[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.

[ROM as a GPS navigation system: how can ROM be used routinely in treatment procedures?] / ROM als tomtom: als routine outcome monitoring echt routine zou zijn.

BACKGROUND: Routine outcome monitoring (rom) is becoming an integral part of many treatment procedures. In order to promote the use of rom in such procedures attention needs to focus more on the functions of rom than on implementation strategies.
AIM: To clarify what functions rom must be able to perform for the clinician and client if it is to be used routinely.
METHOD: We discuss the functions of rom as described in the literature.
RESULTS: The fundamental role of rom is to signal that the client is not responding satisfactorily to treatment. Therefore, rom has to perform three main functions: 1. predict, at any moment, whether the goal will be reached via the current route; 2. provide, at crucial moments, correct and meaningful information about what options are available that will make it easier to achieve the desired goals; 3. integration - in such a way that the system can be used routinely and will switch on automatically when treatments starts.
CONCLUSION: rom seems to be able to provide a range of functions that are urgently required by clinicians and their clients.

[Patients without DSM-IV-disorders and/or subclinical symptoms in generalistic and specialised mental health care]. / Patiënten zonder DSM-IV-diagnose en/of met subklinische klachten in de generalistische en specialistische ggz.

BACKGROUND: Our study was motivated mainly by the results from nemesis-2 which showed that four out of ten patients in ambulantory mental health care had not had any mental disorder in the previous 12 months. A dsm-iv classification of the symptoms of patients is required for receiving insured mental health care.
AIM: To find out whether patients who attended a mental health generalistic or specialised clinic had a dsm-classified mental disorder and to assess the severity of these patients' symptoms. We have given specific attention to the characteristics of patients with subclinical symptoms who turned up at the mental health care clinics.
METHOD: dsm-iv disorders of patients in mental health care were studied by means of the mini 5.0.0 (n = 3072). The oq-45 was used to determine the severity of symptoms in both generalistic (n = 2255) and specialised mental health care (n = 5009). Logistical regression was used to determine the differences between the characteristics of patients who had clinical scores and those of patients who had subclinical scores. For this purpose we also used anonymised data from the personal health records.
RESULTS: During the intake procedure at specialised mental health care clinics only 14.3 % of patients failed to meet the diagnostic criteria of a dsm-iv disorder. Also, 56.5 % of patients seen by a mental health generalist and 70,9 % of patients seen by a mental health specialist had high or very high symptomatic distress, according the oq-45. The proportion of patients with a dsm-iv disorder varied from 52.9 % for patients with subclinical oq-45 scores to 94.8 % for patients with very high oq-45 scores. Predictors of patients with subclinical oq-45 scores were similar in generalistic and specialised mental health care.
CONCLUSION: Only a small number of patients in specialised care did not have an axis 1 dsm-iv diagnosis. Most patients in generalistic and specialised mental health care reported severe symptomatic distress. Symptoms mentioned by patients with subclinical oq-scores at the start of treatment were mainly stress-related.

[Routine outcome monitoring and benchmarking: how can treatment results be compared in a responsible manner?]. / Routine outcome monitoring en benchmarking: hoe kunnen we behandelresultaten op een zorgvuldige manier vergelijken?

BACKGROUND: The structural measurement of the results of treatment under the Dutch mental health services and a comparison of these results between mental health centres help to provide insight into the effectiveness of treatment in general practice. AIM: To provide an overview of the issues that require attention when the results of mental health centres are being compared. METHOD: Documentation, policy information and practical experience with routine outcome monitoring were analysed. RESULTS: We describe the problems that can arise when results obtained by mental health centres are compared and we suggest some solutions for these problems. Important factors that have emerged from our study are as follows: working with routine outcome monitoring is a process of natural growth and involves experiences with several solutions and the making of definitive choices on the basis of experience. CONCLUSION: It is instructive to compare mental health centres with each other and with regards to so-called 'best practices' (benchmarking). However, mental health centres draw on a differing wide mix of patients and use different measurement procedures and instruments. In this article we express the view that in the near future it should be possible to draw meaningful comparisons.

What makes community psychiatric nurses label non-psychotic chronic patients as 'difficult': patient, professional, treatment and social variables.

PURPOSE: To determine which patient, professional, treatment and/or social variables make community psychiatric nurses (CPNs) label non-psychotic chronic patients as 'difficult'. METHODS: A questionnaire was designed and administered to 1,946 CPNs in the Netherlands. Logistic regression was used to design models that most accurately described the variables that contributed to perceived difficulty. RESULTS: Six variables were retained in the final logistic model. Perception-related variables (feeling powerless, feeling that the patient is able but unwilling to change, and pessimism about the patient's change potential) dominated treatment-related variables (number of contacts per week and admission to a locked ward in the last year) and social variables (number of psychosocial problems). CONCLUSION: This research shows that perceived difficulty is related to complex treatment situations, not so much to individual patient characteristics. If the constructed model has good predictive qualities, which remains to be tested in longitudinal research, it may be possible to accurately predict perceived patient difficulty. When used as a screening tool, such a model could improve treatment outcomes.

Perceived sleep quality of psychiatric patients.

This paper aims at acquiring knowledge about the quality of sleep of adult and elderly psychiatric patients who receive clinical or outpatient nursing care, and identifying key factors in perceiving a sleep problem. To do so, a sample of 1699 psychiatric patients were asked whether they perceived a sleep problem and were invited to fill in the Pittsburgh Sleep Quality Index (PSQI) and additional questions. Five hundred and sixty (33%) questionnaires were returned. As a result, we find that 36% of the patients perceived a sleep problem, while the PSQI assessed 66% of the sample as being 'bad sleepers'. Forty-nine per cent of the respondents used sleep medication one or more times a week. Five items of the PSQI were shown to be predictors of a perceived sleep problem. Four of these are insomnia symptoms, while the fifth is the use of sleep medication. Moreover, the patients who used sleep medication most scored significantly worse on all PSQI components than patients who used sleep medication less than once a week. In conclusion, many psychiatric patients perceive a sleep problem and all nurses could be confronted not only with the night-time consequences of this, but also with daytime consequences. Therefore, sleep problems must not be viewed as an isolated problem but must be seen in relation with social functioning.

[Dismantling of the mental healthcare sector. Developments, trends and controversies in the Netherlands]. / Het einde van een sectorale ggz. Ontwikkelingen, trends en controverses in Nederland.

BACKGROUND: The advisory document 'Zorg voor Velen '(Care of Many) (2002) calls for the dismantling of the large integrated mental healthcare institutions in the Netherlands. The minister of Health has taken the advice contained in that document, thus bringing to an end a period of thirty years when policy was directed towards more cohesion in the mental healthcare services. The reactions to this change in policy vary tremendously. AIM: To describe developments within the mental healthcare system and to interpret the advice that was offered and the reactions to it. METHOD: A historical analysis of the Dutch mental healthcare service since 1970 and an interpretation of the indicators and policy choices. RESULTS: The Dutch mental healthcare service has developed into one large healthcare sector and as a result many institutions have been forced to merge. At the same time the number of patients in this sector has increased dramatically, whereas the number of psychiatric patients in primary care has decreased. Meanwhile, care has moved in the directions of medically specialised care, partly because tasks and responsibilities have been transferred from one discipline to another. CONCLUSIONS: The movement towards one large single integrated care sector has led to the categorisation of care for the mentally ill and has increased the number of patients in the mental healthcare sector. Treatment has become more medicalised and specialised. As a result the mental healthcare system has found itself in an intolerable situation. The situation can only be resolved if a much sharper distinction is made between general primary care and specialised secondary care and ifsteps are taken to forge links with general health care.

Stepped care vs. matched care for mood and anxiety disorders: a randomized trial in routine practice.

OBJECTIVE: The effectiveness of two versions of stepped care [with either brief therapy (BT) or cognitive behavioural therapy (CBT) as a first step] is studied in comparison with the traditional matched care approach (CAU) for patients with mood and anxiety disorders. METHOD: A randomized trial was performed in routine mental health care in 12 settings, including 702 patients. Patients were interviewed once in 3 months for 18-24 months (response rate 69%). RESULTS: Overall, patients' health improved significantly over time: 51% had achieved recovery from the DSM-IV disorder(s) after 1 year and 66% at the end of the study. Respectively, 50% and 60% had 'normal' SCL90 and SF36 scores. Cognitive behavioural therapy and BT patients achieved recovery more often than CAU patients (ORs between 1.26 and 1.48), although these results were not statistically significant. CONCLUSION: Stepped care, with BT or CBT as a first step, is at least as effective as matched care.

Short-term effects of enhanced treatment for depression in primary care: results from a randomized controlled trial.

BACKGROUND: Depression is a highly prevalent, often recurring or persistent disorder. The majority of patients are initially seen and treated in primary care. Effective treatments are available, but possibilities for providing adequate follow-up care are often limited in this setting. This study assesses the effectiveness of primary-care-based enhanced treatment modalities on short-term patient outcomes. METHOD: In a randomized controlled trial we evaluated a psycho-educational self-management intervention. We included 267 adult patients meeting criteria for a DSM-IV diagnosis of major depressive disorder, assessed by a structured psychiatric interview. Patients were randomly assigned to: the Depression Recurrence Prevention (DRP) program (n=112); a combination of the DRP program with psychiatric consultation (PC+DRP, n=39); a combination with brief cognitive behavior therapy (CBT+DRP, n=44); and care as usual (CAU, n=72). Follow-up assessments were made at 3 months (response 90%) and 6 months (85%). RESULTS: Patient acceptance of enhanced care was good. The mean duration of the index episode was 11 weeks (S.D.=9.78) and similar in CAU and enhanced care. Recovery rate after 6 months was 67% overall; 17% of all participants remained depressed for the entire 6-month period. CONCLUSION: Enhanced care did not result in better short-term outcomes. We found no evidence that the DRP program was more effective than CAU and no indications for added beneficial effects of either the psychiatric evaluation or the CBT treatment to the basic format of the DRP program. Observed depression treatment rates in CAU were high.

Effects on depression pharmacotherapy of a Dutch general practitioner training program.

BACKGROUND: General practitioners' (GPs) ability to recognize, diagnose and treat depression improved significantly after a comprehensive, 20-h training programme. This study aims to evaluate in more detail the effects of the training on GPs' pharmacotherapy of depression and related issues. METHODS: A pretest-posttest design was used. Both in the pre- and post-training phase, a sample was drawn from consecutive patients of the 17 participating GPs. In the pre-training phase we identified a sample of 31 cases with an ICD-10 depression who received an antidepressant from their GP. The sample was followed for 1 year. Outcome measures were: type of antidepressant, dosage, duration and number of target instructions given by the GP. Then we trained the GPs. In the post-training phase, we identified a new sample (n = 47) from their practices and measured the same outcomes. RESULTS: Improvements were seen in choice for modern antidepressant, adequate dosage, adequate duration, and number of target instructions given. LIMITATIONS: Observed changes can be due to a period effect, inherent in a pre-post design. CONCLUSIONS: A post-academic hands-on training of GPs can improve depression pharmacotherapy according to clinical guidelines with respect to choice of a modern antidepressant, adequate dosage, adequate duration and psychoeducation.

Accuracy of general practitioner's prognosis of the 1-year course of depression and generalised anxiety.

BACKGROUND: A prognosis serves important functions for the management of common mental disorders in primary care. AIMS: To establish the accuracy of the general practitioner's (GP) prognosis. METHOD: The agreement between GP prognosis and observed course was determined for 138 cases of ICD-10 depression and 65 of generalised anxiety disorder, identified among consecutive attenders of 18 GPs. RESULTS: Modest agreement between GP prognosis and course was found, both for depression (kappa=0.21) and generalised anxiety (kappa=0.11). Better agreement (kappa=0.45 for depression, and kappa=0.33 for generalised anxiety) was observed between the course and predictions from a statistical model based on information potentially available to the GP at the time the prognosis was made. This model assesses attainable performance for GPs. CONCLUSIONS: General practitioners do a fair job in predicting the 1-year course of depression and generalised anxiety. Even so, their performance falls significantly short of attainable performance.

Training primary-care physicians to recognize, diagnose and manage depression: does it improve patient outcomes?

BACKGROUND: We developed a comprehensive, 20-hour training programme for primary-care physicians, that sought to improve their ability to detect, diagnose and manage depression. We evaluated the effects of physician training on patient outcomes, using a pre-post design. METHODS: In the pre-training phase of the study, we sampled 1834 consecutive patients of 17 primary-care physicians and evaluated 518 of these patients for the presence of depression. We measured outcomes of all patients with depression at 3 months and 1 year. The outcome measures were: severity of psychopathology; duration of depressive episode; and level of daily functioning. After the 17 physicians completed the training, we drew a new sample from their practices (498 of 1785 consecutive patients were evaluated for depression) and measured outcomes for the depressed patients. RESULTS: We found an effect of the training on short-term outcome, particularly for patients with a recent-onset depression. At 3-month follow-up depressed patients whose physicians had received training had less severe psychopathology and patients with recent-onset depression also showed higher levels of daily functioning than patients of the same physicians prior to the training. The patients with a recent-onset depression that was recognized by trained physicians had shorter depressive episodes, but this was not statistically significant. At 1-year follow-up, all training effects had faded away. CONCLUSIONS: Training primary-care physicians to recognize, diagnose and manage depression can improve short-term patient outcomes, especially for patients with a recent onset of depression. Patients suffering from a recurrent or chronic depression may need more specific interventions, both for acute treatment and long-term management.

Onset of disability in depressed and non-depressed primary care patients.

BACKGROUND: While cross-sectional and longitudinal studies have consistently found depressive illness and disability to be related, understanding whether depression leads to subsequent onset of disability is limited. METHODS: In the context of the multi-centre international WHO Collaborative Study on Psychological Problems in General Health Care, we followed prospectively consulting non-elderly primary care patients who were essentially disability free at baseline but who differed in baseline depression status, comprising 1051 patients free of physical disability at baseline including 14% depression; 914 free of social disability including 9% depression. Depression status was assessed with the CIDI; patient-reported physical disability with the MOS physical functioning scale and social disability with the BDQ role functioning and number of disability days measures; investigator-rated social disability with the Occupational section of Groningen Social Disability schedule; and the treating physicians rated the severity of physical illness. RESULTS: In patients essentially disability free at baseline, depressive illness resulted in a 1.5-fold (at 3 months) and a 1.8-fold (at 12 months) increase in risk of onset of physical disability, after controlling for physical disease severity. Depressive illness also resulted in a 2.2-fold (at 3 months) and a 23-fold (at 12 months) increase in risk of onset of social disability, after controlling for physical disease severity, physical disability and onset of physical disability. CONCLUSIONS: Among non-elderly primary care patients, depressive illness is associated with onset of physical disability and shows an even stronger association with onset of social disability.

Gender differences in the prevalence of depression: a survey in primary care.

Epidemiological surveys demonstrate that unipolar depression is more common in females than in males. Gender-specific cultural and social factors may contribute to the female preponderance. This study explores this possibility in a cross-cultural sample of general-practice patients systematically recruited in the WHO study "Psychological Problems in Primary Care" conducted in 14 countries with identical sampling and assessment strategies. Although absolute prevalence rates are broadly varying between centers proposing that the gender ratio is nearly constant with 1:2. The cultural context does not contribute substantially to the female preponderance. This study lends some support to previous observations that the magnitude of female preponderance is associated with the number of symptoms associated with depression requested for caseness and inversely related to the degree of social impairment. Matching social role variables (marital status, children, occupational status) between females and males reduces the female excess by about 50% across all centers. Therefore, we conclude that social factors are inducing part of the preponderance of females among depressed cases.

Training primary care physicians improves the management of depression.

The purpose of this pretest-posttest study was to evaluate effects of a training program designed to improve primary care physicians' (PCPs) ability to recognize mental health problems (MHP) and to diagnose and manage depression according to clinical guidelines. The primary care settings were in the northern part of The Netherlands. There were eight intensive, hands-on training sessions of 2.5 hours, each of which three were targeting depression (7.5 hours). In the pretraining phase we screened 1778 consecutive patients of 17 PCPs with the 12-item General Health Questionnaire (GHQ-12) and interviewed a stratified sample of 518 patients about presence of current depression with the Primary Health Care version of the Composite International Diagnostic Interview (CIDI-PHC). PCPs registered patient's mental health (status, severity, diagnosis) and treatment prescribed. Then we trained the PCPs. In the posttraining phase, we screened a new group of 1724 consecutive patients of the same PCPs and a new stratified sample of 498 patients went through the same interview and rating procedures as patients in the pretraining phase. Knowledge about depression was assessed pre- and posttraining. PCPs' knowledge of depression improved significantly. Recognition of MHP and accuracy of depression diagnosis improved, but was not statistically significant. The proportion of patients receiving treatment according to the clinical guidelines increased significantly. It was observed that training PCPs improves the management of depression.

Diagnosis of depression by primary care physicians versus a structured diagnostic interview. Understanding discordance.

In this paper, false-negative and false-positive cases of depressive illness are examined, differentiating levels of disagreement between a primary care physician's diagnosis and a standardized research diagnosis. Two stratified random samples of primary care patients in Seattle, USA (N = 373) and Groningen, The Netherlands (N = 340) were examined with the Composite International Diagnostic Interview-Primary Health Care Version (CIDI-PHC). Physician's severity ratings and diagnosis of psychological disorder were obtained. Three levels of disagreement between physician and CIDI diagnosis were distinguished: 1) complete disagreement about the presence of psychiatric symptoms (true false-negative and true false-positive patients); 2) disagreement over severity of recognized psychological illness (underestimated or overestimated); and 3) disagreement over the specific psychiatric diagnosis among those given a diagnosis (misdiagnosed or given another CIDI diagnosis). All three levels of disagreement were common. Only 27% of the false-negative cases were due to complete disagreement (true false-negatives), and 55% of the false-positives were due to complete disagreement (true false-positives). The true false-negative patients were younger, more often employed, rated their own health more favorably, visited their doctor for a somatic complaint and made fewer visits than the underestimated, misdiagnosed, and concordant positive patients. Complete disagreement in depressive diagnoses between the primary care physician and research interview is not as frequent as indicated by an undifferentiated false-negative/ false-positive analysis. Differentiating levels of disagreement does more justice to diagnostic practice in primary care and provides guidance on how to improve the diagnostic accuracy of primary care physicians.

Outcomes of recognized and unrecognized depression in an international primary care study.

Longitudinal data from the World Health Organization Psychological Problems in General Health Care study were used to examine the relationship between recognition and outcomes among depressed primary care patients. A representative sample of primary care patients at 15 sites completed a baseline assessment including the Composite International Diagnostic Interview (CIDI), the 28-item General Health Questionnaire (GHQ), and the Brief Disability Questionnaire (BDQ). The GHQ and BDQ were readministered after 3 months, and the GHQ, BDQ, and CIDI were readministered after 12 months. Of 948 patients with major depression at the baseline assessment, 42% were recognized by the primary care physician and given an appropriate diagnosis. Recognized patients were more severely ill (mean GHQ score 16.2 vs. 12.9, t = 5.44, p < 0.001) and more disabled (mean BDQ score 9.8 vs 8.2, t = 3.22, p < 0.001) at baseline. Recognized patients showed a significantly greater decrease in GHQ score at the 3-month assessment (6.1 vs 4.1, F = 5.33, df = 1, p = 0.02). At 12 months, recognized and unrecognized groups did not differ in either change in GHQ score or change in diagnostic status from baseline. Results were consistent across study sites. Our data suggest that recognition and appropriate diagnosis of depression in primary care is associated with significantly greater short-term improvement. The absence of a relationship between recognition and long-term outcomes may reflect limitations of this observational study. When considered along with other recent studies, these findings suggest that increasing recognition of depression in primary care is only a first step toward more appropriate treatment.

Sex differences in the prevalence and detection of depressive and anxiety disorders in general health care settings: report from the World Health Organization Collaborative Study on Psychological Problems in General Health Care.

BACKGROUND: Understanding the relevance of biological and social factors to sex differences in the prevalence and detection of depressive and anxiety disorders has been impaired by the lack of standardized research methods across cultures. METHOD: Prevalence rates of depressive and anxiety disorders were assessed using a 2-stage design from 26,969 patients attending for primary care in 15 centers from 4 continents. Logistic regression analysis was used to examine sex differences in prevalence and detection across centers. RESULTS: Odds ratios for women compared with men of current depression (1.60; 95% confidence interval [CI], 1.37-1.86) and agoraphobia or panic (1.63; 95% CI, 1.18-2.20) were consistent across centers. The odds ratio for generalized anxiety varied among centers: 3 groups of centers were identified with odds ratios of 0.46 (95% CI, 0.27-0.78), 1.34 (95% CI, 1.08-1.66), and 3.09 (95% CI, 1.60-5.89). There was no sex difference in the detection of depressive and anxiety disorders by physicians across centers. CONCLUSIONS: The absence of a sex-by-center effect for current depression and agoraphobia or panic disorder is consistent with biological and psychosocial factors, either interacting or working alone, that have a similar final effect across cultures. It does not support the idea that sex differences in prevalence are caused by local psychosocial factors that vary from country to country. The variation in the odds ratio for generalized anxiety disorder offers some support to the idea that there are local differences between the centers contributing to the sex difference in rates. Patients' sex does not appear to affect the likelihood of current depression and anxiety being detected by primary care physicians.