Aartjan Beekman

Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group

Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late‐life anxiety disorders.

Psychiatric and Medical Comorbidities: Results from a Bipolar Elderly Cohort Study

OBJECTIVEnBipolar disorder is associated with concurrent mental and physical disorders. Although well studied among younger adults, less is known about concurrent morbidity among older patients. This is important because comorbidity may increase with age and optimal treatment requires awareness of medical and psychiatric comorbidities. This study analyzed psychiatric and medical comorbidity in a Dutch bipolar elderly cohort.nnnMETHODSnThis cross-sectional descriptive study included demographic and clinical data on 101 bipolar patients aged 60 and over (mean age: 68.9 ± 7.8 years); 53.4% were women. Psychiatric diagnoses were confirmed by semistructured diagnostic interviews. Somatic history, including current somatic complaints, was obtained by interview. Medication and indicators of metabolic syndrome were obtained via record review.nnnRESULTSnMost patients received outpatient care. Bipolar I disorder was diagnosed in 56.4% of patients, and 75.6% had an onset of first affective symptoms before age 50. The prevalence rates of psychiatric comorbidities were low, except for lifetime alcohol dependence (24.8%) and abuse (13.9%). On average, there were 1.7 (SD: 1.6) medical comorbid conditions, predominantly hypertension (27.8%), arthrosis (29.1%), and allergies (25.6%). Polypharmacy was found in 31.7% of patients and metabolic syndrome in 28.7%.nnnCONCLUSIONnPsychiatric comorbidity (especially anxiety disorders) was relatively uncommon, except for substance use disorder. Geriatric bipolar patients had on average two comorbid medical conditions and relatively high medication use. Findings underline the need to assess for comorbid conditions in bipolar elders, thereby enabling tailored treatment to optimize the general condition of these patients.

Anxiety Disorders in Older Adults: Looking to DSM5 and Beyond…

Anxiety in late life was for many years the ‘Cinderella’ of psychiatric disorders, often overshadowed by the focus on depression and dementia, and receiving little attention in research and clinical domains. As highlighted by an editorial published in this journal several years ago [1], the scientific study of anxiety in older age has a relatively brief history. Recently, however, there has been increased recognition of the prevalence and clinical consequences of anxiety disorders in older adults and lively debate about their nature and most appropriate diagnostic criteria [2, 3, 4]. The current evidence reveals that anxiety in older adults is more common than depression in community samples [5], often preceding depressive disorders [6]; moreover, co-morbid anxiety and depression has a poorer outcome than either condition alone [7]. Anxiety disorders are even more prevalent in clinical settings [8], and can have serious consequences for recovery from illness [9] and quality of life [10], as well as substantially increasing disability levels [11]. Therefore, anxiety disorders in older adults should be regarded as conditions of great public health importance.

Shared Decision Making in mental health care using Routine Outcome Monitoring as a source of information: a cluster randomised controlled trial

AbstractBackgroundShared Decision Making (SDM) is a way to empower patients when decisions are made about treatment. In order to be effective agents in this process, patients need access to information of good quality. Routine Outcome Monitoring (ROM) may provide such information and therefore may be a key element in SDM. This trial tests the effectiveness of SDM using ROM, primarily aiming to diminish decisional conflict of the patient while making decisions about treatment. The degree of decisional conflict, the primary outcome of this study, encompasses personal certainty about choosing an appropriate treatment, information about options, clarification of patient values, support from others and patients experience of an effective decision making process. Secondary outcomes of the study focus on the working alliance between patient and clinician, adherence to treatment, and clinical outcome and quality of life.Methods/DesignThis article presents the study protocol of a multi-centre two-arm cluster randomised controlled trial (RCT). The research is conducted in Dutch specialised mental health care teams participating in the ROM Quality Improvement Collaborative (QIC), which aims to implement ROM in daily clinical practice. In the intervention teams, ROM is used as a source of information during the SDM process between the patient and clinician. Control teams receive no specific SDM or ROM instructions and apply decision making as usual. Randomisation is conducted at the level of the participating teams within the mental health organisations. A total of 12 teams from 4 organisations and 364 patients participate in the study. Prior to data collection, the intervention teams are trained to use ROM during the SDM process. Data collection will be at baseline, and at 3 and 6xa0months after inclusion of the patient. Control teams will implement the SDM and ROM model after completion of the study.DiscussionThis study will provide useful information about the effectiveness of ROM within a SDM framework. Furthermore, with practical guidelines this study may contribute to the implementation of SDM using ROM in mental health care. Reporting of the results is expected from December 2016 onwards.Trial registrationDutch trial register: TC5262n Trial registration date: 24th of June 2015

The care needs of older patients with bipolar disorder

Objectives: With aging, bipolar disorder evolves into a more complex illness, with increasing cognitive impairment, somatic comorbidity, and polypharmacy. To tailor treatment of these patients, it is important to study their needs, as having more unmet needs is a strong predictor of a lower quality of life. Method: Seventy-eight Dutch patients with bipolar I or II disorder aged 60 years and older in contact with mental health services were interviewed using the Camberwell Assessment of Need in the Elderly (CANE) to assess met and unmet needs, both from a patient and a staff perspective. Results: Patients (mean age 68 years, range 61–98) reported a mean of 4.3 needs compared to 4.4 reported by staff, of which 0.8 were unmet according to patients and 0.5 according to staff. Patients frequently rated company and daytime activities as unmet needs. More current mood symptoms were associated with a higher total number of needs. Less social participation was associated with a higher total number of needs and more unmet needs. Conclusion: Older bipolar patients report fewer needs and unmet needs compared to older patients with depression, schizophrenia, and dementia. A plausible explanation is that older bipolar patients had higher Global Assessment of Functioning scores, were better socially integrated, and had fewer actual mood symptoms, all of which correlated with the number of needs in this study. The results emphasize the necessity to assess the needs of bipolar patients with special attention to social functioning, as it is suggested that staff fail to recognize or anticipate these needs.

Neuropathological correlates of late-life depression

Evaluation of: Tsopelas N, Stewart R, Savva GM et al.; the MRCFAS study. Neuropathological correlates of late-life depression in older people. Br. J. Psychiatry 198, 109–114 (2011). The relationship between depression and both dementia and cerebrovascular pathology has, for good reason, received much attention from researchers and clinicians alike. Over previous decades, several generations of hypotheses have linked depression to the etiology or pathophysiology of dementia. Similarly, a host of studies have looked at the interplay between cerebrovascular pathology and late-life depression. This has resulted in new concepts of late-life depression, such as vascular depression. The study under evaluation sought to assess the neuropathological correlates of late-life depression by examining brains donated for study by a large sample of participants in the Medical Research Council Cognitive Function and Ageing Study. The study is unique in its large size, representative sample of participants and rigorous exclusion of participants who were demented during their life, using structured interviews to diagnose depression at multiple life stages before death. The results suggest that depression is not associated with cortical pathology of either Alzheimer’s dementia or cerebrovascular disease. There were associations with Lewy body pathology and loss of neurons in the hippocampus and other subcortical areas. Although the authors are cautious with regard to drawing firm conclusions, the results suggest that, in the community, depression is not an important etiological factor for the development of the neuropathology of Alzheimer’s disease and there was no association with cerebrovascular pathology. Although restricted to only very few subjects, the association with Lewy body pathology warrants further research, as does the association with neuronal loss in the hippocampus.

Childhood abuse, family history and stressors in older patients with bipolar disorder in relation to age at onset

OBJECTIVESnThe aim of this study is to explore the family history of psychiatric disorders, childhood abuse, and stressors in older patients with Bipolar Disorder (BD) and the association of these variables with the age at onset of BD.nnnMETHODSnThe Questionnaire for Bipolar Disorder (QBP) and the Mini International Neuropsychiatric Interview (MINI-Plus) were obtained from 78 patients aged 60 and over to determine diagnosis, age at onset of the first affective episode, childhood abuse, family history of psychiatric disorders and past and recent stressful life events.nnnRESULTSnIncreased family history of psychiatric disorders was the only factor associated with an earlier age at onset of BD. Less family history of psychiatric disorders and more negative stressors were significantly associated with a later age at onset of the first (hypo)manic episode.nnnLIMITATIONSnAge at onset, history of childhood abuse, and past stressful life events were assessed retrospectively. Family members of BD patients were not interviewed.nnnCONCLUSIONSnOur findings suggest that age at onset can define distinct BD phenotypes. More specifically there was a stronger heredity of BD and other psychiatric disorders in patients with an early age of onset of BD. Negative stressors may play a specific role in patients with a late age at onset of a first (hypo)manic episode.

Schizophrenia in the Netherlands: Continuity of Care with Better Quality of Care for Less Medical Costs

Background Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment. Methods Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008–2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs. Results Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509. Conclusions Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.

Recognition of psychopathology with religious content by clergy members: a case vignette study

Clergy members (CMs) frequently offer support and counselling for people with mental health problems. The current study aims to obtain insight into the ability among CMs to recognise psychopathology and need for psychiatric treatment. A random sample of CMs (Nu2009=u2009143) and a control sample of mental health professionals (MHPs, Nu2009=u200973), were compared as to their evaluations of four vignettes. CMs considered the psychiatric states to be related to religious or spiritual problems to a similar degree as they did for the non-psychiatric states. Sensitivity of CMs with regard to the need of psychiatric care for the psychiatric states was modest (66%) and differed significantly from MHPs (96%). Specificity of the CMs was 89%, which was significantly lower than the MHPs (97%). The CMs did recognise psychopathology with religious content but clearly to a lower extent than MHPs. Requests by CMs for education about recognising psychopathology may be considered as justified.

Collaborative care voor depressieve patiënten

SamenvattingHuijbregts KM, de Jong FJ, Van Marwijk HWJ, Beekman ATF, Hakkaart-Roijen L, Van der Feltz-Cornelis CM. Collaborative care voor depressieve patiënten. Huisarts Wet 2013;56(5):210-3.AchtergrondVan alle patiënten bij wie een depressie wordt vaststeld, krijgt de meerderheid een behandeling in de eerste lijn. Lang niet al deze patiënten krijgen zorg conform de NHG-Standaard. Mogelijk speelt hierbij mee dat huisartsen te weinig tijd beschikbaar hebben om regie te voeren bij deze patiënten, die met complexe psychosociale problemen te kampen hebben. Zogeheten competing demands (deze patiënten komen zelden alleen met een depressie) kunnen hierbij ook een rol spelen. Het collaborative care-model kan een oplossing bieden, aangezien de huisarts hierbij ondersteuning krijgt van een caremanager in de eerste lijn, die bepaalde aspecten van de zorg overneemt, zoals monitoring en kortdurende gespreksbehandeling, Problem Solving Treatment (PST). Ook is een consulent psychiater gemakkelijk beschikbaar voor overleg en kunnen de caremanager en de huisarts gebruikmaken van een web-based patiëntvolgsysteem, dat advies geeft over de te volgen stappen.MethodeIn een clustergerandomiseerde trial vergeleken we collaborative care met de gebruikelijke Nederlandse huisartsenzorg. We randomiseerden 18 gezondheidscentra. Honderdvijftig patiënten kwamen in aanmerking voor deelname na screening met de PHQ-9 (een vragenlijst die op basis van de 9 DSM-IV-criteria voor depressie een ernstscore tussen de 0 en 27 genereert), dan wel na aanmelding door de deelnemende huisartsen. De huisartsen meldden 56 patiënten aan, allen op een na in de collaborative care-groep. Vijfenveertig patiënten kregen collaborative care na identificatie door screening en 49 patiënten kregen gebruikelijke zorg (allen behalve één na screening). De primaire uitkomstmaat was behandelrespons (een afname van 50% op de PHQ-9-score tussen baseline en een vervolgmeting).ResultatenCollaborative care bleek effectiever dan de gebruikelijke zorg na 3 (oddsratio 5,2 (95%-BI 1,41-16,09), number needed to treat 2) en 9 maanden (oddsratio 5,6 (95%-BI 1,40-22,58), number needed to treat 3).ConclusieCollaborative care bleek zowel in de aangemelde als in de gescreende groep effectiever dan de gebruikelijke zorg. De lage numbers needed to treat getuigen hiervan. Een beperking van het onderzoek was wel het relatief hoge percentage patiënten (36,5%) dat een of meer van de vragenlijsten niet terugstuurde. Ook screening voor depressie per post bleek lastig, waardoor de inclusie aanvankelijk traag verliep. Aanmelding via de huisarts bleek aanmerkelijk succesvoller. De huisartsen bleken in staat om een groep patiënten te identificeren die veel baat had bij de interventie. Implementatie van collaborative care in de Nederlandse eerste lijn lijkt al met al zeker de moeite waard.