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Objective: This study determined the gap between actual care and optimal care (recommended in the clinical guideline) for patients with borderline personality disorder in the Netherlands. Factors that affected guideline implementation were identified.Methods: Ten specialized mental health organizations participated in this cross-sectional study. The number and proportion of patients who received optimal diagnosis and treatment were calculated. Focus groups explored implementation barriers.Results: Records of 422 patients with a diagnosis of borderline personality disorder were analyzed, and 315 records from six organizations contained the necessary data. Across the six organizations, most of these patients received this as an initial diagnosis (median 85%). However, only a minority received psychotherapy as a first-step treatment (median 23%). Capacity problems and organizational barriers were the main barriers to providing psychotherapy.Conclusions: Most patients with borderline personality disorder did not receive the recommended first-step treatment (psychotherapy). Care pathways may help improve efficiency and quality of care. [ABSTRACT FROM AUTHOR]

Objective: Borderline personality disorder affects up to 2% of the population and is associated with poor functioning, low quality of life and increased mortality. Psychotherapy is the treatment of choice, but it is unclear whether specialized psychotherapies (dialectical behavior therapy, mentalization-based treatment, transference-focused therapy and schema therapy) are more effective than non-specialized approaches (e.g. protocolized psychological treatment, general psychiatric management). The aim of this systematic review is to investigate the effectiveness of these psychotherapies., Methods: PubMed, PsycINFO, CINAHL, EMBASE and CENTRAL were searched from inception to November 2017. Included randomized controlled trials were assessed on risk of bias and outcomes were meta-analyzed. Confidence in the results was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Results: A total of 20 studies with 1375 participants were included. Specialized psychotherapies, when compared to treatment as usual or community treatment by experts, were associated with a medium effect based on moderate quality evidence on overall borderline personality disorder severity (standardized mean difference = -0.59 [95% confidence interval: -0.90, -0.28]), and dialectical behavior therapy, when compared to treatment as usual, with a small to medium effect on self-injury (standardized mean difference = -0.40 [95% confidence interval: -0.66, -0.13]). Other effect estimates were often inconclusive, mostly due to imprecision., Conclusion: There is moderate quality evidence that specialized psychotherapies are effective in reducing overall borderline personality disorder severity. However, further research should identify which patient groups profit most of the specialized therapies.

It is important that depressed patients receive adequate and safe care as described in clinical guidelines. The aim of this study was to evaluate the implementation of the Dutch depression guideline for children and adolescents, and to identify factors that were associated with the uptake of the guideline recommendations. The study took place in specialised child and adolescent mental healthcare. An implementation project was initiated to enhance the implementation of the guideline. An evaluation study was performed alongside the implementation project, using structured registration forms and interviews with healthcare professionals. Six multidisciplinary teams participated in the implementation study. The records of 655 patients were analysed. After 1 year, 72% of all eligible patients had been screened for depression and 38% were diagnosed with the use of a diagnostic instrument. The severity of the depression was assessed in 77% of the patients during the diagnostic process, and 41% of the patients received the recommended intervention based on the depression severity. Of the patients that received antidepressants, 25% received weekly checks for suicidal thoughts in the first 6 weeks. Monitoring of the patients' response was recorded in 32% of the patients. A wide range of factors were perceived to influence the uptake of guideline recommendations, e.g. the availability of capable professionals, available time, electronic tools and reminders, and the professionals' skills and attitudes. With the involvement of the teams, recommendations were provided for nationwide implementation of the guideline. In conclusion, a systematic implementation programme using stepped care principles for the allocation of depression interventions seems successful, but there remains room for further improvement.

Background: Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care., Methods: Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire., Results: Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals was considered an important factor for improvement by nearly all GPs., Conclusions: The management of depression in primary care seems in line with stepped care principles, although it can be improved by applying more elements of a stepped care approach. Collaboration between GPs and mental health care providers in primary care and secondary care should be enhanced.

Background: Minor depression is common in primary care and associated with increased health care costs. Many mildly depressed patients are prescribed antidepressants, although there is insufficient information on the cost-effectiveness of antidepressants for these patients. The objective of this study was to evaluate whether usual care without antidepressants is equivalent to (i.e. as effective as and as expensive as) usual care with antidepressants in patients with minor or mild-major depression., Methods: Severity of depression was measured using the Montgomery Asberg Depression Rating Scale (MADRS) and quality-adjusted life-years (QALYs) using the EuroQol. Resource use was measured from a societal perspective using cost diaries. Bootstrapping was used to analyze the cost-effectiveness data., Results: Equivalence could not be shown for improvement in MADRS score or QALYs gained at 52 weeks. The mean (95% CI) difference in total costs between usual care without antidepressants and usual care with antidepressants was -euro751 (-3601; 1522). Using an equivalence margin of euro500 equivalence in costs could not be shown. In the cost-effectiveness analyses equivalence also could not be shown., Limitations: This study was underpowered for economic outcomes. Another limitation was the loss-to-follow-up., Conclusions: Although equivalence could not be shown in the costs and cost-effectiveness analyses, 95% confidence intervals also did not show that usual care without antidepressants was vastly superior or inferior to usual care with antidepressants. Therefore, we recommend general practitioners to show restraint when prescribing antidepressants to mildly depressed patients.

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

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

Background: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire that has been developed in primary care to distinguish non-specific general distress from depression, anxiety and somatization. The purpose of this paper is to evaluate its criterion and construct validity., Methods: Data from 10 different primary care studies have been used. Criterion validity was assessed by comparing the 4DSQ scores with clinical diagnoses, the GPs' diagnosis of any psychosocial problem for Distress, standardised psychiatric diagnoses for Depression and Anxiety, and GPs' suspicion of somatization for Somatization. ROC analyses and logistic regression analyses were used to examine the associations. Construct validity was evaluated by investigating the inter-correlations between the scales, the factorial structure, the associations with other symptom questionnaires, and the associations with stress, personality and social functioning. The factorial structure of the 4DSQ was assessed through confirmatory factor analysis (CFA). The associations with other questionnaires were assessed with Pearson correlations and regression analyses., Results: Regarding criterion validity, the Distress scale was associated with any psychosocial diagnosis (area under the ROC curve [AUC] 0.79), the Depression scale was associated with major depression (AUC = 0.83), the Anxiety scale was associated with anxiety disorder (AUC = 0.66), and the Somatization scale was associated with the GPs' suspicion of somatization (AUC = 0.65). Regarding the construct validity, the 4DSQ scales appeared to have considerable inter-correlations (r = 0.35-0.71). However, 30-40% of the variance of each scale was unique for that scale. CFA confirmed the 4-factor structure with a comparative fit index (CFI) of 0.92. The 4DSQ scales correlated with most other questionnaires measuring corresponding constructs. However, the 4DSQ Distress scale appeared to correlate with some other depression scales more than the 4DSQ Depression scale. Measures of stress (i.e. life events, psychosocial problems, and work stress) were mainly associated with Distress, while Distress, in turn, was mainly associated with psychosocial dysfunctioning, including sick leave., Conclusion: The 4DSQ seems to be a valid self-report questionnaire to measure distress, depression, anxiety and somatization in primary care patients. The 4DSQ Distress scale appears to measure the most general, most common, expression of psychological problems.

Background: The Montgomery Asberg Depression Rating Scale (MADRS) is a frequently used observer-rated depression scale. In the present study, a telephonic rating was compared with a face-to-face rating in 66 primary care patients with minor or mild-major depression. The aim of the present study was to assess the validity of the administration by telephone. Additional objective was to study the validity of the first item, 'apparent sadness', the only item purely based on observation., Methods: The present study was a validity study. During an in-person interview at the patient's home a trained interviewer administered the MADRS. A few days later the MADRS was administered again, but now by telephone and by a : Mean total score on the in-person administration was 24.0 (SD = 11.1), and on the telephone administration 23.5 (SD = 10.4). The ICC for the full scale was 0.65. Homogeneity analysis showed that the observation item 'apparent sadness' fitted well into the scale., Conclusion: The full MADRS, including the observation item 'apparent sadness', can be administered reliably by telephone.

Minor depression is common in the general population. There is no consensus about prognostic indicators that can identify people at high and low risk of chronicity. We systematically reviewed the available literature on the prognosis of minor depression in the general population and identified five studies. Two of these were considered to be of relatively high methodological quality. There was a wide variety among the studies in the definitions of minor depression, the characteristics of the study population, length of follow-up and type of outcome measure. The results show that the majority of people with minor depression have a favorable prognosis; 46-71.4% achieve remission after a follow-up of 1-6 years. However, 16-62.3% still have a minor depression after 5 months to 1 year of follow-up, suggesting that for many people minor depression is chronic or recurrent; 12.7-27% develop a more severe form of depression; they were diagnosed with dysthymia or major depression after 1-6 years of follow-up. There was inconsistent evidence regarding mortality and functional impairment. No study presented results of prognostic factors, so it remains unclear which people have a more favorable course than others. The results of our review need to be interpreted with caution because of the small number of studies and the large heterogeneity among studies.

There are different kinds of randomised controlled trials: trials in which the superiority of a treatment can be demonstrated (superiority trials) and trials in which the equal efficacy of two treatments can be shown (equivalence trials). The main reason for performing an equivalence trial is that for many diseases and disorders an effective treatment already exists. Equivalence trials are appropriate when a new treatment offers some advantages over an existing treatment (less cost, greater safety, improved convenience or freedom of choice for the patient), in addition to the expected equal therapeutic effectiveness. The design of equivalence trials is to a large extent comparable to that of superiority trials, but there are some methodological differences. In equivalence trials, the null hypothesis and alternative hypothesis are interchanged, compared to superiority trials. In equivalence trials, an equivalence margin is defined for the different treatments. Clinical professionals decide on the equivalence margin beforehand on the basis of the clinical relevance. To demonstrate equivalence, the confidence interval of the difference between two treatments must lie completely within the equivalence margin. In equivalence trials, there are usually more patients needed: the smaller the equivalence margin, the more patients are needed. In equivalence trials, both per-protocol analyses and intention-to-treat analyses should be used to prove the equal therapeutic effectiveness of the treatments under study.