Prevalence and prediction of dropout during depression treatment in routine outpatient care: an observational study.

Efficacious treatments are available for major depressive disorder (MDD), but treatment dropout is common and decreases their effectiveness. However, knowledge about prevalence of treatment dropout and its risk factors in routine care is limited. The objective of this study was to determine the prevalence of and risk factors for dropout in a large outpatient sample. In this retrospective cohort analysis, routinely collected data from 2235 outpatients with MDD who had a diagnostic work-up between 2014 and 2016 were examined. Dropout was defined as treatment termination without achieving remission before the fourth session within six months after its start. Total and item scores on the Dutch Measure for Quantification of Treatment Resistance in Depression (DM-TRD) at baseline, and demographic variables were analyzed for their association with dropout using logistic regression and elastic net analyses. Data of 987 subjects who started routine outpatient depression treatment were included in the analyses of which 143 (14.5%) dropped out. Higher DM-TRD-scores were predictive for lower dropout odds [OR = 0.78, 95% CI = (0.70-0.86), p < 0.001]. The elastic net analysis revealed several clinical variables predictive for dropout. Higher SES, higher depression severity, comorbid personality pathology and a comorbid anxiety disorder were significantly associated with less dropout in the sample. In this observational study, treatment dropout was relatively low. The DM-TRD, an easy-to-use clinical instrument, revealed several variables associated with less dropout. When applied in daily practice and combined with demographical information, this instrument may help to reduce dropout and increase treatment effectiveness.

[Geriatric syndromes, multimorbidity and geriatric psychiatry; an integrated perspective]. / Geriatrische syndromen, multimorbiditeit en ouderenpsychiatrie; een geïntegreerd perspectief.

BACKGROUND: The prevalence of geriatric syndromes, frailty and multimorbidity increases in older age, with a negative impact on health outcomes. Little is known on these problems in older adults with psychiatric disorders. AIM: To evaluate the prevalence of geriatric syndromes and multimorbidity in older adults with psychiatric disorders and their impact on treatment outcomes. METHOD: We conducted a pilot study and a case-control study on older adults with medically insufficiently explained symptoms, a prospective cohort study in older adults, acutely admitted to psychiatric wards and a systematic review to evaluate whether geriatric syndromes were considered in RCTs on depression treatment. RESULTS: Unexplained symptoms were often accompanied by frailty, multimorbidity and psychiatric disorders. Older adults who were acutely admitted to psychiatric wards had a high level of multimorbidity, about half of them were frail, and a third undernourished. Frailty and multimorbidity were independent predictors for not being discharged to their own home. Frailty also strongly predicted the 5-year mortality rate. Geriatric syndromes were hardly considered in study design or as secondary outcome in treatment studies on depression in older adults. CONCLUSION: Overall, geriatric problems are highly prevalent among older adults with psychiatric disorders and have a relevant prognostic impact. The complexity of older psychiatric patients is probably best addressed by interdisciplinary, integrated diagnostic and treatment trajectories.

[Treatment plan for female adolescents in the grip of chronic suicidality]. / Behandelbeleid bij vrouwelijke adolescenten gegijzeld door chronische suïcidaliteit.

BACKGROUND: A psychological autopsy study (Mérelle e.a. 2020) demonstrates a subgroup of female adolescents with chronic suicidal behavior and severe internalizing problems. AIM: To describe characteristics of the suicidal process and the challenges experienced in providing mental health care for this subgroup. METHOD: A case description and review of literature. RESULTS: The persistent suicidal threat and the following despair of the patient and its parents are forcing care providers into an impasse: the primary focus of treatment is to guarantee the patient's safety, whereby the treatment of underlying problems is underexposed. Based on expert knowledge we make recommendations including autonomy-promoting treatment policy, treating suicidality as a transdiagnostic phenomenon, creating a multidisciplinary network of care providers and making chronic suicidality tolerable for care providers. CONCLUSION: We propose preliminary practical recommendations in our quest for optimal mental health care for chronic suicidal adolescents.

[Consultation from centers of excellence in Dutch mental healthcare; the value for patient and specialist]. / Hoogspecialistische consultatie in de sggz; de waarde voor patiënt en specialist.

The consultation function of centers of excellence is still used to a limited extent. In this article we explain possibilities and contributions of highly specialized consultation to support standard mental healthcare by means of vignettes. Case descriptions from the consultation practice of four centers of excellence are presented. More intensive use of consultation options by mental health care providers can help improve the quality, efficiency and effectiveness of care.

[The best intervention for depression is early detection and prevention in youth]. / De beste behandeling voor depressie is vroegsignalering en preventie bij jeugdigen.

Background A more preventive and proactive approach in youth mental health care can contribute to reduce the severity of psychological problems in young people and help to reduce the risk on treatment resistance. Aim To show opportunities to organize youth mental health care more proactively. Method Discuss new approaches based on existing literature and examples from clinical practice. Results It is essential that young people receive treatment that is appropriate for the severity of their problems. Early detection and prevention can be systematically carried out in collaboration with public health service and schools. In addition, it is imperative that young people receive appropriate (specialized) mental health care based on their prognosis. Conclusion Committing to the right care at the right time is essential to prevent the development of co-morbidities, stagnation in development tasks and therapy resistance. Tijdschrift voor psychiatrie 63(2021)2, 111-114.

[Routine outcome monitoring (ROM) early in treatment and disorder specific. Observational study into generic and specific questionnaires to measure the early change in depression treatment]. / ROM vroeg in de behandeling en specifiek; observationeel onderzoek naar generieke en specifieke vragenlijsten bij meten van vroege verandering bij depressiebehandeling.

BACKGROUND: Mental health care institutions use routine outcome monitoring (ROM) to determine whether a patient responds well to treatment. However, it has been still unanswered whether disorder specific or generic measurement instruments can best be used for this purpose. In addition, little is known about when a first indication can be given for the outcome of the treatment.
AIM: To provide insight into the sensitivity to change of two questionnaires: a generic and a specific one, which were both used for clients with a depressive disorder. An additional objective is to provide insight into when a first indication can be given for the outcome of the treatment.
METHOD: An observational cohort study with data from 518 patients with a depressive disorder. The Outcome Questionnaire (OQ-45.2) and the Inventory of Depressive Symptomatology (IDS-SR) were used to measure the course of treatment.
RESULTS: The depression specific IDS-SR appeared to be more sensitive to change than the generic OQ-45.2, especially at the beginning of treatment. With a measurement frequency of once every four weeks, the best time to get a first indication on the outcome of the treatment was between week 4 and week 8.
CONCLUSION: For clients and practitioners whose treatment focus is reducing depressive symptoms, a disorder specific questionnaire is preferable to monitor this. The measurement between 4 and 8 weeks is important for, if necessary, adjusting the treatment, and to improve the treatment outcome.

[The effectiveness of monoamine oxidase inhibitors in treatment-resistant depressive disorders in clinical practice; a retrospective open-label study]. / De effectiviteit van monoamineoxidase-remmers bij therapieresistente depressie in de klinische praktijk; een retrospectieve openlabelstudie.

BACKGROUND: Monoamine oxidase (mao)-inhibitors are often prescribed in patients suffering from treatment-resistant depression, but the evidence of its effectiveness in this type of depression is limited: a restricted amount of similar studies describes response-rates of 12-75%.
AIM: To get more insight in the effectiveness of mao-inhibitors in treatment-resistant depression in clinical practice.
METHOD: We investigated medical files of patients with a uni- or bipolar, treatment-resistant depression and looked at the difference in score on the Inventory of Depressive Symptomatology - Self Report (ids-sr) before and after 3 months of treatment with a mao-inhibitor. After that, we investigated how often patients achieved remission, response, partial response, no response or drop-out due to of side-effects.
RESULTS: The included 17 patients achieved a mean decrease of 8.6 (sd:15.1) points, which corresponded with a decrease of 16.8% (p = 0.032). One patient (6%) achieved remission, 2 patients (12%) achieved response, 5 patients (29%) had partial response and 7 patients (41%) did not respond at all. Three patients (18%) quitted because of side-effects.
CONCLUSION: The results of this and similar studies are modest and ask for critical thinking and critical prescribing of mao-inhibitors, because of the possibly limited effectiveness in treatment-resistant depressions.

[Decrease of depression and outcome in treatment of anxiety disorders - an observational study of ROM data]. / Afname van depressie en de uitkomst bij de behandeling van angststoornis ­ een observationele studie van ROM-data.

BACKGROUND: Most mental health hospitals in the Netherlands use disorder specific standards of care. In case of comorbidity, we lack evidence in choosing the treatment of preference when both depressive- and anxiety disorder(s) are present in the same patient.
AIM: To investigate the prevalence of depression and anxiety (including obsessive compulsive disorder and post-traumatic stress disorder) in an outpatient mental health hospital population treated for their anxiety disorder, and to investigate the difference in outcome of (anxiety) treatment between patients with and without a comorbid depressive disorder.
METHOD: A retrospective study using outcome data from 2012 to 2017. In this period, we identified 127 patients for whom outcome data and diagnostic criteria were available. Comorbidity in this group was determined by a clinical interview. During treatment symptoms were monitored using self-reporting scales, among others the Inventory of Depressive Symptomatology (IDS) and the Beck Anxiety Inventory (BAI).
RESULTS: In 46,5% of the patients a comorbid depressive disorder was diagnosed. No significant difference in treatment outcome was observed between the group of patients with and the group of patients without a comorbid depressive disorder. However, the amount of reduction of depressive symptoms measured by the ids was a good predictor of the reduction of anxiety: a faster reduction of depressive symptoms predicts a better outcome of the treatment of anxiety.
CONCLUSION: Comorbid depressive disorders were observed in almost half of the patients treated in specialized (outpatient) clinics for anxiety disorders. A slower reduction of depressive symptoms predicts worse outcome of the treatment of anxiety.

[Antidepressants are frequently prescribed but still critized; a perspective on causes and solutions]. / Antidepressiva: al decennia voor­geschreven én toch nog steeds bekritiseerd; een perspectief op oorzaken en oplossingen.

BACKGROUND: From around 1980, antidepressants (ad) have increasingly been prescribed, for longer periods of time, especially selective serotonin reuptake inhibitors (ssris). Paradoxically, their effectiveness is still doubted, especially outside the psychiatric profession.
AIM: To explain increase and offer a perspective on causes and solutions, and to indicate how to reach consensus.
METHOD: Position paper with critical analysis and synthesis of relevant literature.
RESULTS: The rise in AD prescriptions results from: 1. increased safety and ease of prescribing, 2. increased presentation and recognition of depression in primary care, 3. extension of indication criteria, 4. effective marketing strategies, and 5. effectiveness in acute phase (aad) and of relapse/recurrence prevention in continuation/maintenance phases (coad).Critics point to: 1. low added value of aad relative to placebo, 2. many drop-outs and non-responders, 3. relapse/recurrence prevention with coad works only for responders to aad, 4. relapse/recurrence after AD discontinuation often involves withdrawal symptoms, and 5. publication bias, selective reporting, selective patient selection, and suboptimal blinding, resulting in overestimated effectiveness and underestimated disadvantages.Factors that keep fueling the controversy are: 1. critics stress the net effectiveness of AD whereas proponents point at gross effectiveness which includes spontaneous recovery and placebo effect; 2. persistence of distrust in industry-funded rcts; 3. ideological positions, reinforced by conflicts of interest and selective citations; 4. lack of rcts with relevant long-term outcome measurements.
CONCLUSION: Although consensus is difficult to achieve given the ideological component, there are options. Three factors are critically important: confer to establish which data convince the opposition, response prediction (what works for whom), and rcts with long-term functional outcomes.

Predicting clinical course in major depressive disorder: The association between DM-TRD score and symptom severity over time in 1115 outpatients.

BACKGROUND: The Dutch Measure for Quantification of Treatment Resistance in Depression (DM-TRD) is a promising prediction tool for major depressive disorder (MDD) based on variables associated with treatment outcome. The objective of our study was to examine the association between the DM-TRD and clinical course in a large cohort of MDD outpatients receiving treatment as usual. Furthermore, we examined whether the addition of an item measuring the presence of childhood adversity improved this association. METHODS: We included 1115 subjects with MDD (according to the DSM-IV) who were naturalistically treated at seven outpatient departments of a secondary mental healthcare center in the Netherlands. Data on subjects who had a diagnostic work-up between June 2014 and June 2016 were analyzed. Multilevel analyses were performed to examine the association between the DM-TRD score at baseline and clinical course, defined by symptom severity according to scores on the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) over time. We also investigated whether an extra item measuring childhood adversity improved the model. RESULTS: The model including the DM-TRD and its interaction with time was superior to previous models. The addition of childhood adversity and its interaction with time did not improve the model. CONCLUSIONS: In depressed outpatients receiving treatment as usual, the solid longer-term association between higher DM-TRD scores and worse clinical course supports its usefulness in clinical practice. Childhood adversity did not improve the model value indicating that-counterintuitively-this parameter offers no additional predictive power to the variables included.

[Lithium augmentation to monoamine oxidase-inhibitors in treatment-resistant depressive disorders: case report and overview of literature]. / Lithiumadditie bij monoamine-oxidaseremmers bij therapieresistente depressie: casusbeschrijvingen en literatuuroverzicht.

Three patients suffering from a treatment-resistant depression were being treated with a monoamine oxidase (mao-)inhibitor and received lithium augmentation to achieve better recovery. One patient showed significant improvement of depressive symptoms within 24 hours, one patient showed very little respons and one patient did not respond at all. Literature research led to other casereports, where adding lithium to mao-inhibitors had also been effective. The growing amount of arguments of a positive effect of lithium augmentation to mao-inhibitors asks for more research to collect more evidence and a better understanding of this new, potentially effective treatment.

[Prevalence and recognition of bipolarity in patients with a treatment-resistant depressive disorder: a systematic review]. / Prevalentie en herkenning van bipolariteit bij patiënten met een therapieresistente depressieve stoornis; een systematische review.

BACKGROUND: Studies have indicated an association between treatment refractoriness in unipolar depression and unrecognised bipolar spectrum disorder (bsd). If confirmed, this may have implications for diagnosis and treatment.
AIM: To provide an overview on the prevalence and recognition of bsd in treatment resistant depression (trd).
METHOD: A search was made in PubMed concerning the prevalence of bsd in trd and clinical features that may be suggestive of bipolar depression.
RESULTS: Three articles were found that examined the prevalence of bsd in trd; they reported that 26-47% of patients with trd had an underlying bsd. Five cross-sectional studies described the predictors of clinical features in patients with a major depression. The following features occurred significantly more often: positive family history of bsd, young age of onset, higher number of recurrences, and atypical features.
CONCLUSION: There seems to be an association between trd and having an underlying bsd. A few clinical features may help to detect bsd in trd.

[The care standard 'Depressive disorders']. / De zorgstandaard Depressieve stoornissen.

BACKGROUND: The care standard 'Depressive disorders' describes the complete patient journey for patients with depressive symptoms and disorders from the age of 8 years onwards.
AIM: To describe the most important recommendations in this care standard.
METHOD: The care standard is an adaptation of the existing guidelines for depression, supplemented with practical knowledge from professionals and patients' values and preferences.
RESULTS: Core elements in the care for depression are an appropriate use of care and a focus on relapse prevention. A combination of psychotherapy and medication is indicated for persistent depression and more sessions of psychotherapy might be required. There is some evidence for the use of repetitive transcranial magnetic stimulation in treatment-resistant depression.
CONCLUSION: The care standard is an important instrument to improve the quality of care for depression at both the organisational and the regional level.

[Consensus statement on the application of rTMS in depression in the Netherlands and Belgium]. / Consensusverklaring voor de toepassing van rTMS bij depressie in Nederland en België.

BACKGROUND: Since 2017, repetitive transcranial magnetic stimulation (rTMS) has become eligible for reimbursement for the treatment of therapy-resistant depression in the Dutch healthcare system.
AIM: To initiate a guideline in the Netherlands and Belgium for the safe and effective application of rTMS for the treatment of depression.
METHOD: Based on literature review, existing guidelines and consensus among Dutch rTMS experts, recommendations were developed regarding the implementation of rTMS as a treatment of depression. All available evidence was weighed and discussed among all co-authors and recommendations were reached by consensus among the group.
RESULTS: rTMS targeting the dorsolateral prefrontal cortex (DLPFC) should be seen as a first choice in the treatment of depression using high-frequency rTMS (left) or, as an alternative, low-frequency rTMS (right). Stimulation protocols should use more than 1000 pulses per session for an average of 20-30 sessions, offered in 2-5 sessions per week. Contraindications for rTMS include epilepsy, intracranial presence of (magnetisable) metals, pacemaker and cochlear implant.
CONCLUSION: rTMS, performed by competent professionals is an effective and safe treatment for depression.

Indicators to facilitate the early identification of patients with major depressive disorder in need of highly specialized care: A concept mapping study.

BACKGROUND: Early identification of the subgroup of patients with major depressive disorder (MDD) in need of highly specialized care could enhance personalized intervention. This, in turn, may reduce the number of treatment steps needed to achieve and sustain an adequate treatment response. The aim of this study was to identify patient-related indicators that could facilitate the early identification of the subgroup of patients with MDD in need of highly specialized care. METHODS: Initial patient indicators were derived from a systematic review. Subsequently, a structured conceptualization methodology known as concept mapping was employed to complement the initial list of indicators by clinical expertise and develop a consensus-based conceptual framework. Subject-matter experts were invited to participate in the subsequent steps (brainstorming, sorting, and rating) of the concept mapping process. A final concept map solution was generated using nonmetric multidimensional scaling and agglomerative hierarchical cluster analyses. RESULTS: In total, 67 subject-matter experts participated in the concept mapping process. The final concept map revealed the following 10 major clusters of indicators: 1-depression severity, 2-onset and (treatment) course, 3-comorbid personality disorder, 4-comorbid substance use disorder, 5-other psychiatric comorbidity, 6-somatic comorbidity, 7-maladaptive coping, 8-childhood trauma, 9-social factors, and 10-psychosocial dysfunction. CONCLUSIONS: The study findings highlight the need for a comprehensive assessment of patient indicators in determining the need for highly specialized care, and suggest that the treatment allocation of patients with MDD to highly specialized mental healthcare settings should be guided by the assessment of clinical and nonclinical patient factors.

Cognitive reactivity as outcome and working mechanism of mindfulness-based cognitive therapy for recurrently depressed patients in remission.

Major depressive disorder is a prevalent condition with high relapse rates. There is evidence that cognitive reactivity is an important vulnerability factor for the recurrence of depression. Mindfulness-based interventions are designed to reduce relapse rates, with cognitive reactivity as one of the proposed working mechanisms. In a randomised controlled trial we compared the effect of mindfulness-based cognitive therapy (MBCT) with treatment-as-usual (TAU) on cognitive reactivity in recurrently depressed patients (N = 115). Depressive symptoms, cognitive reactivity, and mindfulness skills were assessed pre and post treatment. Patients in the MBCT group reported a significantly greater reduction in cognitive reactivity than those in the TAU group (d = .51). The reduction of cognitive reactivity appeared to mediate the association between MBCT/TAU and decrease of depressive symptoms, using pre and post scores. The current study provides evidence that MBCT reduces cognitive reactivity and preliminary evidence that cognitive reactivity is a working mechanism of MBCT.

[Personalised diagnosis and treatment of depression]. / Personalised diagnostiek en behandeling van depressie.

BACKGROUND: It is often said that a patient with depression can derive considerable benefit from personalised diagnostics and treatment.
AIM: To find out whether we have enough data to demonstrate that personalised diagnostics and personalised treatment of depression are better than what we do now and, if so, what specific action we should take.
METHOD: We review the literature on the foregoing topic.
RESULTS: There is ample evidence to support the view that the efficacy of treatment may improve quite dramatically if we are able to diagnose with much greater precision and select a treatment that is best suited to an individual person. Although there is less empirical evidence available with regard to a system that makes use of short regular feedback of unique personal data of patients and of the personal input of the professionals involved, these factors may nevertheless improve efficacy still further.
CONCLUSION: Although no hard evidence is available so far, for instance as a result of trials, there is sufficient evidence to support the further development of personalised diagnostics and personalised treatment of depression.

[New numbers on the duration of major and minor depressive episodes in the general population; results from NEMESIS-2]. / Nieuwe cijfers over de duur van depressieve episoden in de algemene bevolking; resultaten van nemesis-2.

BACKGROUND: Relatively little research has been conducted that can reliably be used by psychiatrists, psychologists and general practitioners to estimate the recovery time of their patients suffering from depression. The treatment guideline for depression submits that half of those with mdd will recover within three months.
AIM: To present the findings from nemesis-2 (the Netherlands Mental Health Survey and Incidence Study-2) on both the duration of depressive episodes in the general population and associated risk indicators.
METHOD: The respondents that had developed a depressive episode between the first two follow-up assessments were selected; 286 with a clinical depression according to dsm-iv criteria (mdd) and 107 with a subclinical depression (MinDD). The episode duration was assessed with the Life Chart Interview.
RESULTS: Half of the patients with mdd recovered within 6 months and 12% had not recovered after 3 years. The mean duration for mdd was 10.7 months. Better physical and mental health before depression onset predicted shorter duration. Longer duration was associated with comorbid dysthymia or anxiety disorder. In comparison, the median duration of MinDD was half the length of mdd (3 months), whereas the mean duration (8.7 months), the percentage that had not recovered after 3 years (10%) and risk indicators for episode duration hardly differed.
CONCLUSION: In the guideline for depression it is assumed that half of those with mdd will recover within three months. Our study, however, found the median duration of mdd to be twice as long. Consequently, only a short period without active treatment can be justified. This paper also concludes that MinDD cannot be regarded as a transient, self-limiting mood state.

Duration of major and minor depressive episodes and associated risk indicators in a psychiatric epidemiological cohort study of the general population.

OBJECTIVE: Hardly any studies exist on the duration of major depressive disorder (MDD) and factors that explain variations in episode duration that lack biases. This limits clinical decision-making and leaves patients wondering when they will recover. METHOD: Data were used from the Netherlands Mental Health Survey and Incidence Study-2, a psychiatric epidemiological cohort study among a nationally representative adult population. Respondents with a newly originated depressive episode were selected: 286 MDD and 107 minor depressive disorder (MinDD) cases. DSM-IV diagnoses were assessed with the Composite International Diagnostic Interview 3.0 and episode duration with the Life Chart Interview. RESULTS: Among MDD cases, median episode duration was 6 months, mean duration was 10.7 months, and 12% had not recovered at 36 months. Longer duration was associated with comorbid dysthymia, anxiety disorder, psychotropic medication use (i.e. antidepressants or benzodiazepines prescribed by a mental health professional), mental health care use and suicidal behaviour. Better physical and mental functioning before depression onset predicted shorter duration. Among MinDD cases, shorter median duration (3 months) but similar mean duration (8.7 months), risk of chronicity (10% not recovered at 36 months) and risk indicators for episode duration were found. CONCLUSION: As the risk of chronicity was similar for MDD and MinDD, MinDD cannot be dismissed as a merely brief mood state.

[Adequacy of treatment for chronic anxiety or depression; an exploratory study of treatment practice]. / Adequaatheid van de behandeling bij chronische angst en depressie; verkennende studie naar de behandelpraktijk.

BACKGROUND: Many patients with anxiety or depression receiving specialised outpatient treatment at mental health centres do not fully recover. Relapse and chronic course are common. This raises questions about the adequacy of the treatment they receive.
AIM: To obtain insight into the type and length of the treatment given to patients with chronic anxiety or depression.
METHOD: We collected data as part of a national study involving 12 mental health trusts. To be included in the study, patients had to satisfy certain criteria: they had to have received specialised treatment for anxiety or depression for at least two years and there had to be concerns whether these patients would benefit from further treatment in this setting. We gathered information about patient characteristics, diagnosis and treatment history.
RESULTS: On the basis of our selection criteria, 268 patients participated in our study; 65% of the patients were female. Patients were grouped in three categories: 67% were suffering from major depression, 25% from anxiety disorder and 8% from comorbid anxiety and depression. On average, patients had been treated for six years. More than one third of patients had received poor-quality treatment: treatment in the form of psychotherapy and/or pharmacotherapy had not been carried out in accordance with treatment guidelines.
CONCLUSION: In practice, much current treatment falls short of expectations. In particular, pharmacotherapy for depression needs to be improved. Longer periods of treatment should be evaluated at least once every six months.