Effect of chronic somatic diseases on the course of late-life depression.

OBJECTIVE: To examine the influence of specific chronic somatic diseases and overall somatic diseases burden on the course of depression in older persons. METHODS: This was a prospective cohort study with a 2-year follow-up. Participants were depressed persons (n = 285) from the Netherlands Study of Depression in Older Persons. The presence of chronic somatic diseases was based on self-report. Diagnosis of depression was assessed with the Composite International Diagnostic Interview, and severity of depression was measured with the Inventory of Depressive Symptomatology Self-report. RESULTS: Cardiovascular diseases (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.02-2.72, p = 0.041), musculoskeletal diseases (OR = 1.71, 95% CI = 1.04-2.80, p = 0.034), and the number of chronic somatic diseases (OR = 1.37, 95% CI = 1.16-1.63, p < 0.001) were associated with having a depressive disorder at 2-year follow-up. Furthermore, chronic non-specific lung diseases, cardiovascular diseases, musculoskeletal diseases, cancer, or cumulative somatic disease burden were associated with a chronic course of depression. CONCLUSIONS: Somatic disease burden is associated with a poor course of late-life depression. The course of late-life depression is particularly unfavorable in the presence of chronic non-specific lung diseases, cardiovascular diseases, musculoskeletal diseases, and cancer. Copyright © 2016 John Wiley & Sons, Ltd.

The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation.

BACKGROUND: fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity. OBJECTIVE: to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients. METHODS: the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region. RESULTS: developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples. CONCLUSIONS: by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.

Musicians seeking psychiatric help: a preliminary study of psychiatric characteristics.

Musicians are at increased risk for mental disorders, in particular performance anxiety. Likely causes are high levels of occupational stress, special personality traits, and coping skills. In this cross-sectional study, routine outcome monitoring (ROM) data on clinical and psychosocial characteristics were collected from the first 50 musicians visiting our outpatient psychiatric clinic for performing artists and were compared to those of a large sample of psychiatric outpatients (n=1,498) and subjects from the general population. Of the musician outpatients, 82% (n=41) met the criteria of an Axis I psychiatric disorder. Performance anxiety could not be accurately diagnosed with the MINI-plus, and in a few cases it masked different psychiatric disorders. Musician outpatients scored significantly better on functional scales despite their Axis I disorder, with equal scores on scales measuring distress compared to general outpatients. Musicians displayed significantly higher mean scores on the DAPP-sf subscale measuring narcissistic personality traits than general outpatients and non-patient controls (p=0.001). Diagnostic challenges, in particular regarding performance anxiety, of musicians seeking psychiatric care are thoroughly discussed. Musicians with psychiatric disorders may constitute a group of patients with specific characteristics who may benefit from specialized psychiatric care, and health professionals should be aware of the high prevalence of psychiatric disorders in musicians.

Predicting outcome of depression using the depressive symptom profile: the Leiden Routine Outcome Monitoring Study.

BACKGROUND: To investigate the predictive value of items for individual depressive symptoms measured with the self-rated Beck Depression Inventory-Revised (BDI-II) self-report scale on outcome in a large naturalistic cohort of depressive outpatients. METHODS: We used a cohort of 1,489 adult patients aged 18-65 years with major depressive disorder or dysthymic disorder established with the MINI-Plus diagnostic interview. All patients had a routine outcome monitoring baseline measurement in 2004-2009, with a maximum of 2 years follow-up. We used multivariable Cox regression models to predict remission (MADRS < 10; where MADRS stands for Montgomery-Åsberg Depression Rating Scale) and response (≥50% improvement), and adjusted for clinical and demographic characteristics (i.e. marital status, level of education, working status, comorbid anxiety, avoidant and borderline personality traits, and suicidality) that were identified as predictors in earlier studies. RESULTS: Of the 21 BDI-II items, the items "pessimism" and "loss of energy" independently predicted for both remission and response. For pessimism, the hazard ratio (HR) for remission was 0.81 (95% confidence interval [CI]: 0.73-0.89, P < .001) and for loss of energy, the HR was 0.81 (95% CI: 0.72-0.92, P = .001). CONCLUSIONS: These findings of robust prediction of poor outcome by baseline items of "pessimism" and "loss of energy" in a naturalistic treatment setting may help clinicians to identify depressive patients in need for additional or alternative therapeutic approaches.

Assessing adherence to guidelines for common mental disorders in routine clinical practice.

OBJECTIVE: To measure the overall level of adherence to clinical guidelines with a set of cross-diagnostic process indicators in a randomly selected sample of outpatients who started an acute phase treatment for a common mental disorder in a routine clinical setting. SETTING AND PARTICIPANTS: We developed a generic set of quality measures to asses the implementation of guidelines in daily practice. This set was tested in a retrospective cohort study in a randomly selected sample of 300 outpatients who started an acute phase psychiatric treatment for various psychiatric disorders. Patients were treated with pharmacotherapy, psychotherapy or a combination of both. MAIN OUTCOME MEASURE: Scores on cross-diagnostic process indicators. RESULTS: Most indicators were positive in a high to very high percentage, indicating that most treatment elements in this routine clinical practice setting were delivered according to the guidelines for the acute treatment phase. We observed significant lower scores in the combined treatment group as compared with the two other treatment groups on the indicators 'correct treatment module' and 'stepped care' (P ≤ 0.005). Patients receiving psychotherapy had the best results on the separate indicators. Overall, only a minority of the patients in this sample was treated in complete accordance with the guidelines and treatment manuals. CONCLUSIONS: Assessment of guideline adherence is feasible with this cross-diagnostic set of process indicators and hampering factors of implementation could be easily detected. Future research should focus on the relationship with treatment outcomes.

Assessing adherence to guidelines with administrative data in psychiatric outpatients.

RATIONALE, AIMS AND OBJECTIVES: To assess (feasibility) of adherence to treatment guidelines among outpatients with common mental disorders in a routine Dutch clinical outpatient setting for common mental disorders using administrative data. METHODS: In a retrospective cohort study, we analysed routinely collected administrative data of 5346 patients, treated for mood, anxiety or somatoform disorders with pharmacotherapy, psychotherapy or a combination of both. Available administrative data allowed assessment of guideline adherence with a disorder-independent set of five quality indicators, assessing psychotherapy, pharmacotherapy, a combination of both and routine outcome measurements (ROM) during diagnostic and therapeutic phases. Associations between the socio-demographic variables age, gender, clinical diagnosis and treatment type on the one hand and non-adherence to guidelines were tested using logistic regression analysis. RESULTS: Patients were aged 39.5 years (SD 13.0) on average. The majority of patients were treated with a combination of pharmacotherapy and psychotherapy (50.1%), followed by psychotherapy (44.2%) and pharmacotherapy (5.6%). The majority of patients were suffering from a mood disorder (50.0%), followed by anxiety (43.9%) and somatoform disorders (6.1%). A diagnosis of anxiety or somatoform disorder was associated with higher odds of suboptimal duration [odds ratio (OR): 1.55 and 1.82[ and suboptimal frequency of psychotherapeutic treatment (OR of 0.89 and 0.63), and absence of ROM in the diagnostic phase (ORs 1.31 and 1.36, respectively) compared with depressive disorders. No ROM in the diagnostic phase was also predicted for by increasing age (ORs for the age categories of 56 and older of 1.48). CONCLUSIONS: In this proof of principal study, we were able to assess some key indicators assessing adherence to clinical guidelines by using administrative data. Also, we could identify predictors of adherence with simple parameters available in every administrative data. Administrative data could help to monitor and aid guideline adherence in routine care, although quality may vary between settings.

A Pilot Study Evaluating the Physiological Parameters of Performance-Induced Stress in Undergraduate Music Students.

Music performance anxiety (MPA) is a specific condition for musicians. Although it can have a negative influence on their music careers, little attention is paid to this phenomenon both in the professional environment and in stress research. In the current pilot study, insight was gained into the physiology of the autonomic stress response related to anxiety in musicians when performing on stage by using a wearable biosensor patch for registration of a range of physiological parameters. Also, the validity of two different psychometric questionnaires in objectifying the stress response on stage to predict the individual stress response was explored. The autonomic physiological parameters (heart rate, respiratory rate, skin temperature) of 11 violists and violinists were collected while performing on stage and in resting state using the VitalConnect HealthPatch®. In addition, scores on validated questionnaires in research on MPA (State Anxiety Inventory, Kenny Music Performance Anxiety Inventory, Short Form Health Survey) were collected in order to try to objectify the magnitude of the subjective level of both MPA and experienced stress. The registration of the autonomic parameters showed a significant increase in heart rate, respiratory rate, and stress level from resting state measurements during stage performance. Analysis of heart rate variability showed a shift from indices of parasympathetic nervous system activity during baseline measurements towards indices of sympathetic nervous system activity during stress measurements. Surprisingly, none of the questionnaires was correlated to the physiological stress parameters on stage. In conclusion, the wearable biosensor patch proved to be an adequate tool to assess physiological stress parameters on stage. The different questionnaires did not contribute to the prediction of its occurrence in a group of musicians.

When Contact Is Not Enough: Affecting First Year Medical Students' Image towards Older Persons.

CONTEXT: Many medical schools have initiated care internships to familiarize their students with older persons and to instil a professional attitude. OBJECTIVE: To examine the impact of care internships on the image that first-year medical students have of older persons and to explore the underlying concepts that may play a role in shaping this image. DESIGN: Survey before and after a two-week compulsory care internship using the Aging Semantic Differential (ASD; 32 adjectives) and the Attitudes toward Old People (AOP; 34 positions) questionnaires. PARTICIPANTS: Before and after a care internship involving interpersonal contact, 252 and 244 first-year medical students at the Leiden University Medical Centre (LUMC) in the academic year 2012-2013 participated. METHOD: Descriptive statistics, analyses of variance, and principal component analysis were used; clusters of adjectives and positions were reduced into concepts to examine dominant patterns of views. Changes in image were investigated as mean differences of the total and concept scores. RESULTS: Both the ASD and the AOP questionnaires showed a poor general image of older persons that significantly worsened after the care internship (p < 0.01). The percentage of students considering over 75 years as being old increased from 17.2% to 31.2% (p < 0.01) and those who thought they would find as much satisfaction in care for older as for younger patients decreased from 78.5% to 62.1% (p < 0.001). Exploratory principal component analysis showed particularly low scores on 'comportment' and 'pleasurable interaction' whereas the scores on 'personality traits' and 'habitual behaviour' significantly deteriorated (both p < 0.001). These patterns were irrespective of the student's gender and previous contact experience. CONCLUSION: Medical schools should carefully consider care internships to ensure that students do not worsen their views on older patients, which may occur due to inadequate contact depth and quality within a rather unsupportive context.

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders.

OBJECTIVE: To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting. METHODS: In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow-up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF-36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence. RESULTS: Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF-36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF-36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06-1.71). No significant differences were found within socio-demographic variables, co-morbidity and the scores on the BSI subscales between the adherence groups. CONCLUSIONS: We found that patients with low scores on the vitality subscale of the SF-36 were at the highest risk to receive low guideline-concordant care. Understanding factors that affect treatment adherence may help to prevent non-adherence and increase the quality of care as well as cost-effectiveness.

Routine outcome monitoring and feedback on physical or mental health status: evidence and theory.

OBJECTIVES: Routine Outcome Monitoring (ROM) is an important quality tool for measuring outcome of treatment in health care. The objective of this article is to summarize the evidence base that supports the provision of feedback on ROM results to (mental) health care professionals and patients. Also, some relevant theoretical aspects are considered. METHODS: Literature study (Pubmed, Medline, PsychINFO, Embase Psychiatry, 1975-2009) concerning randomized controlled trials (RTC's) of ROM and feedback on physical or mental health status of patients of all ages. Main search terms were routine outcome monitoring/measurement, feedback, health status measurement, patient reported outcome measures. RESULTS: Included were 52 RCT's concerning ROM and feedback with adult or older patients: of these seven RCT's were exclusively focused on physical health and 45 RCT's (also) on the mental health of the patient, although not always in a mental health care setting or as primary outcome measure. There appears to be a positive impact of ROM on diagnosis and monitoring of treatment, and on communication between patient and therapist. Other results were less clear. There were no published RCT's on this topic with children or adolescents. CONCLUSIONS: ROM appears especially effective for the monitoring of patients who are not doing well in therapy. Further research into this topic and the clinical-and cost-effectiveness of ROM is recommended, especially in mental health care for both adults and children. Also, more theory-driven research is needed with relevant conceptualizations such as Feedback Intervention Theory, Therapeutic Assessment.

Predicting outcomes of mood, anxiety and somatoform disorders: the Leiden routine outcome monitoring study.

BACKGROUND: Mood, anxiety and somatoform (MAS) disorders are highly prevalent disorders with substantial mutual comorbidity and a large disease burden. Early identification of patients at risk for poor outcome in routine clinical practice is of clinical importance. The purpose of this study was to predict outcomes in outpatients with MAS disorders using routine outcome monitoring (ROM) data. METHODS: We conducted a cohort study of 892 adult MAS patients in a naturalistic outpatient psychiatric specialty care setting and validated our results in a replication cohort of 1392 patients. Poor outcome was defined as a <50% reduction (compared to baseline) on the self-report brief symptom inventory (BSI) or a score of ≥3 on the observer-rated clinical global impression severity scale (CGI-S). During a follow-up of up to 2 years, Cox regression models were used to analyze the independent baseline predictors for poor outcome. RESULTS: In multivariable Cox regression models, independent and replicated predictors for poor outcome were higher age (overall p<0.001 for combined cohorts in multivariable Cox regression model), having comorbid MAS disorders or a somatoform disorder (<0.001), dysfunctional personality traits (i.e., tendency to self-harm [p<0.001], intimacy problems [p<0.001] and affective lability [p<0.001]), and a low reported general health status (p<0.001). LIMITATIONS: Detailed treatment information was not available. CONCLUSIONS: MAS patients meeting the profile of being elderly, suffering from comorbid MAS disorders or a somatoform disorder, with cluster B personality traits, and a poor reported general health may need special preventive measures to minimise the risk of poor outcome.