Prediction of Mental Health Services Use One Year After Regular Referral to Specialized Care Versus Referral to Stepped Collaborative Care.

Referral to collaborative mental health care within the primary care setting is a service concept that has shown to be as effective as direct referral to specialized mental health care for patients with common mental disorders. Additionally it is more efficient in terms of lower mental health services use. This post-hoc analysis examines if treatment intensity during 1-year of follow-up can be predicted prospectively by baseline characteristics. With multilevel multivariate regression analyses baseline characteristics were examined as potential predictors of visit counts. Results showed that only the enabling factors service concept and referral delay for treatment had a significant association with mental health visit counts, when outcome was dichotomized in five or more visits. Inclusion of the outcome variable as a count variable confirmed the predictive value of service concept and referral delay, but added marital status as a significant predictor. Overall, enabling factors (service concept and referral delay) seem to be important and dominant predictors of mental health services use.

A pilot study of bright light therapy in schizophrenia.

Negative symptoms and episodes of major depressive disorder in patients with schizophrenia are common and there is an overlap in symptoms. Unfortunately, there is no effective primary treatment for negative symptoms yet. Depressive disorder in patients with schizophrenia is associated with a decreased quality of life and an increased risk of psychotic relapses. Previous research has shown that Bright Light Therapy (BLT) has a positive impact on negative symptoms of patients with schizophrenia. Our aim was to investigate the feasibility and the effect of Bright Light Therapy in a severely ill population of patients who were admitted to a closed ward. This pilot study was a single center, open label add-on trial with two control groups and included 20 patients. RESULTS: Neither negative nor positive symptoms were affected. However, there was a trend towards increase on the general psychopathology scale of the Positive And Negative Syndrome Scale in the BLT group. BLT did not change daily mood ratings. One participant from the BLT group was withdrawn from the study due to a manic state possibly triggered by BLT. Patients participating in our study did not benefit from BLT. It was an additional burden on the participants and worsened general psychopathology at a follow-up. Based on this study, we did not find any beneficial effect of BLT for patients with schizophrenia.

Five-Year Mental Health Care Use by Patients Referred to Collaborative Care or to Specialized Care.

OBJECTIVE: This study compared long-term use of mental health care by two groups of patients who had common mental disorders in the Netherlands-those treated in a collaborative care setting and those referred to off-site specialized mental health services if indicated. METHODS: The study was a retrospective analysis of use of mental health care over five years by 139 patients who participated in a cluster-randomized parent study. The parent study involved 27 general practitioners (GPs) who provided either collaborative care or usual care. In the collaborative care condition, a mental health professional worked on site at the GP's practice and was available to provide short-term treatment. In the usual-care condition, the GP referred the patient to off-site specialized mental health services if indicated; if not indicated, the GP provided usual care. The two treatment groups were compared on the number of mental health care contacts and total treatment duration, the proportion that initiated a new treatment episode after termination of the initial treatment, and time to new treatment. RESULTS: Patients in the collaborative care condition received about half the number of mental health care contacts as those in the usual-care condition, and no differences were found in the rate of initiation of new treatment episodes after initial treatment, time to new treatment, and total treatment duration. CONCLUSIONS: Referral of patients with common mental disorders to collaborative mental health care as a first intervention led to fewer contacts with a mental health care professional over the long term, compared with referral to specialized mental health care.

Effects of mood state on divided attention in patients with bipolar disorder: evidence for beneficial effects of subclinical manic symptoms.

A relatively small number of studies have been dedicated to the differential effects of the current mood state on cognition in patients with a bipolar disorder (BD). The aim of the current study was to investigate the effect of current mood state on divided attention (DA) performance, and specifically examine possible beneficial effects of the (hypo-) manic state. Over a maximum period of 24 months, medication use, divided attention test (a subtest of the Test for Attentional Performance (TAP)) was assessed every 6 months in 189 outpatients with BD. Data were analyzed with multilevel regression analysis (i.e. linear mixed models). DA performance varied considerable over time within patients. Corrected for psychotropic medication a significant quadratic relationship between manic symptoms and DA performance was found, with mild hypomanic symptoms having a positive influence on divided attention scores and moderate to severe manic symptoms having a negative influence. No association between depressive symptoms and DA performance was found. In future research on mania and cognition as well as in the clinical practice both the beneficial and negative effects of mania should be taken into account.

Is there a difference in clinical efficacy of bright light therapy for different types of depression? A pilot study.

BACKGROUND: There is growing interest in the possible applications of Bright Light Therapy (BLT). BLT might be a valid alternative or add-on treatment for many other psychiatric disorders beyond seasonal affective disorder. This pilot study aims to examine whether the efficacy of Bright Light Therapy (BLT) is similar for different subtypes of mood disorders. METHODS: Participants were 48 newly admitted outpatients with major depressive disorder with either melancholic features (n=20) or atypical features (n=28). Morning BLT was administered daily for 30 min at 5.000-10.000 lx on working days for up to 3 consecutive weeks. RESULTS: Participants' depressive symptoms improved significantly after BLT (p<.05, d=-.53). The effects of BLT remained stable across a 4 week follow-up. There were no significant differences in efficacy of BLT between groups (p>.05). No effect of seasonality on the improvement in depressive symptoms after BLT was found, (p=.781). LIMITATIONS: The study had a small sample size and lacked a control condition. CONCLUSIONS: This pilot study provides preliminary evidence that BLT could be a promising treatment for depression, regardless of the melancholic or atypical character of the depressive symptoms.

Serum BDNF concentrations show strong seasonal variation and correlations with the amount of ambient sunlight.

Earlier findings show seasonality in processes and behaviors such as brain plasticity and depression that in part are regulated by Brain-Derived Neurotrophic Factor (BDNF). Based on this we investigated seasonal variation in serum BDNF concentrations in 2,851 persons who took part in the Netherlands Study of Depression and Anxiety (NESDA). Analyses by month of sampling (monthly n's >196) showed pronounced seasonal variation in serum BDNF concentrations (P<.0001) with increasing concentrations in the spring-summer period (standardized regression weight (ß) = 0.19, P<.0001) and decreasing concentrations in the autumn-winter period (ß = -0.17, P<.0001). Effect sizes [Cohen's d] ranged from 0.27 to 0.66 for monthly significant differences. We found similar seasonal variation for both sexes and for persons with a DSM-IV depression diagnosis and healthy control subjects. In explorative analyses we found that the number of sunshine hours (a major trigger to entrain seasonality) in the week of blood withdrawal and the 10 weeks prior to this event positively correlated with serum BDNF concentrations (Pearson's correlation coefficients ranged: 0.05-0.18) and this could partly explain the observed monthly variation. These results provide strong evidence that serum BDNF concentrations systematically vary over the year. This finding is important for our understanding of those factors that regulate BDNF expression and may provide novel avenues to understand seasonal dependent changes in behavior and illness such as depression. Finally, the findings reported here should be taken into account when designing and interpreting studies on BDNF.

Long-term cortisol in bipolar disorder: associations with age of onset and psychiatric co-morbidity.

INTRODUCTION: Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is hypothesized to play a role in the pathogenesis of bipolar disorder (BD). Conflicting results have been reported when saliva or serum was used to measure cortisol levels. A recently developed method is to measure cortisol in scalp hair, with 1cm of scalp hair representing 1 month. We studied whether there are differences in long-term hair cortisol levels between BD patients and healthy individuals and whether there are associations between hair cortisol and disease characteristics. METHODS: Hair samples were collected in 100 BD patients and 195 healthy controls. Long-term cortisol levels were determined in 3 cm hair segments. Saliva samples were collected on two consecutive evenings. Documented disease characteristics were disease state, age of onset and psychiatric co-morbidity. RESULTS: Hair cortisol levels were not statistically different in BD patients compared to healthy controls (p=0.233) and were not associated with the disease state at the moment of sample collection (p=0.978). In the subgroup of patients with age of onset ≥ 30 years, hair cortisol levels were significantly elevated compared to the subgroup with age of onset <30 years and to healthy controls (p=0.004). Psychiatric co-morbidity was associated with elevated cortisol levels (44.87 versus 31.41 pg/mg hair; p=0.021), with the exclusion of panic disorder, which was associated with decreased cortisol levels (22.13 versus 34.67 pg/mg hair; p=0.019). CONCLUSIONS: Elevated long-term cortisol levels might play a role in a subgroup of patients with BD. There may be differences in pathogenesis of younger and older onset BD suggesting two different disease entities.

Antipsychotics switching strategies in real life. A longitudinal study in clinical practice

Background and Objectives: Switching antipsychotics (APs) in the treatment of mental illnesses such as schizophrenia is common practice for clinicians as well as a transitional moment associated with the possibility of adverse events and recurrence of psychoses. As in recent years, AP switching strategies have received more attention, a number of authors have recommended transitions with overlapping drug dosage regimens in time (such as tapering, cross-tapering, plateau switching) over abrupt switches. However, there is a paucity of data documenting how clinicians are switching APs in real life. Moreover, the question if recently recommended switching strategies are converted into everyday practice is still very much unanswered. The present investigation aims to study if indeed there is a preference for tapered approaches over abrupt switching. Methods: In a retrospective longitudinal descriptive study, electronic prescription data from a large clinical psychiatric setting in the Netherlands were collected for the year2007. Timelines of medication regimens were constructed for individual patients, enabling to identify transitions between APs. As patients could have been subjected to multiple switches in a given time period, transitions were expressed as episodes. Abrupt switches were defined as switches having no overlap in time. Results: From a total of 5322 AP prescriptions involving 1465 patients, a total of 180episodes (associated with 158 patients) were identified where APs were switched. Of these 180 episodes, 110 (61%) involved abrupt transitions. 70 episodes (39%) had overlap in time with an average taper length of 16.1 (SEM 1.6) days. Conclusions: In the majority of cases in the studied clinical setting, APs are switched Abruptly (AU)

Reducing symptoms in women with chronic anorexia nervosa. A pilot study on the effects of bright light therapy.

OBJECTIVE: To examine the effect of bright light therapy on the sleep-wake rhythm, the menstrual cycle, mood, and key eating pathology symptoms in chronic anorexia nervosa. METHODS: Five chronic anorectic women (mean duration of illness: 15.3 years) received 5 daily sessions of 30 minutes bright light therapy (10,000 LUX). Participants completed a diagnostic interview and questionnaires at pre-test, post-test and at a three month follow-up. RESULTS: At follow up there was a slight improvement on core eating pathology, a fair decrease of depressive symptoms and an clinically important improvement on global distress. CONCLUSIONS: Bright light therapy has on short term a positive effect on the physiological and psychological well being of chronic anorectic women. However, at follow-up the effects were partly lost. It is recommended to enhance the exposure period and repeat the treatment after 3 months.

Functional polymorphism of the glucocorticoid receptor gene associates with mania and hypomania in bipolar disorder.

OBJECTIVES: In affective disorders, dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis is a frequently observed phenomenon. Subtle changes in glucocorticoid receptor (GR) functioning caused by polymorphisms of the GR gene (NR3C1) may be at the base of the altered reaction of the HPA axis to stress and subsequently related to the development and course of affective disorders. The aim of our study is to evaluate associations between GR gene polymorphisms and bipolar disorder (BD). METHODS: In this study, 245 patients with BD were interviewed to confirm diagnosis and BD subtype. Data on medication use and sociodemographic details were also collected. The control group consisted of 532 healthy blood donors, from which data on sex and age were collected. To perform genotyping, blood was collected from all patients and healthy controls. RESULTS: A trend was found for a protective effect of the exon 9beta polymorphism (p = 0.14) and the TthIIII polymorphism (p < 0.05) on the manifestation of the disease. These effects were significantly influenced by male gender for both polymorphisms. Patients with BD and the A/G variant in exon 9beta had significantly fewer manic and hypomanic episodes than noncarriers (p < 0.05). No further associations were found with the other investigated GR gene polymorphisms and BD. These findings were not corrected for multiple comparisons. CONCLUSIONS: We conclude that the exon 9beta polymorphism and the TthIIII polymorphism of the GR gene may be associated with a protective effect on the clinical manifestation and course in patients with BD. Furthermore, no associations were found between the other studied GR gene polymorphisms and this disease.

Collaborative mental health care versus care as usual in a primary care setting: a randomized controlled trial.

OBJECTIVE: This study compared the effectiveness of treating common mental disorders in a collaborative care program in a primary care setting and the effectiveness of treating such disorders through traditional referral of patients to mental health services. METHODS: In a cluster randomized controlled trial, 27 general practitioner practices in the Netherlands were designated to provide either collaborative care or usual care. In the collaborative care condition, a mental health care professional worked on site at the primary care practice and was available to provide patients a maximum of five appointments if they were referred by the general practitioner. If indicated, referral to specialized mental health services followed. In the usual care condition, if indicated, general practitioners would refer patients to off-site specialized mental health services. The study included 165 patients. At baseline and at three, six, and 12 months, the study assessed patients' psychopathology, patients' quality of life, and patients' and general practitioners' satisfaction with the treatment provided. Delay in seeing a mental health provider, duration of treatment, number of appointments, and related treatment costs were assessed at 12 months. The data were analyzed with hierarchical linear models. RESULTS: Level of patients' psychopathology and quality of life significantly improved over time, and there were no significant differences between models of care. There was no significant difference in patients' satisfaction with care in either condition. The collaborative care condition resulted in significantly higher satisfaction with services among general practitioners, shorter referral delay, reduced time in treatment, fewer appointments, and consequently lower treatment costs. CONCLUSIONS: Collaborative care for a heterogeneous group of persons with common mental disorders seems to be as effective as the usual practice of referral to mental health services for reducing psychopathology, but it is significantly more efficient regarding referral delay, duration of treatment, number of appointments, and related treatment costs.

Combination treatment for acute depression is superior only when psychotherapy is added to medication.

BACKGROUND: Although several forms of effective therapy exist for outpatients suffering from major depressive disorder, many patients do not profit from treatment. Combining psychotherapy and medication may be an effective strategy. However, earlier studies have rarely found a clear advantage for the combination. Where an advantage was found, a possible placebo effect of adding 2 types of treatment could not be ruled out as cause for the superior effect of the combination. METHODS: A total of 353 patients were screened, of whom 193 were randomized over 4 conditions: nefazodone plus clinical management, interpersonal psychotherapy (IPT), the combination of the two or the combination of IPT and pill-placebo. All patients suffered from major depressive disorder and had a score of at least 14 on the 17-item Hamilton Rating Scale (HAMD). The patients were treated for 12-16 weeks. At baseline, at 6 weeks and on completion of treatment, ratings were performed by independent raters. The primary outcome measure was the HAMD, and the Montgomery-Asberg Depression Rating Scale (MADRS) the secondary outcome measure. RESULTS: Of the 193 patients included, 138 completed the trial. All treatments were effective. Using a random regression model, no differences between treatments were found on the HAMD. On the MADRS, however, the combination of medication with psychotherapy was more effective in reducing depressive symptoms compared to medication alone, but not to psychotherapy alone or IPT with pill-placebo. CONCLUSIONS: The results of this study yield support for the use of combining medication with psychotherapy instead of using medication only in the treatment of depressed outpatients. Combination treatment does not have an advantage over psychotherapy alone in the present study.