[The relation between sleep problems and the onset and course of anxiety and mood disorders]. / De relatie tussen slaapproblemen en het ontstaan en beloop van angst- en stemmingsstoornissen.

BACKGROUND: Sleep gets little attention in mental health care treatments. Epidemiological research with regards to the association between sleep problems and anxiety and mood disorders can contribute to good clinical decision making. AIM: Based on data from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), we examined the relation between sleep problems and first onset, recurrence and persistence of anxiety and mood disorders within a 3 year period. METHOD: Different groups of respondents were selected to examine the relation between sleep problems and different stages of anxiety and mood disorders within three years. DSM-IV diagnoses were determined using the Composite International Diagnostic Interview (CIDI 3.0) and sleep problems with the Women’s Health Initiative Insomnia Rating Scale (IRS; ≥ 9). Logistic regression was performed. Multivariable analysis took into account a large number of potentially confounding variables. RESULTS: Almost a quarter of the respondents without an anxiety or mood disorder and almost half of the respondents with an anxiety or mood disorder experience sleep problems. In the multivariable analysis, sleep problems were associated with recurrence of an anxiety disorder (OR 2.10; 95% CI 1.31-3.38), but not with the first onset and persistence of an anxiety disorder. Furthermore, sleep problems appear to be associated with the first onset of a mood disorder (OR 2.18; 95% CI 1.27-3.74) and with the persistence of a mood disorder (OR 2.51; 95% CI 1.17-5.37), but not with recurrence of this disorder. CONCLUSION: The results underline the importance of identifying sleep problems of people with (an increased risk of) anxiety and mood disorders. The treatment of sleep problems may contribute to a reduced incidence of these mental disorders and a better and sustainable recovery.

Transdiagnostic factors predicting the 2-year disability outcome in patients with anxiety and depressive disorders.

BACKGROUND: Both anxiety and depressive disorders are associated with significant long-term disability. Since experienced impairments vary between patients independent of diagnosis and disease severity, identifying transdiagnostic factors that predict the course of disability may provide new targets to reduce disability. This study examines transdiagnostic factors predicting the 2-year disability outcome in patients with anxiety and/or depressive disorders (ADD), focusing on potentially malleable factors. METHODS: Six hundred fifteen participants with a current diagnosis of ADD from the Netherlands Study of Depression and Anxiety (NESDA) were included. Disability was assessed at baseline and after 2 years of follow-up, using the 32-item WHODAS II questionnaire. Transdiagnostic predictors of 2-year disability outcome were identified using linear regression analysis. RESULTS: In univariable analyses, transdiagnostic factors associated with the 2-year disability outcome were locus of control (standardized ß = -0.116, p = 0.011), extraversion (standardized ß = -0.123 p = 0.004) and experiential avoidance (standardized ß = 0.139, p = 0.001). In multivariable analysis, extraversion had a unique predictive value (standardized ß = -0.143 p = 0.003). A combination of sociodemographic, clinical and transdiagnostic variables resulted in an explained variance (R2) of 0.090). The explained variance of a combination of transdiagnostic factors was 0.050. CONCLUSION: The studied transdiagnostic variables explain a small but unique part of variability in the 2-year disability outcome. Extraversion is the only malleable transdiagnostic factor predictive of the course of disability independent of other variables. Due to the small contribution to the variance in the disability outcome, the clinical relevance of targeting extraversion seems limited. However, its predictive value is comparable to that of accepted disease severity measures, supporting the importance of looking beyond using disease severity measures as predictors. Furthermore, studies including extraversion in combination with other transdiagnostic and environmental factors may elucidate the unexplained part of variability of the course of disability in patients with ADD.

[The effects of shared decision making in depression: systematic review and meta-analysis]. / Het effect van samen beslissen bij depressie: systematische review en meta-analyse.

BACKGROUND: Shared decision making (SDM) is advised in the treatment guideline for depressive disorders. However, it’s unclear if SDM contributes to the optimization of care. AIM: To provide an overview of the effects of SDM within the treatment of depression on treatment outcome, patient satisfaction and adherence through a meta-analysis and systematic review. METHOD: In a literature search (PubMed, PsycINFO, Embase), randomised controlled studies with patients who suffer from depression or depressive symptoms were selected. The effect of a SDM intervention previous to treatment was compared to no SDM intervention on the outcome measures. Effect sizes were computed with random effects models and risk of bias was assessed. RESULTS: Five studies were included (N = 850). SDM did not result in superior treatment outcome (Cohen’s d = 0.02;
95%-BI:-0.12-0,16; p = 0.773) and adherence (Cohen’s d = 0.29; 95%-BI:-0.01-0.58; p = 0.056). SDM did lead to higher patient satisfaction with a medium-large effect size (Cohen’s d = 0.53; 95%-BI:0,17-0.90; p = .004). CONCLUSION: SDM resulted in higher patient satisfaction, no effects were found regarding treatment outcome and adherence. However, operationalisation of SDM in the studies were variable. SDM appears to be a versatile construct in clinical practice.

Do better nights lead to better days? Guided internet-based cognitive behavioral therapy for insomnia in people suffering from a range of mental health problems: Protocol of a pragmatic randomized clinical trial.

BACKGROUND: Insomnia is the transdiagnostically shared most common complaint in disorders of anxiety, stress and emotion regulation. Current cognitive behavioral therapies (CBT) for these disorders do not address sleep, while good sleep is essential for regulating emotions and learning new cognitions and behaviours: the core fundaments of CBT. This transdiagnostic randomized control trial (RCT) evaluates whether guided internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) (1) improves sleep, (2) affects the progression of emotional distress and (3) enhances the effectiveness of regular treatment of people with clinically relevant symptoms of emotional disorders across all mental health care (MHC) echelons. METHODS: We aim for 576 completers with clinically relevant symptoms of insomnia as well as at least one of the dimensions of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), posttraumatic stress disorder (PTSD) or borderline personality disorder (BPD). Participants are either pre-clinical, unattended, or referred to general- or specialized MHC. Using covariate-adaptive randomization, participants will be assigned to a 5 to 8-week iCBT-I (i-Sleep) or a control condition (sleep diary only) and assessed at baseline, and after two and eight months. The primary outcome is insomnia severity. Secondary outcomes address sleep, severity of mental health symptoms, daytime functioning, mental health protective lifestyles, well-being, and process evaluation measures. Analyses use linear mixed-effect regression models. DISCUSSION: This study can reveal for whom, and at which stage of disease progression, better nights could mean substantially better days. TRIAL REGISTRATION: International Clinical Trial Registry Platform (NL9776). Registered on 2021-10-07.

[Guided discontinuation of antidepressants: approach and first results of a Dutch multidisciplinary outpatient clinic]. / Werkwijze en eerste resultaten van multidisciplinaire afbouwpoli anti-depressiva.

BACKGROUND: Discontinuation of antidepressant medication can be difficult due to withdrawal symptoms and relapse risk. Scientific evidence on the questions of who, when, and how to stop antidepressants is limited. In Amsterdam a multidisciplinary outpatient clinic was started to provide advice and guidance. AIM: To substantiate the design of the clinic. Central questions relate to knowing which patients are referred, the background of their request, and their experiences with the outpatient clinic. METHOD: The first 51 patients of the clinic were described on the basis of file research, in addition a survey was conducted into patient experiences. RESULTS: Half of the patients (55%) actually started discontinuation, 39% were advised not to do so (yet). Patients at the clinic had used antidepressants for an average of 10 years, and 76% had previously attempted to stop. 21% had now successfully stopped and 25% were satisfied with a lower dose. One patient relapsed during tapering. CONCLUSION: So far, patients with long-term antidepressant use and multiple quit attempts have been referred. Our experiences are aimed at helping individual patients but can also result in more knowledge about who can stop at what moment, and how this should be done.

Predicting the course of anxiety disorders: The role of biological parameters.

OBJECTIVE: Clinical characteristics appear limited in their ability to predict course of anxiety disorders, therefore we explored the predictive value of biological parameters on course of anxiety disorders. METHODS: 907 persons with an anxiety (panic, social phobia, generalised anxiety) disorder with a baseline and two-year follow-up measure were selected from the Netherlands Study of Depression and Anxiety (NESDA). Previously, three course trajectories were distinguished which vary in terms of symptom severity and chronicity. Baseline clinical parameters like anxiety severity, anxiety duration, and disability were limited in their ability to predict the two-year course. This study explored whether metabolic syndrome, hypothalamic-pituitary-adrenal-axis functioning, inflammation markers, and neuroplasticity were indicators of two-year course and whether these parameters improved the model containing the most predictive clinical parameters only. RESULTS: Baseline diastolic blood pressure of persons with chronic moderate symptoms was significantly higher than of persons with non-chronic mild symptoms (odds ratio [OR] = 1.18, 95% confidence interval [CI95%] 1.01 to 1.38). Baseline high-density lipid cholesterol of persons with severe chronic symptoms was significantly lower than of persons with non-chronic mild symptoms (OR = 0.77, CI95% 0.62 to 0.96). The predictive ability of both parameters was however low with concordance statistics of 0.55 and 0.57 respectively. Addition of biological parameters did not improve the predictive ability of the model containing the clinical parameters. CONCLUSIONS: In addition to clinical characteristics, biological parameters did not improve the predictive ability of the model for course trajectory of anxiety disorders. Prediction of course trajectory in anxiety disorders remains difficult and warrants further research.

[Psychopathology in families: an integral approach via the family outpatient clinic]. / Psychiatrische stoornissen binnen gezinnen: een integrale benadering via de familiepoli.

BACKGROUND: Psychiatric disorders run in families. To bridge the gap between child and youth psychiatry and adult psychiatry, GGZ inGeest has started screening parents of new registered children for psychopathology - and if indicated - offers parents treatment in the same department as their children. AIM: To examine the feasibility and usefulness of this procedure, to investigate how many parents agree to screening, further diagnostics and treatment, and to find out how many parents have in fact suffered from recent psychiatric problems. METHOD: Prior to the children's first appointment, the parents were asked to complete a questionnaire, the Adult Self Report (ASR), about their own problems. If these scores were (sub)clinical, parents were invited to participate in a telephonic interview. This consisted of the Composite International Diagnostic Interview (CIDI) and Conners' Adult ADHD Rating Scales (CAARS). If the results indicate psychopathology, further psychiatric assessment and, if necessary, treatment is offered. RESULTS: The first response was 55.7% and, if indicated, most of the parents agreed on further diagnostics. On the ASR 2 out of 5 mothers (42.1%) and 1 out of 5 fathers (21.8%) reported problems that could point to a psychiatric disorder. According to the ASR, within this high-risk group 37% of the mothers met the criteria for an axis I diagnosis (less than one month earlier) compared to 70.6% of the fathers. A mood disorder was the primary diagnosis for women, whereas men most often suffered from an anxiety disorder. In total, 19.1% of the parents screened were suffering from recent psychopathology and 75% of this group agreed to receive mental health care (treatment at the family outpatient clinic or referred to another clinic). CONCLUSION: Implementation of the family outpatient clinic scheme is feasible. However, further efforts are needed in order to reach a larger group of parents, particularly fathers. The family outpatient clinic is useful because parents who suffer from psychopathology do not always receive mental health care. However, a randomised control trial is needed to determine whether parallel treatment of parents and children can improve the treatment outcome for children.

Trajectories of functioning after remission from anxiety disorders: 2-year course and outcome predictors.

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

A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial.

BACKGROUND: Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our aim was to examine efficacy of brief CBT in reducing anxiety and depressive symptoms in patients with noncardiac chest pain and comorbid panic and/or depressive disorders. METHODS: In this 24-week randomized controlled trial comparing CBT (n = 60) versus treatment as usual (TAU, n = 53), we included all adults who presented at the cardiac emergency unit of a university hospital with noncardiac chest pain, scored ≥8 on the hospital anxiety and depression scale (HADS) and were diagnosed with a comorbid panic and/or depressive disorder with the Mini International Neuropsychiatric Interview. CBT consisted of six individual sessions. Main outcome was disease severity assessed with the clinical global inventory (CGI) by a blinded independent rater. RESULTS: ANCOVA in the intention-to-treat and completer sample showed that CBT was superior to TAU after 24 weeks in reducing disease severity assessed with CGI (P < .001). Secondary outcomes on anxiety (HADS-anxiety, state trait anxiety inventory (STAI)-trait) and depressive symptoms (Hamilton depression rating scale) were in line with these results except for HADS-depression (P = .10), fear questionnaire (P = .13), and STAI-state (P = .11). CONCLUSIONS: Brief CBT significantly reduces anxiety and depressive symptoms in patients with noncardiac chest pain who are diagnosed with panic and/or depressive disorders. Patients presenting with noncardiac chest pain should be screened for psychopathology and if positive, CBT should be considered.

[The characterisation of anxiety disorders: staging and profiling based on common sense]. / De karakterisering van angststoornissen: stageren en profileren met gezond verstand.

BACKGROUND: Clinicians need to be well informed about staging and profiling so that they can divide patients with anxiety disorders into groups according to the phase and severity of their illness. The group to which the patient is assigned determines the types of treatment he or she receives. AIM: To investigate ways in which clinicians can be helped to apply staging and profiling procedures to patients with anxiety disorders. METHOD: We searched the literature for articles about the staging and profiling of anxiety disorders. RESULTS: There seems to be practically no literature relating to the staging and profiling of anxiety disorders. However, in daily practice clinicians do attempt to classify their patients and use forms of staging when deciding on special types of treatment for their patients and when assessing the length of treatment required. The revised Dutch guidelines on anxiety disorders include a generalised form of staging, called 'stepped care’. These revisions have been made on the basis of consensus decisions reached by the guideline committee. CONCLUSION: The revised guidelines on anxiety disorders assist clinicians with the application of staging in their daily practice. However, because of the lack of scientific data, our article closes with the presentation of a research agenda.

[Obsessive-compulsive disorder from a family perspective; implications for treatment and research]. / De obsessieve-compulsieve stoornis vanuit gezinsperspectief; implicaties voor behandeling en onderzoek.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a chronic, psychiatric disease which can be highly resistant to treatment. Several studies have suggested that family factors may play a role in the etiology and course of OCD. AIM: To provide an overview of current knowledge about the complex interaction between OCD and family factors. METHOD: We performed a systematic search of the literature, using PubMed and Psychinfo. RESULTS: OCD places a heavy burden on partners and family members, and their responses to symptoms influence the course of the disease, particularly the effect of cognitive behavioural therapy (CBT). Interventions aimed at improving communicative skills and creating a more balanced family response can have a positive influence on the course of OCD. CONCLUSION: It is advisable to integrate family factors into the treatment of OCD. Further research on this topic is needed.

The 7-year course of depression and anxiety in the general population.

OBJECTIVE: Insight into the long-term course of depression and anxiety. METHOD: Data were derived from Netherlands Mental Health Survey and Incidence Study/Netherlands Study of Depression and Anxiety, epidemiologic surveys in the adult population in the Netherlands. Three hundred and three respondents with depressive and/or anxiety Composite International Diagnostic Interview (CIDI) disorder were interviewed, examining the 7-year course of depression (n = 141), anxiety (n = 102) and the comorbid state (n = 60) and possible prognostic factors. Outcomes were CIDI diagnostic status after 7 years and percentage of time during 7 years with depressive and/or anxiety symptoms, retrospectively assessed by the Life Chart Interview (LCI). RESULTS: After 7 years, 60.7% of the subjects were free from a 12-month CIDI depression or anxiety diagnosis. The odds were higher for subjects with anxiety and comorbidity compared to subjects with depression. Low physical functioning and high neuroticism predicted the presence of a diagnosis after 7 years. During 7-year follow-up, 37.3% of the subjects were free from depressive and anxiety symptoms according to the LCI, 51.8% had symptoms <50% of the time, and 10.9%≥50% of the time. (Comorbid) anxiety resulted in a poorer course. High neuroticism and childhood adversity predicted more follow-up time with symptoms. CONCLUSION: Course trajectories were more favorable than expected, although comorbidity resulted in poorer course. Neuroticism, physical functioning, and childhood adversity predicted an unfavorable course.

Identifying target groups for the prevention of anxiety disorders in the general population.

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

The 2-year prognosis of panic episodes in the general population.

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

[Epidemiology of panic]. / De epidemiologie van paniek.

BACKGROUND: There is uncertainty about the clinical relevance of panic disorder and subsyndromal panic disorder. AIM: To assess the clinical relevance ofpanic disorder and subsyndromal panic disorder. METHOD: We searched Medline and PsycINFO for population studies performed as from 1980. We used as search terms: 'general population', 'psychiatr', 'prevalence' and 'panic'. On the basis of the studies found we compiled a review of the epidemiology of panic which enabled us to assess the clinical relevance. RESULTS: The life time prevalence of panic disorder is 2.1%; subsyndromal panic disorder is more prevalent (limited symptom attacks 7.5%, infrequent panic attacks 5.1%). Lifetime psychiatric comorbidity is high. The risk and symptom profile for panic disorder and subsyndromal panic disorder is the same. The course of both disorders is unfavourable. There is an increased risk that someone with panic disorder will develop a depression; subsyndromal panic disorder is a non-specific precursor of psychopathology. Both panic disorder and subsyndromal panic disorder are associated with attempted suicide, deficiencies and the use of the health care services, even after comorbidity has been corrected for. CONCLUSION: It is incorrect only to label panic symptoms 'pathological' if they satisfy the DSM criteriafor panic disorder; both panic disorder and subsyndromal panic disorder are clinically relevant.