 5L values. Differences in quality-adjusted life years (QALYs) between countries were tested using paired t tests, with United Kingdom as reference. Cost-utility outcomes were estimated for both studies and both EQ-5D versions, including differences in QALYs and cost-effectiveness acceptability curves., Results: For the 3L, QALYs ranged between 0.650 (Taiwan) and 0.892 (United States) in the LBP study and between 0.619 (Taiwan) and 0.879 (United States) in the depression study. In both studies, most country-specific QALY estimates differed statistically significantly from that of the United Kingdom. Incremental cost-effectiveness ratios ranged between &OV0556;2044/QALY (Taiwan) and &OV0556;5897/QALY (Zimbabwe) in the LBP study and between &OV0556;38,287/QALY (Singapore) and &OV0556;96,550/QALY (Japan) in the depression study. At the NICE threshold of &OV0556;23,300/QALY (≈£20,000/QALY), the intervention's probability of being cost-effective versus control ranged between 0.751 (Zimbabwe) and 0.952 (Taiwan) and between 0.230 (Canada) and 0.396 (Singapore) in the LBP study and depression study, respectively. Similar results were found for the 5L, with extensive differences in ICERs and moderate differences in the probability of cost-effectiveness., Conclusions: This study indicates that the use of different EQ-5D country-specific value sets impacts on cost-utility outcomes. Therefore, to account for the fact that health state preferences are affected by sociocultural differences, relevant country-specific value sets should be used.

Objective: To assess the cost-effectiveness of a brief cognitive behavioural intervention for patients with medically unexplained physical symptoms (MUPS) provided by a mental health nurse practitioner (MHNP) in primary care in comparison with usual care., Methods: We performed an economic evaluation from a societal perspective alongside a cluster randomised controlled trial with 12 months follow-up. The primary outcome was quality-adjusted life-years (QALYs). Secondary outcomes were the RAND-36 physical component summary score (PCS), somatic symptom severity (Patient Health Questionnaire (PHQ-15), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale (HADS)). Missing data were imputed using multiple imputation. We used non-parametric bootstrapping to estimate statistical uncertainty. The bootstrapped cost-effect pairs were used to estimate cost-effectiveness planes and cost-effectiveness acceptability curves., Results: Mean total costs in the intervention group were significantly lower than in the usual care group (mean difference - 2300€, 95% CI -3257 to -134). The mean difference in QALYs was 0.01 (95% CI -0.01 to 0.04), in PCS 2.46 (95% CI 1.44 to 3.47), in PHQ-15 -0.26 (95% CI -0.81 to 0.28), and in HADS -0.07 (-0.81 to 0.67). At a willingness to pay of 0 € per additional unit of effect, the probability of the intervention being cost-effective was 0.93 for QALYs and 0.92 for PCS, PHQ-15 and HADS scores., Conclusion: Our intervention is cost-effective compared to usual care for patients with MUPS. Implementation of the intervention has the potential to result in a significant decline in costs. However, large scale implementation would require increased deployment of MHNPs., Competing Interests: Declaration of Competing Interest The authors have no competing interests to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To examine the longitudinal association between pain and suicidal ideation in the general adult population., Method: Data were used from two waves (baseline and three-year follow-up) of the Netherlands Mental Health Survey and Incidence Study-2. Persons without prior 12-month suicidal ideation at baseline were included in this study (N = 5242). Pain severity and interference due to pain in the past month were measured using the 36-item Short Form Health Survey. Suicidal ideation and DSM-IV mental disorders were assessed using the Composite International Diagnostic Interview. Logistic regression analyses were performed., Results: Moderate to very severe pain (OR 3.39, p < .001) and moderate to very severe interference due to pain (OR 2.35, p .01) were associated with a higher risk for incident suicidal ideation at follow-up after adjustment for baseline sociodemographic variables and mental disorders. No interaction effects were found between pain severity or interference due to pain and mental disorders., Conclusion: Moderate to severe pain and interference due to pain are risk factors for suicidal ideation independently of concomitant mental disorders. We suggest taking assessment and management of suicidal ideation in patients with pain into account both in clinical treatment as well as in suicide prevention action plans., Competing Interests: Conflict of interests Prof. van der Feltz-Cornelis reports grants from Eli Lilly, non-financial support from GGz inGeest and Arkin outside the submitted work; Prof. Beekman reports personal fees from Lundbeck, outside the submitted work; all other authors have nothing to disclose., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To examine if chest pain increases the risk of depression and anxiety, or, on the other hand, depression and anxiety increase the risk of chest pain onset in patients with coronary heart disease (CHD)., Design: Prospective clinical study., Setting: 16 general practices in the Greater London Primary Care Research Network., Participants: 803 participants with a confirmed diagnosis of CHD at baseline on the Quality and Outcomes Framework (QOF) CHD registers., Main Outcome Measures: Rose Angina Questionnaire, HADS depression and anxiety subscales and PHQ-9 were assessed at seven time points, each 6 months apart. Multi-Level Analysis (MLA) and Structural Equation Modelling (SEM) were applied., Results: Chest pain predicts both more severe anxiety and depression symptoms at all time points until 30 months after baseline. However, although anxiety predicted chest pain in the short term with a strong association, this association did not last after 18 months. Depression had only a small, negative association with chest pain., Conclusions: In persons with CHD, chest pain increases the risk of both anxiety and depression to a great extent. However, anxiety and depression have only limited effects on the risk for chest pain. This evidence suggests that anxiety and depression tend to be consequences rather than causes of cardiac chest pain. Intervention studies that support persons with CHD by providing this information should be devised and evaluated, thus deconstructing potentially catastrophic cognitions and strengthening emotional coping., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To examine the effectiveness of a cognitive behavioural intervention delivered by mental health nurse practitioners (MHNPs) to patients with undifferentiated somatoform disorder (USD), compared to usual care., Methods: We conducted a cluster randomized trial among primary care patients with USD comparing the intervention to usual care. The intervention consisted of six sessions with the MHNP. Primary outcome was physical functioning (RAND-36 physical component summary score). Secondary outcomes were the RAND-36 mental component summary score and the eight subscales; anxiety and depression (Hospital Anxiety and Depression Scale) and somatic symptom severity (Patient Health Questionnaire-15). Outcomes were assessed at baseline, 2, 4 and 12 months. We analysed data using linear mixed models by intention-to-treat, and investigated effect modifiers., Results: Compared to usual care (n = 87), the intervention group (n = 111) showed an improvement in physical functioning (mean difference 2.24 [95% CI 0.51; 3.97]; p = .011), a decrease in limitations due to physical problems (mean difference 10.82 [95% CI 2.14; 19.49]; p. = 0.015) and in pain (mean difference 5.08 [95% CI 0.58; 9.57]; p = .027), over 12 months. However effect sizes were small and less clinically relevant than expected. We found no differences for anxiety, depression and somatic symptom severity. Effects were larger and clinically relevant for patients with more recent symptoms and fewer physical diseases., Conclusion: The cognitive behavioural intervention was effective in improving pain and physical functioning components of patients' health. It was particularly suitable for patients with symptoms that had been present for a limited number of years and with few comorbid physical diseases., Trial Registration: The trial is registered in the Dutch Trial Registry, www.trialregister.nl, under NTR4686., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Depressive symptoms and impaired physical functioning are prevalent among older adults. Supplementation with vitamin D might improve both conditions, particularly in persons with low vitamin D status., Objective: The D-Vitaal study primarily aimed to investigate the effect of vitamin D supplementation on depressive symptoms, functional limitations, and physical performance in a high-risk older population with low vitamin D status. Secondary aims included examining the effect of vitamin D supplementation on anxiety symptoms, cognitive functioning, mobility, handgrip strength, and health-related quality of life., Methods: This study was a randomized placebo-controlled trial with 155 participants aged 60-80 y who had clinically relevant depressive symptoms, ≥1 functional limitations, and serum 25-hydroxyvitamin D [25(OH)D] concentrations of 15-50/70 nmol/L (depending on season). Participants received 1200 IU/d vitamin D3 (n = 77) or placebo tablets (n = 78) for 12 mo. Serum 25(OH)D was measured at baseline and 6 mo; outcomes were assessed at baseline, 6 mo, and 12 mo. Linear mixed-models analyses were conducted to assess the effect of the intervention., Results: The supplementation increased serum 25(OH)D concentrations in the intervention group to a mean ± SD of 85 ± 16 nmol/L compared with 43 ± 18 nmol/L in the placebo group after 6 mo (P < 0.001). No relevant differences between the treatment groups were observed regarding depressive symptoms, functional limitations, physical performance, or any of the secondary outcomes., Conclusions: Supplementation with 1200 IU/d vitamin D for 12 mo had no effect on depressive symptoms and physical functioning in older persons with relatively low vitamin D status, clinically relevant depressive symptoms, and poor physical functioning. This trial is registered with the Netherlands Trial Register (www.trialregister.nl) under NTR3845., (Copyright © American Society for Nutrition 2019.)

Background: Comorbid depression is common among patients with diabetes and has severe health consequences, but often remains unrecognized. Several questionnaires are used to screen for depression. A systematic review and meta-analysis regarding the diagnostic accuracy of depression questionnaires in adults with diabetes is unavailable. Our aim was to conduct a systematic review and meta-analysis to evaluate the diagnostic accuracy of depression questionnaires in adults with type 1 or type 2 diabetes., Methods: PubMed, Embase and PsycINFO were searched from inception to 28 February 2018. Studies were included when the diagnostic accuracy of depression questionnaires was assessed in a diabetes population and the reference standard was a clinical interview. Data extraction was performed by one reviewer and checked by another. Two reviewers independently conducted the quality assessment (QUADAS-2). Diagnostic accuracy was pooled in bivariate random effects models. The main outcome was diagnostic accuracy, expressed as sensitivity and specificity, of depression questionnaires in an adult diabetes population. This study is reported according to PRISMA-DTA and is registered with PROSPERO (CRD42018092950)., Results: A total 6,097 peer-reviewed articles were screened. Twenty-one studies (N = 5,703 patients) met the inclusion criteria for the systematic review. Twelve different depression questionnaires were identified, of which the CES-D (n = 6 studies) and PHQ-9 (n = 7 studies) were the most frequently evaluated. Risk of bias was unclear for multiple domains in the majority of studies. In the meta-analyses, five (N = 1,228) studies of the CES-D (≥16), five (N = 1,642) of the PHQ-9 (≥10) and four (N = 822) of the algorithm of the PHQ-9 were included in the pooled analysis. The CES-D (≥16) had a pooled sensitivity of 85.0% (95%CI, 71.3-92.8%) and a specificity of 71.6% (95%CI, 62.5-79.2%); the PHQ-9 (≥10) had a sensitivity of 81.5% (95%CI, 57.1-93.5%) and a specificity of 79.7% (95%CI, 62.1-90.4%). The algorithm for the PHQ-9 had a sensitivity of 60.9% (95%CI, 52.3-90.8%) and a specificity of 64.0% (95%CI, 53.0-93.9%)., Conclusions: This review indicates that the CES-D had the highest sensitivity, whereas the PHQ-9 had the highest specificity, although confidence intervals were wide and overlapping. The algorithm for the PHQ-9 had the lowest sensitivity and specificity. Given the variance in results and suboptimal reporting of studies, further high quality studies are needed to confirm the diagnostic accuracy of these depression questionnaires in patients with diabetes., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Depressive symptoms and low vitamin D status are common in older persons and may be associated, but findings are inconsistent. This study investigated whether 25-hydroxyvitamin D (25(OH)D) concentrations are associated with depressive symptoms in older adults, both cross-sectionally and longitudinally. We also examined whether physical functioning could explain this relationship, to gain a better understanding of the underlying mechanisms., Methods: Data from two independent prospective cohorts of the Longitudinal Aging Study Amsterdam were used: an older cohort (≥65 years, n = 1282, assessed from 1995-2002) and a younger-old cohort (55-65 years, n = 737, assessed from 2002-2009)., Measurements: Depressive symptoms were measured at baseline and after 3 and 6 years with the Center of Epidemiological Studies Depression Scale. Cross-sectional and longitudinal linear regression techniques were used to examine the relationship between 25(OH)D and depressive symptoms. The mediating role of physical functioning was examined in the longitudinal models., Results: Cross-sectionally, associations were not significant after adjustment for confounders. Longitudinally, women in the older cohort with baseline 25(OH)D concentrations up to 75 nmol/L experienced 175 to 24% more depressive symptoms in the following 6 years, compared with women with 25(OH)D concentrations >75 nmol/L. Reduced physical performance partially mediated this relationship. In men and in the younger-old cohort, no significant associations were observed., Conclusions: Older women showed an inverse relationship between 25(OH)D and depressive symptoms over time, which may partially be explained by declining physical functioning. Replication of these findings by future studies is needed., (Copyright © 2018 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Purpose: To conduct a systematic review on measurement properties of questionnaires measuring depressive symptoms in adult patients with type 1 or type 2 diabetes., Methods: A systematic review of the literature in MEDLINE, EMbase and PsycINFO was performed. Full text, original articles, published in any language up to October 2016 were included. Eligibility for inclusion was independently assessed by three reviewers who worked in pairs. Methodological quality of the studies was evaluated by two independent reviewers using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Quality of the questionnaires was rated per measurement property, based on the number and quality of the included studies and the reported results., Results: Of 6286 unique hits, 21 studies met our criteria evaluating nine different questionnaires in multiple settings and languages. The methodological quality of the included studies was variable for the different measurement properties: 9/15 studies scored 'good' or 'excellent' on internal consistency, 2/5 on reliability, 0/1 on content validity, 10/10 on structural validity, 8/11 on hypothesis testing, 1/5 on cross-cultural validity, and 4/9 on criterion validity. For the CES-D, there was strong evidence for good internal consistency, structural validity, and construct validity; moderate evidence for good criterion validity; and limited evidence for good cross-cultural validity. The PHQ-9 and WHO-5 also performed well on several measurement properties. However, the evidence for structural validity of the PHQ-9 was inconclusive. The WHO-5 was less extensively researched and originally not developed to measure depression., Conclusion: Currently, the CES-D is best supported for measuring depressive symptoms in diabetes patients.

Objective: Collaborative care (CC) improves depressive symptoms in people with comorbid depressive disorder in chronic medical conditions, but its effect on physical symptoms has not yet systematically been reviewed. This study aims to do so., Methods: Systematic review and meta-analysis was conducted using PubMed, the Cochrane Library, and the European and US Clinical Trial Registers. Eligible studies included randomized controlled trials (RCTs) of CC compared to care as usual (CAU), in primary care and general hospital setting, reporting on physical and depressive symptoms as outcomes. Overall treatment effects were estimated for illness burden, physical outcomes and depression, respectively., Results: Twenty RCTs were included, with N=4774 patients. The overall effect size of CC versus CAU for illness burden was OR 1.64 (95%CI 1.47;1.83), d=0.27 (95%CI 0.21;0.33). Best physical outcomes in CC were found for hypertension with comorbiddepression. Overall, depression outcomes were better for CC than for CAU. Moderator analyses did not yield statistically significant differences., Conclusions: CC is more effective than CAU in terms of illness burden, physical outcomes and depression, in patients with comorbid depression in chronic medical conditions. More research covering multiple medical conditions is needed., Protocol Registration Number: The protocol for this systematic review and meta-analysis has been registered at the International Prospective Register of Systematic Reviews (PROSPERO) on February 19th 2016: http://www.crd.york.ac.uk/PROSPERO/DisplayPDF.php?ID=CRD42016035553., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To examine longitudinal associations of multiple physical symptoms with recurrence of depressive and anxiety disorders., Methods: Follow-up data of 584 participants with remitted depressive or anxiety disorders were used from the Netherlands Study of Depressive and Anxiety disorders. Multiple physical symptoms were measured at baseline (T1) and two-year follow-up (T2) by the Four-Dimensional Symptom Questionnaire (4DSQ) somatization subscale. Recurrence of depressive and anxiety disorders was assessed at two-year (T2) and four-year (T4) follow-up with the Composite International Diagnostic Interview. Logistic Generalized Estimating Equations were used to examine associations of multiple physical symptoms with recurrence of depressive and anxiety disorders. Depressive (IDS-SR) and anxiety symptoms (BAI), and other relevant covariates were taken into account., Results: Multiple physical symptoms were significantly associated with recurrence of depression (OR=1.04, 95%CI=1.00-1.08), anxiety (OR=1.07, 95%CI=1.03-1.12), and depressive or anxiety disorders (OR=1.06, 95%CI=1.02-1.10), on average over time. Odds ratios did not change substantially when the IDS-SR mood-cognition and BAI subjective scale were included as covariates., Conclusion: The presence of multiple physical symptoms was positively related to recurrence of depressive and anxiety disorders, independent of depressive and anxiety symptoms. Knowledge of risk factors for recurrence of depressive and anxiety disorders, such as the presence of multiple physical symptoms, could provide possibilities for better targeting interventions to prevent recurrence., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The burden and economic consequences of depression are high, mostly due to its recurrent nature. Due to current budget and time restraints, a preventive, low- cost, accessible minimal intervention is much needed. In this study, we evaluated the effectiveness of a supported self-help preventive cognitive therapy (S-PCT) added to treatment as usual (TAU) in primary care, compared to TAU alone., Methods: We conducted a randomized controlled trial among 248 patients with a history of depression, currently in full or partial remission or recovery. Participants were randomized to TAU augmented with S-PCT (n = 124) or TAU alone (n = 124). S-PCT consisted of an 8-week self-help intervention, supported by weekly telephone guidance by a counselor. The intervention included a self-help book that could be read at home. The primary outcome was the incidence of relapse or recurrence and was assessed over the telephone by the Structured Clinical Interview for DSM-IV axis 1 disorders. Participants were observed for 12 months. Secondary outcomes were depressive symptoms, quality of life (EQ-5D and SF-12), comorbid psychopathology, and self-efficacy. These secondary outcomes were assessed by digital questionnaires., Results: In the S-PCT group, 44 participants (35.5%) experienced a relapse or recurrence, compared to 62 participants (50.0%) in the TAU group (incidence rate ratio = 0.71, 95% CI 0.52-0.97; risk difference = 14, 95% CI 2-24, number needed to treat = 7). Compared to the TAU group, the S-PCT group showed a significant reduction in depressive symptoms over 12 months (mean difference -2.18; 95% CI -3.09 to -1.27) and a significant increase in quality of life (EQ-5D) (mean difference 0.04; 95% CI 0.004-0.08). S-PCT had no effect on comorbid psychopathology, self-efficacy, and quality of life based on the SF-12., Conclusions: A supported self-help preventive cognitive therapy, guided by a counselor in primary care, proved to be effective in reducing the burden of recurrent depression., (© 2017 The Author(s) Published by S. Karger AG, Basel.)

Lowering elevated plasma homocysteine (Hcy) concentrations by supplementing vitamin B 12 and folic acid may reduce depressive symptoms and improve health-related quality of life (HR-QoL) in older adults. This study aimed to test this hypothesis in a randomized controlled trial. Participants ( N = 2919, ≥65 years, Hcy concentrations ≥12 µmol/L) received either 500 µg vitamin B 12 and 400 µg folic acid daily or placebo for two years. Both tablets contained 15 µg vitamin D₃. Depressive symptoms were measured with the Geriatric Depression Scale-15 (GDS-15). HR-QoL was assessed with the SF-12 Mental and Physical component summary scores and the EQ-5D Index score and Visual Analogue Scale. Differences in two-year change scores were analyzed with Analysis of Covariance (ANCOVA). Hcy concentrations decreased more in the intervention group, but two-year change scores of the GDS-15 and three of four HR-QoL measures did not differ between groups. The EQ-5D Index score declined less in the intervention group than in the placebo group (mean change 0.00 vs. -0.02, p = 0.004). In conclusion, two-year supplementation with vitamin B 12 and folic acid in older adults with hyperhomocysteinemia showed that lowering Hcy concentrations does not reduce depressive symptoms, but it may have a small positive effect on HR-QoL., Competing Interests: The authors declare no conflict of interest. The funding sources had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Observational studies suggest that low concentrations of serum 25-hydroxyvitamin D (25(OH)D) and high concentrations of parathyroid hormone (PTH) are associated with a higher risk of mortality. The aim of this study was to examine whether 25(OH)D and PTH concentrations are independently associated with overall and disease-specific (cardiovascular and cancer-related) mortality in a large, prospective population-based cohort of older adults. Data from 1317 men and women (65-85 years) of the Longitudinal Aging Study Amsterdam were used. Cox proportional hazard analyses were used to examine whether 25(OH)D and PTH at baseline were associated with overall mortality (with a follow-up of 18 years) and disease-specific mortality (with a follow-up of 13 years). Compared to persons in the reference category of ≥75nmol/L, persons with serum 25(OH)D <25nmol/L (HR 1.46; 95% CI: 1.12-1.91) and 25-49.9nmol/L (HR 1.24; 95% CI: 1.01-1.53) had a significantly higher risk of overall mortality, as well as men with baseline PTH concentrations ≥7pmol/L (HR 2.54 (95% CI: 1.58-4.08)), compared to the reference category of <2.33pmol/L. The relationship of 25(OH)D with overall mortality was partly mediated by PTH. Furthermore, men with PTH concentrations of ≥7pmol/L (HR 3.22; 95% CI: 1.40-7.42) had a higher risk of cardiovascular mortality, compared to the reference category. No significant associations of 25(OH)D or PTH with cancer-related mortality were observed. Both 25(OH)D and PTH should be considered as important health markers., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Depression is common among type 2 diabetes mellitus (DM2)/coronary heart disease (CHD) patients and is associated with adverse health effects. A promising strategy to reduce burden of disease is to identify patients at risk for depression in order to offer indicated prevention. This study aims to assess the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) to be used as a tool to identify high risk patients., Methods: In this cross-sectional study, 586 consecutive DM2/CHD patients aged >18 were recruited through 23 general practices. PHQ-9 outcomes were compared to the Mini International Neuropsychiatric Interview (MINI), which was considered the reference standard. Diagnostic accuracy was evaluated for minor and major depression, comparing both sum- and algorithm based PHQ-9 scores., Results: For minor depression, the optimal cut-off score was 8 (sensitivity 71%, specificity 71% and an AUC of 0.74). For major depression, the optimal cut-off score was 10 resulting in a sensitivity of 84%, a specificity of 82%, and an AUC of 0.88. The positive predictive value of the PHQ-9 algorithm for diagnosing minor and major depression was 25% and 33%, respectively., Limitations: Two main limitations apply. MINI Interviewers were not blinded for PHQ-9 scores and less than 10% of all invited patients could be included in the analyses. This could have resulted in biased outcomes., Conclusions: The PHQ-9 sum score performs well in identifying patients at high risk of minor and major depression. However, the PHQ-9 showed suboptimal results for diagnostic purposes. Therefore, it is recommended to combine the use of the PHQ-9 with further diagnostics to identify depression., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: In this study, we aimed to examine somatisation as a risk factor for the onset of depressive and anxiety disorders., Methods: 4-year follow-up data from the Netherlands Study of Depression and Anxiety (NESDA), a multisite cohort study of the course of depression and anxiety, was analysed. Participants (18-65 years) without a lifetime depressive or anxiety disorder at baseline were included (n=611). Somatisation was measured at baseline with the somatisation subscale of the 4 Dimensional Symptoms Questionnaire. Onset of depression and anxiety was assessed with the CIDI interview at 2-year and 4-year follow-up., Results: Somatisation was a risk factor for the incidence of depression [Hazard Ratio per unit increase (HR); 95% Confidence Interval (CI): 1.13; 1.09-1.17] and anxiety [HR; 95% CI: 1.14; 1.09-1.18]. Associations attenuated but remained statistically significant after adjusting for socio-demographic characteristics, chronic somatic disorders, and baseline levels of (subclinical) depressive or anxiety symptoms [adjusted HR for depression; 95% CI: 1.06; 1.00-1.12, adjusted HR for anxiety; 95% CI: 1.13; 1.07-1.20]., Conclusion: Persons who somatise have an increased risk of becoming depressed or anxious in subsequent years, over and above baseline levels of depressive or anxiety symptoms. They may represent a target group for prevention of depressive and anxiety disorders., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Although depression and loneliness are common among older adults, the role of loneliness on the prognosis of late-life depression has not yet been determined. Therefore, we examined the association between loneliness and the course of depression., Methods: We conducted a 2-year follow-up study of a cohort from the Netherlands Study of Depression in Older Persons (NESDO). This included Dutch adults aged 60-90 years with a diagnosis of major depression, dysthymia, or minor depression according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. We performed regression analyses to determine associations between loneliness at baseline and both severity and remission of depression at follow-up. We controlled for potential confounders and performed multiple imputations to account for missing data., Results: Of the 285 respondents, 48% were still depressed after 2 years. Loneliness was independently associated with more severe depressive symptoms at follow-up (beta 0.61; 95% CI 0.12-1.11). Very severe loneliness was negatively associated with remission after 2 years compared with no loneliness (OR 0.25; 95% CI 0.08-0.80)., Limitations: Despite using multiple imputation, the large proportion of missing values probably reduces the study's precision. Generalizability to the general population may be limited by the overrepresentation of ambulatory patients with possibly more persistent forms of depression., Conclusion: In this cohort, the prognosis of late-life depression was adversely affected by loneliness. Health care providers should seek to evaluate the degree of loneliness to obtain a more reliable assessment of the prognosis of late-life depression., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: Major depression is a great burden on society, as it is associated with high disability/costs. The aim of this study was to evaluate the cost-utility of Collaborative Care (CC) for major depressive disorder compared to Care As Usual (CAU) in a primary health care setting from a societal perspective., Methods: A cluster randomized controlled trial was conducted, including 93 patients that were identified by screening (45-CC, 48-CAU). Another 57 patients were identified by the GP (56-CC, 1-CAU). The outcome measures were TiC-P, SF-HQL and EQ-5D, respectively measuring health care utilization, production losses and general health related quality of life at baseline three, six, nine and twelve months. A cost-utility analysis was performed for patients included by screening and a sensitivity analysis was done by also including patients identified by the GP., Results: The average annual total costs was €1131 (95% C.I., €-3158 to €750) lower for CC compared to CAU. The average quality of life years (QALYs) gained was 0.02 (95% C.I., -0.004 to 0.04) higher for CC, so CC was dominant from a societal perspective. Taking a health care perspective, CC was less cost-effective due to higher costs, €1173 (95% C.I., €-216 to €2726), of CC compared to CAU which led to an ICER of 53,717 Euro/QALY. The sensitivity analysis showed dominance of CC., Conclusion: The cost-utility analysis from a societal perspective showed that CC was dominant to CAU. CC may be a promising treatment for depression in the primary care setting. Further research should explore the cost-effectiveness of long-term CC., Trial Registration: Netherlands Trial Register ISRCTN15266438., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Previous research has shown socioeconomic inequality in prevalence and onset of depressive disorders. It is not yet clear whether perceived financial strain is associated with depressive and/or anxiety disorders in addition to an objective indicator, such as income. This study examines whether financial strain is associated with the prevalence and onset/recurrence of depressive and/or anxiety disorders, above income., Methods: Data are from the Netherlands Study of Depression and Anxiety. Associations between financial strain, income and presence of depressive and/or anxiety disorder at baseline were assessed among 2937 participants (18-65 years). Impact of financial strain and income on 4-year onset/recurrence of depressive and/or anxiety disorders were examined among 1250 participants without a depressive or anxiety disorder at baseline. Depressive and anxiety disorders were determined with the Composite-International-Diagnostic-Interview. Financial strain and income were assessed in an interview., Results: Participants with mild or severe financial strain had higher odds of being depressed (OR=1.68, 95% CI 1.35 to 2.09; OR=3.88, 95% CI 2.58 to 5.81) or remitted (OR=1.56, 95% CI 1.24 to 1.96; OR=1.99, 95% CI 1.27 to 3.11) at baseline compared with healthy controls, after adjusting for income. Mild or severe financial strain was not associated with onset/recurrence of depressive and/or anxiety disorders during follow-up (OR=1.08, 95% CI 0.83 to 1.42; OR=1.05, 95% CI 0.64 to 1.73)., Conclusions: Financial strain was associated with having a depressive and/or anxiety disorder, above the effect of income. Healthcare and social services should be alert to this association, even for higher income households. However, financial strain and income were not related with 4-year onset/recurrence of depressive and/or anxiety disorders., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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: Major depression is probably best seen as a chronically recurrent disorder, with patients experiencing another depressive episode after remission. Therefore, attention to reduce the risk of relapse or recurrence after remission is warranted. The aim of this review is to meta-analytically examine the effectiveness of psychological interventions to reduce relapse or recurrence rates of depressive disorder., Methods: We systematically reviewed the pertinent trial literature until May 2014. The random-effects model was used to compute the pooled relative risk of relapse or recurrence (RR). A distinction was made between two comparator conditions: (1) treatment-as-usual and (2) the use of antidepressants. Other sources of heterogeneity in the data were explored using meta-regression., Results: Twenty-five randomised trials met inclusion criteria. Preventive psychological interventions were significantly better than treatment-as-usual in reducing the risk of relapse or recurrence (RR=0.64, 95% CI=0.53-0.76, z=4.89, p<0.001, NNT=5) and also more successful than antidepressants (RR=0.83, 95% CI=0.70-0.97, z=2.40, p=0.017, NNT=13). Meta-regression showed homogeneity in effect size across a range of study, population and intervention characteristics, but the preventive effect of psychological intervention was usually better when the prevention was preceded by treatment in the acute phase (b=-1.94, SEb=0.68, z=-2.84, p=0.005)., Limitations: Differences between the primary studies in methodological design, composition of the patient groups and type of intervention may have caused heterogeneity in the data, but could not be evaluated in a meta-regression owing to poor reporting., Conclusions: We conclude that there is supporting evidence that preventive psychological interventions reduce the risk of relapse or recurrence in major depression., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objectives: Many older adults have significant depressive symptoms but few people access care for these. This study explores which personal, clinical and need factors facilitate or hinder acceptance of a new outreaching preference-led intervention programme., Methods: From a sample of 9661 community-dwelling 65+ year olds, 244 persons with depressive symptoms according to the Patient Health Questionnaire-9 were included. Data on programme effectiveness in terms of care utilisation were collected. Associations between programme acceptance and personal, clinical and need factors were studied using quantitative (logistic regression analyses) and qualitative methods (semi-structured interviews with 26 subjects, who accepted (n = 20) or declined (n = 6) the programme)., Results: Fifty-six per cent (n = 137) took part in the interventions. Quantitative logistic regression analyses showed that participants were more often female, suffered from more severe depressive symptoms and perceived more loneliness. Qualitative analyses revealed that people accepting the intervention programme felt that medical terms as having a depressed mood were applicable to their situation, more often perceived their symptoms as hindering, felt lonely and more often perceived a need for care. They were more often advised by their general practitioner to participate than individuals who refused the interventions. Many participating individuals did not see a match between the intervention programme and their needs, especially with respect to meeting new people., Conclusion: Many older persons with depressive symptoms did not feel the need to take part in the programme. Providing support in alleviating loneliness and further adaptation to older adults' illness representations and perceptions when discussing depressive symptoms might enhance care utilisation.

Objective: Many patients with depression and/or anxiety (D/A) persistently report pain. However, it is not clear how the course of D/A is associated with pain over time. The present study assessed longitudinal associations between D/A and pain, and compared pain over time between D/A and healthy controls., Methods: 2676 participants of the Netherlands Study of Depression and Anxiety were followed-up for four years. At three waves (baseline, 2, 4years) we assessed depressive and anxiety symptom severity. Using DSM-IV criteria, we also assessed four different D/A disorder courses over time (n=2093): incident, remitted, chronic, and no D/A (reference group). Pain was assessed at the three waves by severity and number of locations., Results: Change in D/A symptoms was positively associated with change in pain symptoms. Compared to healthy controls (n=519), D/A subjects - incident (n=333), remitted (n=548) or chronic (n=693) - reported more severe pain (b=0.4-0.7, p<0.001) and more pain locations (b=0.8-1.4, p<.001) at all waves, with the highest ratings in chronic D/A. Remission of D/A during follow-up was associated with a significant decline in pain (severity; p=0.002, number of locations; p<.001), but pain levels remained significantly higher compared to healthy controls. Findings were similar for separate depression or anxiety course., Conclusions: This study largely confirms synchrony of change between depression, anxiety and pain. However, even after depression and anxiety remission, subjects report higher pain ratings over time. Individuals with D/A (history) seem to be at increased risk of chronic pain., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: To compare alcohol use between depressed and nondepressed older adults, and to investigate correlates of alcohol abstinence and at-risk alcohol consumption in depressed older adults., Design: Cross-sectional study., Setting: Netherlands Study of Depression in Older Persons (NESDO)., Participants: A total of 373 participants (mean [standard deviation] age: 70.6 [7.3] years; 66% women) diagnosed with a depressive disorder, and 128 nondepressed participants., Measurements: Alcohol use was assessed with the Alcohol Use Disorders Identification Test (AUDIT). Participants were categorized into abstainers (AUDIT score: 0), moderate drinkers (AUDIT score: 1-4), and at-risk drinkers (AUDIT score: ≥5). Multinomial logistic regression analysis was performed with AUDIT categories as outcome, and demographic, social, somatic, and psychological variables as determinants., Results: The depressed group consisted of 40.2% abstainers, 40.8% moderate drinkers, and 19.0% at-risk drinkers. The depressed participants were more often abstinent and less often moderate drinkers than the nondepressed participants; they did not differ in at-risk drinking. Depressed abstainers more often used benzodiazepines but less often used antidepressants, and they had a poorer cognitive function than depressed moderate drinkers. Depressed at-risk drinkers were more often smokers and had fewer functional limitations but more severe depressive symptoms than depressed moderate drinkers., Conclusions: Although alcohol abstinence was more common in depressed than in nondepressed older adults, 19% of depressed persons were at-risk drinkers. Because at-risk drinking is associated with more severe depression and may have a negative impact on health and treatment outcome, it is important that physicians consider alcohol use in depressed older adults., (Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Depression and anxiety are common in residents of elderly homes. Both disorders have negative effects on functioning, well-being and health-care utilisation. Besides treatment, prevention can be an option to reduce the burden of mental disorders. The objective of this study was to evaluate the cost-effectiveness of a stepped care programme to prevent the onset of depression and anxiety disorders in residents of elderly homes compared with usual care from a societal perspective., Methods: Outcomes were incidence of depression and/or anxiety, severity of depressive and anxiety symptoms and quality-adjusted life years. Health-care utilisation was measured during interviews. Multiple imputation was used to impute missing cost and effect data. Uncertainty around cost differences and incremental cost-effectiveness ratios was estimated using bootstrapping. Cost-effectiveness planes and acceptability curves were created., Results: The incidence of depression and anxiety combined in the intervention group was not reduced in comparison with the usual care group. There was also no effect on the other outcomes. Mean total costs in the intervention group were €838 higher than in the usual care group, but this difference was not statistically significant (95% confidence interval, -593 to 2420). Cost-effectiveness planes showed that there was considerable uncertainty. Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective in comparison with usual care was 0.46 for reducing the incidence of depression and anxiety combined., Conclusion: A stepped care programme to prevent depression and anxiety in older people living in elderly homes was not considered cost-effective in comparison with usual care., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objectives: The objective of this study was to evaluate the 2-year effects of a stepped-care programme to prevent the onset of a major depressive disorder (MDD) in older people living in residential homes., Methods: A 2-year follow-up study of a pragmatic randomised controlled trial was conducted in 14 residential homes in the Netherlands. A total of 185 residents (Center for Epidemiologic Studies Depression Scale score >7), who did not meet the diagnostic criteria for MDD, were randomised to a stepped-care programme (n = 93) or to usual care (n = 92). Stepped-care participants sequentially underwent watchful waiting, a self-help intervention, life review and a consultation with the general practitioner. The primary outcome measure was the incidence of MDD during a period of 2 years, according to the Mini International Neuropsychiatric Interview., Results: After 2 years, the incidence of MDD was not significantly reduced in the intervention group compared with the control group (incidence rate ratio: 0.98; 95% confidence interval (CI) [0.54, 1.81]). However, in the completer analysis, on the basis of 79 residents who completed the 2-year measurements, there was a significant difference in favour of the intervention group (incidence rate ratio: 0.53; 95% CI [0.32, 0.87]). Dropout percentages were high (44%), mostly accounted for by illness and death (68%)., Conclusion: A minority of residents had benefit from the intervention that sustained after 2 years in the completer group. Yet, these findings cannot be generalised as the majority of the residents did not opt for participation in the project and many dropped out. Ways should be sought to motivate residents with depressive symptoms to engage in preventive interventions., (Copyright © 2013 John Wiley & Sons, Ltd.)

Patients with pain may be at increased risk of developing a first episode of depressive or anxiety disorder. Insight into possible associations between specific pain characteristics and such a development could help clinicians to improve prevention and treatment strategies. The objectives of this study were to examine the impact of pain symptomatology on depression and anxiety onset and to determine whether these associations are independent of subthreshold depressive and anxiety symptoms. Data from the Netherlands Study of Depression and Anxiety, collected between 2004 and 2011, were used. A total of 614 participants with no previous history and no current depression or anxiety at baseline were followed up for 4 years. Onset of depressive or anxiety disorder was assessed at 2- and 4-year follow-up by Composite International Diagnostic Interview. Baseline pain characteristics were location, duration, and severity, as assessed by chronic pain grade. Onset of depressive or anxiety disorder occurred in 15.5% of participants. Using Cox survival analyses, onset of depression and anxiety was associated with 6 pain locations (neck, back, head, orofacial area, abdomen, and joints; hazard ratio [HR]=1.96 to 4.02; P<.05), increasing number of pain locations (HR=1.29; P<.001), and higher severity of pain (HR=1.57; P<.001). By contrast, there was no association with duration of pain symptoms (HR=1.47; P=.12). Independent of subthreshold affective symptoms, only joint pain and increasing number of pain locations were still significantly associated with depression and anxiety onset. Clinicians should be aware that regardless of affective symptoms, pain, particularly at multiple locations, is a risk indicator for developing depressive and anxiety disorders., (Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Recognition of depression and anxiety by general practitioners (GPs) is suboptimal and there is uncertainty as to whether particular somatic health problems hinder or facilitate GP recognition. The objective of this study was to investigate the associations between somatic health problems and GP recognition of depression and anxiety., Methods: We studied primary care patients with a DSM-IV based psychiatric diagnosis of depressive or anxiety disorder during a face-to-face interview (n=778). GPs' registrations of depression and anxiety diagnoses, based on medical file extractions, were compared with the DSM-IV based psychiatric diagnoses as reference standard. Somatic health problems were based on self-report of several chronic somatic diseases and pain symptoms, using the Chronic Pain Grade (CPG), during the interview., Results: Depression and anxiety was recognized in sixty percent of the patients. None of the health problems were negatively associated with recognition. Greater severity of pain symptoms (OR=1.18, p=.02), and chest pain (OR=1.56, p=.02), in particular, were associated with more GP recognition of depression and anxiety. Mediation analyses showed that depression and anxiety in these patients were better recognized through the presence of more severe psychiatric symptoms., Limitations: Some specific chronic diseases had low prevalence., Conclusions: This study shows that the presence of particular chronic diseases does not influence GP recognition of depression and anxiety. GPs tend to recognize depression and anxiety better in patients with pain symptoms, partly due to more severe psychiatric symptoms among those with pain., (© 2013 Elsevier B.V. All rights reserved.)

Purpose: Although numerous studies have identified risk factors for sickness absence, few studies have addressed the role of personality characteristics in absenteeism. The aim of this study was to examine the associations of the Big 5 personality characteristics (neuroticism, extraversion, openness, agreeableness and conscientiousness) and locus of control with absenteeism, taking the presence of depressive and anxiety disorders into account., Methods: Cross-sectional data from the baseline measurement of the Netherlands Study of Depression and Anxiety (NESDA) were examined. NESDA includes persons with current or remitted depressive and anxiety disorders and healthy controls, of which 1883 working participants were selected. Personality characteristics were included as predictor variables, short-term (0-2 weeks) and long-term (>2 weeks) absenteeism as outcome measure. The presence of depressive and anxiety disorders was considered as modifying covariate., Results: In healthy workers, high neuroticism, external locus of control, low extraversion, low agreeableness and low conscientiousness were associated with short-term absenteeism. In addition, high neuroticism, low extraversion and low openness were related to long-term absenteeism in healthy workers. In workers with psychopathology, similar associations were found for persons with this profile (high neuroticism, external locus of control, low extraversion and low conscientiousness) with long-term absenteeism, but no associations of these characteristics were found with short-term absenteeism., Conclusions: Personality characteristics were significantly associated with work absenteeism in both workers with and without anxiety or depression. Interventions aimed at preventing sickness absence may focus on reducing neuroticism and strengthening extraversion, conscientiousness and locus of control.

Background: Practice variation in the primary care treatment of depression may be considerable in the Netherlands, due to relatively small and unregulated practices. We adapted the collaborative care model for the treatment of Major Depressive Disorder (MDD) to accommodate existing practice variation and tested whether this had added value over Care as Usual (CAU)., Methods: A cluster randomized controlled trial was conducted to compare an adapted target driven collaborative care model with Care as Usual (CAU). Randomization was at the level of 18 (sub)urban primary care centers. The care manager and GP were supported by a web-based tracking and decision aid system that advised targeted treatment actions to achieve rapid response and if possible remission, and that warned the consultant psychiatrist if such treatment advice was not followed up. Eligible patients had a score of 10 or higher on the PHQ9, and met diagnostic criteria for major depression at the subsequent MINI Neuropsychiatric interview. A total of 93 patients were identified by screening. They received either collaborative care (CC) or CAU. Another 56 patients received collaborative care after identification by the GP. The outcome measures were response to treatment (50% or greater reduction of the PHQ9-total score from baseline) at three, six, nine and twelve months, and remission (a score of 0-4 on the PHQ9 at follow-up)., Results: Treatment response and remission in CAU were low. Collaborative care was more effective on achieving treatment response than CAU at three months for the total group of patients who received collaborative care [OR 5.2 ((1.41-16.09), NNT 2] and at nine months [OR 5.6 ((1.40-22.58)), NNT 3]. The effect was not statistically significant at 6 and 12 months., Limitations: A relatively high percentage of patients (36.5%) did not return one or more follow-up questionnaires. There was no evidence for selective non response., Conclusions: Our adapted target driven CC was considerably more effective than CAU for MDD in primary care in the Netherlands. The Numbers Needed To Treat (NNT) to achieve response in one additional patient were low (2-3), which suggest that introducing CC at a larger scale may be beneficial. The relatively large effects may be due to our focus on reducing practice variation through the introduction of easy to use web based tracking and decision aids. The findings are highly relevant for the application of the model in areas where practices tend to be small and for mixed healthcare systems such as in many countries in Europe., Trial Registration: Dutch trial register ISRCTN15266438 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=820)., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Depressive and anxiety disorders are highly overlapping, heterogeneous conditions that both have been associated with an increased risk of cardiovascular disease (CVD). Cognitive vulnerability traits for these disorders could help to specify what exactly drives CVD risk in depressed and anxious subjects. Our aim is to examine sensitivity to depression or anxiety in association with indicators of subclinical CVD., Methods: Data from 635 participants (aged 20-66 years) of the Netherlands Study of Depression and Anxiety were analyzed. Depression sensitivity was measured by the revised Leiden Index of Depression Sensitivity. Anxiety sensitivity was measured by the Anxiety Sensitivity Index. Subclinical CVD was measured as (1) carotid intima-media thickness and plaque presence using B-mode ultrasonography and (2) central arterial stiffness (augmentation index) using calibrated radial applanation tonometry., Results: After adjustment for sociodemographics, blood pressure, and LDL cholesterol, higher scores of anxiety sensitivity were associated with both increased likelihood of carotid plaques (OR per SD increase=1.34, 95%CI=1.06-1.68) and increased arterial stiffness (β=.06, p=.01). No significant associations were found with carotid intima-media thickness nor for depression sensitivity., Limitations: The cross-sectional design precludes causal inference. Current mood state could have influenced the self-reported sensitivity data., Conclusions: The presence of carotid plaques and central arterial stiffness was especially increased in subjects who tend to be highly fearful of anxiety-related symptoms. These observations suggest that vulnerability to anxiety, rather than to depression, represents a correlate of subclinical CVD., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Aim: To assess to what extent a high physical symptom count influences the effect of treatment for major depressive disorder (MDD), and whether or not actual comorbid medical conditions explain this relationship., Method: Secondary data-analysis on a cluster-randomized trial in primary care, comparing the effectiveness of collaborative care with care as usual (CAU). MDD was measured using the PHQ-9. The Physical Symptoms Questionnaire (PSQ) was filled out at baseline by 115 patients (77.2% of those who entered the trial). Multilevel logistic regression models were used to test whether a high physical symptom count predicted lack of response to treatment, adding interaction terms to test differential effects on collaborative care versus CAU., Results: A high physical symptom count negatively influenced the effect of both collaborative care and care as usual (no interaction). Specifically, a high physical symptom count predicted lack of response in both conditions at 3 (odds ratio=6.8), 6 (OR=4.1), and 9 months follow-up (OR=6.4). This was not explained by chronic physical illness., Conclusion: In this RCT, patients with MDD accompanied by a high physical symptom count benefited less from treatment for MDD in primary care, regardless of the type of treatment (either collaborative care or CAU). This was not explained by the presence of comorbid medical conditions. Further research is needed to improve treatment for MDD accompanied by a high physical symptom count, although collaborative care for depression is still more effective than CAU for this group of patients., Trial Registration: Dutch trial register ISRCTN15266438., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this study is to review recent evidence of the effects of enhanced depression care, focusing (1) on symptomatic, functional and economic outcomes and (2) across different countries, (3) ethnic groups and (4) settings., Recent Findings: Collaborative care is currently by far the most influential and best studied method to enhance depression care. Recent trials and reviews provide firm evidence that collaborative care is more effective than care as usual (CAU), though with small effects. These effects generalized across several important health outcomes are probably more pronounced in patients with more complex or severe disorders. Cost-effectiveness and cost utility data demonstrate that collaborative care is of good value for money, and this is probably more pronounced in patients with higher a-priori levels of healthcare utilization. Collaborative care is readily exported to other healthcare systems, other regions of the world and other cultures., Summary: Given parallel development and successful testing of other cheaper and more simple interventions targeting depression (such as guided self-help and e-mental health), it may be that collaborative care will focus on the more severe, complex or recurrent forms of affective disorder in the future. Including effects of collaborative care on other outcomes, especially on work-related functioning and economic productivity, seems fruitful.

Background: Major Depressive Disorder (MDD) is common among elderly people. However, it appears that only a minority receives treatment. This study aims to identify and analyse the factors that determine whether elderly people with depressive disorders have contact with health care professionals for mental problems., Method: Cross-sectional analysis of cohort data collected in the Netherlands Study of Depression in Older persons (NESDO) and the Netherlands Study of Depression and Anxiety (NESDA) among 167 respondents aged ≥55 with a depressive disorder as indicated by the CIDI. Contacts for mental health problems during the past six months (TiC-P), and indicators of predisposing, enabling, and objective need factors were assessed by interview., Results: Of the total sample, 70% had contact for mental health problems, almost entirely within primary care (62%). The odds of having contact increased with advancing age; for respondents born in the Netherlands; for those who felt less lonely; and for those with a higher household income., Limitations: Our study is based on base-line interviews and thus has a cross-sectional character. Therefore, causal conclusions cannot be drawn. Furthermore, we studied the respondents' perception whether mental health care was received., Conclusions: The contact rate for mental health problems is high. Health care professionals should be aware that having contact is not associated with a higher objective need, but rather with increasing age, being Dutch-born, being less lonely and having a higher household income., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Anxiety disorders are highly prevalent in primary care and cause a substantial burden of disease. Screening on risk status, followed by preventive interventions in those at risk may prevent the onset of anxiety disorders, and thereby reduce the disease burden. The willingness to participate in screening and interventions is crucial for the scope of preventive strategies, but unknown. This feasibility study, therefore, investigated participation rates of screening and preventive services for anxiety disorders in primary care, and explored reasons to refrain from screening., Methods: In three general practices, screening was offered to individuals visiting their general practitioner (total n = 2454). To assess risk status, a 10-item questionnaire was followed by a telephone interview (including the CIDI) when scoring above a predefined threshold. Preventive services were offered to those at risk. Participation rates for screening and preventive services for anxiety disorders were assessed. Those not willing to be screened were asked for their main reason to refrain from screening., Results: Of all individuals, 17.3% participated in initial screening, and of those with a possible risk status, 56.0% continued screening. In 30.1% of those assessed, a risk status to develop an anxiety disorder was verified. Of these, 22.6% already received some form of mental health treatment and 38.7% of them agreed to participate in a preventive intervention and were referred. The most frequently mentioned reasons to refrain from screening were the emotional burden associated with elevated risk status, the assumption not to be at risk, and a lack of motivation to act upon an elevated risk status by using preventive services., Conclusions: Screening in general practice, followed by offering services to prevent anxiety disorders in those at risk did not appear to be a feasible strategy due to low participation rates. To enable the development of feasible and cost-effective preventive strategies, exploring the reasons of low participation rates, considering involving general practitioners in preventive strategies, and looking at preventive strategies in somatic health care with proven feasibility may be helpful.

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: The aim of this study was to evaluate the effectiveness of a stepped-care program to prevent the onset of depression and anxiety disorders in elderly people living in residential homes., Methods: A pragmatic randomized controlled trial was conducted to compare the intervention with usual care in 14 residential homes in the Netherlands. A total of 185 residents with a minimum score of 8 on the Centre for Epidemiologic Studies Depression Scale, who did not meet the diagnostic criteria for a depressive or anxiety disorder, and were not suffering from severe cognitive impairment, were recruited between April 2007 and December 2008. They were randomized to a stepped-care program (N = 93) or to usual care (N = 92). The stepped-care participants sequentially underwent watchful waiting, a self-help intervention, life review, and a consultation with the general practitioner. The primary outcome measure was the incidence of a major depressive disorder (MDD) or anxiety disorder during a period of one year according to the Mini International Neuropsychiatric Interview., Results: The intervention was not effective in reducing the incidence of the combined outcome of depression and anxiety (incidence rate ratio (IRR) = 0.50; 95% confidence interval (CI) = 0.23-1.12). However, the intervention was superior to usual care in reducing the risk of MDD incidence (IRR = 0.26; 95% CI = 0.12-0.80) contrary to anxiety incidence (IRR = 1.32; 95% CI = 0.48-3.62)., Conclusions: These results suggest that the stepped-care program is effective in reducing the incidence of depression, but is not effective in preventing the onset of anxiety disorders in elderly people living in residential homes.

Background: Major Depressive Disorder is a leading cause of disability, tends to run a recurrent course and is associated with substantial economic costs due to increased healthcare utilization and productivity losses. Interventions aimed at the prevention of recurrences may reduce patients' suffering and costs. Besides antidepressants, several psychological treatments such as preventive cognitive therapy (PCT) are effective in the prevention of recurrences of depression. Yet, many patients find long-term use of antidepressants unattractive, do not want to engage in therapy sessions and in the primary care setting psychologists are often not available. Therefore, it is important to study whether PCT can be used in a nurse-led self-help format in primary care. This study sets out to test the hypothesis that usual care plus nurse-led self-help for recurrent depression in primary care is feasible, acceptable and cost-effective compared to usual care only., Design: Patients are randomly assigned to 'nurse-led self-help treatment plus usual care' (134 participants) or 'usual care' (134 participants). Randomisation is stratified according to the number of previous episodes (2 or 3 previous episodes versus 4 or more). The primary clinical outcome is the cumulative recurrence rate of depression meeting DSM-IV criteria as assessed by the Structured-Clinical-Interview-for-DSM-IV- disorders at one year after completion of the intervention. Secondary clinical outcomes are quality of life, severity of depressive symptoms, co-morbid psychopathology and self-efficacy. As putative effect-moderators, demographic characteristics, number of previous episodes, type of treatment during previous episodes, age of onset, self-efficacy and symptoms of pain and fatigue are assessed. Cumulative recurrence rate ratios are obtained under a Poisson regression model. Number-needed-to-be-treated is calculated as the inverse of the risk-difference. The economic evaluation is conducted from a societal perspective, both as a cost-effectiveness analysis (costs per depression free survival year) and as a cost-utility analysis (costs per quality adjusted life-year)., Discussion: The purpose of this paper is to outline the rationale and design of a nurse-led, cognitive therapy based self-help aimed at preventing recurrence of depression in a primary care setting. Only few studies have focused on psychological self-help interventions aimed at the prevention of recurrences in primary care patients., Trial Registration: NTR3001 (http://www.trialregister.nl).

Background: Although most depressed patients are treated in primary care, not all are recognized as such. This study explores the determinants of (non-)recognition of depression by general practitioners (GPs), with a focus on specific depression symptoms as possible determinants., Methods: Recognition of depression by GPs was investigated in 484 primary care participants of the Netherlands Study of Depression and Anxiety, with a DSM-IV diagnosis of depression in the past year. Recognition (yes/no) by GPs was based on medical file extractions (GP diagnosis of depressive symptoms/depressive disorder and/or use of antidepressants/referral to mental health care). Potential determinants of (non-)recognition (patient, depression, patient-GP interaction, and GP characteristics) were bivariately tested and variables with a p-value ≤0.2 entered into a multilevel multivariate model. Subgroup analysis was performed on 361 respondents with more reliable GP diagnosis data., Results: 60.5% of patients were recognized by their GP. Patients who did not consult their GP for mental problems, and without comorbid anxiety disorder(s) were less often recognized. In the subgroup, where 68.7% was recognized, in addition to these, decreasing number of symptoms of depression and increased appetite were associated with decreased recognition. No GP characteristics were retained in the final model., Limitations: Some data on recognition were collected retrospectively., Conclusions: In addition to patients without a comorbid anxiety disorder or who did not consult their GP for mental problems, GPs less often recognized patients with fewer depression symptoms or with increased appetite. Recognition may be improved by informing/teaching GPs that also increased appetite can be a symptom of depression., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: Optimising care for dementia patients and their informal carers is imperative in light of the impending dementia epidemic. An important aspect of care is accurate recognition and diagnosis of dementia. The aim of this review was to estimate family physicians' diagnostic accuracy at the different stages of dementia., Methods: Pubmed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched for articles comparing family physicians' 'dementia' and 'cognitive impairment' diagnoses in the primary care setting to reference standard dementia diagnoses., Results: Data from six cross-sectional studies of moderate to reasonable methodological quality were extracted for the analysis. One study considered the accuracy of family physicians' recollected diagnoses, and three studies focussed on documented diagnoses. In these four studies, the sensitivity of family physicians' combined diagnostic categories of 'cognitive impairment' together with 'dementia' was 0.48-0.67 for mild dementia and 0.76-0.85 for moderate to severe dementia. The sensitivity of their diagnostic category 'dementia' alone was 0.14-0.33 for mild and 0.28-0.61 for moderate to severe dementia. Specificity was excellent for all severity stages in both comparisons. Three studies examined the accuracy of family physicians' judgement of cognition during consultation. Compared with the studies on recollection and documentation, these studies reported higher sensitivity and lower specificity., Conclusion: Many individuals with dementia are not recognised or not diagnosed as such; particularly mild dementia is under-diagnosed. Collaboration within primary care and education focussing both on knowledge and attitude are recommended to improve the accuracy of family physicians' dementia diagnosis., (Copyright © 2011 John Wiley & Sons, Ltd.)

The combination of pain and depression or anxiety is commonly seen in clinical practice. Little is known about the influence of pain on psychopathology over time, as previous studies have been mainly cross-sectional. The objectives of this study are to determine the impact of pain on the course of depressive and/or anxiety disorders, and investigate to what extent the association between pain and course of these mental disorders is mediated by psychiatric characteristics. Data from the Netherlands Study of Depression and Anxiety (NESDA), collected between 2004 and 2009, were used. A total of 1209 participants with a depressive and/or anxiety disorder at baseline were followed up for 2 years. Baseline pain was assessed by location, duration, use of pain medication, and severity (based on Chronic Pain Grade). Course of depressive and anxiety disorders was assessed by Composite International Diagnostic Interview (CIDI) and Life Chart Interview. A higher number of pain locations (OR=1.10; P=.008), joint pain (OR=1.64; P<.001), ≥ 90 days of pain (OR=1.40; P=.009), daily use of pain medication (OR=1.57; P=.047), and a higher Chronic Pain Grade score (OR=1.27; P<.001) were associated with worse course of depressive and anxiety disorders. These associations were largely mediated by baseline severity of the mental disorder. However, joint pain remained associated with a worse course independent of baseline psychiatric characteristics. This study shows that patients with pain are more prone to a chronic course of depressive and anxiety disorders. More attention to pain seems to be necessary when diagnosing and treating these disorders. Future research should focus on treatment modalities for this co-occurrence, with joint pain in particular., (Copyright © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)