D.B. Oosterbaan

An open study of paroxetine in hypochondriasis

1. Despite the high prevalence of hypochondriasis, this disorder is found to be the focus of research only minimally. 2. This open study evaluates the efficacy and tolerance of paroxetine in 11 patients with DSM-III-R hypochondriasis. 3. Using paired samples t-test, a significant reduction on measures of hypochondriasis was found after 12 weeks of treatment compared to baseline. Two patients dropped out prematurely. At post-test, eight out of nine patients who completed the study had improved to a clinically relevant degree. Of these, five attained scores in the reach of the normal population. 4. In one patient who completed the study and one patient who dropped out, tolerance of paroxetine was poor, whereas in remaining patients tolerance was moderate to good. 5. The results of this study suggest that patients with hypochondriasis may be responsive to paroxetine. A controlled study is recommended.

Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomised controlled trial.

BACKGROUND Thus far collaborative stepped care (CSC) studies have not incorporated self-help as a first step. AIMS To evaluate the effectiveness of CSC in the treatment of common mental disorders. METHOD An 8-month cluster randomised controlled trial comparing CSC to care as usual (CAU) (Dutch Trial Register identifier NTR1224). The CSC consisted of a stepped care approach guided by a psychiatric nurse in primary care with the addition of antidepressants dependent on the severity of the disorder, followed by cognitive-behavioural therapy in mental healthcare. RESULTS Twenty general practitioners (GPs) and 8 psychiatric nurses were randomised to provide CSC or CAU. The GPs recruited 163 patients of whom 85% completed the post-test measurements. At 4-month mid-test CSC was superior to CAU: 74.7% (n = 68) v. 50.8% (n = 31) responders (P = 0.003). At 8-month post-test and 12-month follow-up no significant differences were found as the patients in the CAU group improved as well. CONCLUSIONS Treatment within a CSC model resulted in an earlier treatment response compared with CAU.

The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study: design and rationale of a longitudinal naturalistic study of the course of OCD and clinical characteristics of the sample at baseline.

In half of Obsessive Compulsive Disorder (OCD) patients the disorder runs a chronic course despite treatment. The factors determining this unfavourable outcome remain unknown.

The placebo response in social phobia.

The placebo response forms a growing problem in randomized, placebo-controlled clinical trials in psychiatry. Research into the placebo response is on the increase, but remains very limited in relation to social phobia. Together with the dropout rate, the placebo effect is an important factor limiting the discriminative properties of any study. In this study, we reviewed 15 placebo-controlled studies in social phobia, focussing on patients and study characteristics. In social phobia, the placebo effect has turned out to be moderately large and has shown no increase over the past decade. Placebo response was highest in large, multicentred trials and was independent of study duration. No validation for a placebo run-in was found. Taking into account both response to placebo and active drug, as well as dropout rate, the most discriminative results are probably to be expected in a sample of patients who are moderately to severely impaired. More research in the field of the placebo response is needed.

Implementing practice guidelines for anxiety disorders in secondary mental health care: a case study

BackgroundRecent years have seen the large-scale development of clinical practice guidelines for mental disorders in several countries. In the Netherlands, more than ten multidisciplinary guidelines for mental health care have been developed since 2003. The first dealt with the treatment of anxiety disorders. An important question was whether it is feasible to implement these guidelines because implementing practice guidelines is often difficult. Although several implementation interventions have proven effective, there seems to be no ready-made strategy that works in all circumstances.Case descriptionThe Dutch multidisciplinary guidelines for anxiety disorders were implemented in a community mental health care centre, located in the east of the Netherlands. The centre provides secondary outpatient care. The unit within the centre that specializes in the treatment of anxiety disorders has 16 team members with diverse professional backgrounds. Important steps in the process of implementing the guidelines were analysing the care provided before start of the implementation to determine the goals for improvement, and analysing the context and target group for implementation. Based on these analyses, a tailor-made multifaceted implementation strategy was developed that combined the reorganization of the care process, the development of instruction materials, the organization of educational meetings and the use of continuous quality circles to improve adherence to guidelines.Discussion and evaluationSignificant improvements in adherence rates were made in the aspect of care that was targeted for change. An increase was found in the number of patients being provided with recommended forms of psychotherapeutic treatment, ranging from 43% to 54% (p < 0.01). The delivery of adequate pharmacological treatment was not explicitly targeted for change remained constant.ConclusionThe case study presented here shows that the implementation of practice guidelines for anxiety disorders in mental health care is feasible. Based on the results of our study, the implementation model used offers a useful approach to guideline implementation. By describing the exact steps that were followed in detail and providing some of the tools that were used in the study, we hope the replication of this implementation methodology is made more practical for others in the future.

The effectiveness of adhering to clinical-practice guidelines for anxiety disorders in secondary mental health care: the results of a cohort study in the Netherlands

BACKGROUND While studies into the implementation of clinical practice guidelines for mental health care are scarce, studies on the effectiveness of implementing practice guidelines for anxiety disorders appear to be entirely non-existent. OBJECTIVE To examine whether adherence to anxiety disorder clinical practice guidelines in secondary mental health care yields superior treatment results than non-adherence. METHOD A closed-cohort study of 181 outpatients with an anxiety disorder or hypochondriasis who were treated in a routine mental health setting. Preceding the inclusion of these 181 patients, a start was made on the implementation of the Dutch national multidisciplinary practice guidelines for anxiety disorders. Patients were asked to complete several questionnaires before the start of treatment and again 1 year later. The medical records of these patients were reviewed to assess guideline adherence. Ultimately, adherence or non-adherence to the different treatment algorithms described in the guidelines was related to changes in the severity of psychiatric symptomatology, psychiatric functioning, general well-being and satisfaction with treatment. RESULTS Compared with patients whose treatment did not adhere to the guidelines, those whose treatment adhered to the guidelines were found to have greater symptom reduction after 1 year (P < 0.01). The latter group of patients also rated their satisfaction with their treatment significantly higher (P = 0.01). No significant differences were found after 1 year with respect to changes in impairment of functioning and quality of life in the two groups of patients. CONCLUSIONS Adherence to anxiety disorder guidelines yields superior treatment results and increased patient satisfaction with treatment when compared with patients whose treatment did not adhere to the clinical guidelines. These results should encourage a more widespread implementation of such guidelines in mental health care facilities.

Effectiveness of the implementation of guidelines for anxiety disorders in specialized mental health care

To examine the effect of implementing anxiety disorders guidelines on guideline adherence and patient outcomes in specialized mental health care.

Predictors of non-response and persistent functional impairments in treatment adhering to evidence-based practice guidelines for anxiety disorders

Background: Several countries have developed guidelines for anxiety disorders containing algorithms that summarize the recommended treatment steps for these disorders. It is important to know which patients have a poor prognosis for treatment according to such algorithms. Aims: To investigate the predictive power of variables known to be able to influence treatment prognosis in situations where practice guidelines for anxiety disorders are adhered to. Method: To study the predictive power of variables that are known to be able to influence treatment prognosis, 81 patients who participated in a guideline implementation study and whose treatment was found to adhere to available guidelines were selected. Using logistic regression analysis two models were constructed: one to predict treatment nonresponse; another to predict persistent functional impairments at the 1-year follow-up. Results: The final prediction model for treatment non-response contains only gender and secondary gain variables. It appears that: males have a higher likelihood (p=.074), and patients that report hopes of obtaining external benefits by seeking treatment have a lower likelihood (p=.054) of showing treatment non-response at the 1-year follow-up. The discriminatory power of this model was found to be poor, however. The model for persistent functional impairments includes gender, satisfaction with the accessibility of healthcare services and the presence of a comorbid anxiety disorder. It appears that: males (p=.87) and patients who express dissatisfaction with the accessibility of care (p=.008) have a higher likelihood, and that; patients who suffer from an additional comorbid anxiety disorder have a lower likelihood (p=.079) of persistent functional impairments. The discriminatory power of this model is excellent. Conclusion: It remains difficult to predict which anxiety disorder patients will not benefit from treatment that is tailored according to available practice guideline recommendations, therefore no one should be prevented from being offered such treatment, if one removes barriers in attending treatment.

Sociale fobie: minder op de achtergrond

SamenvattingOosterbaan DB, Van Balkom AJLM. Sociale fobie: minder op de achtergrond. Huisarts Wet 2004;47(2):110-4.Sociale fobie is een van de vaakst voorkomende psychiatrische stoornissen. De gevolgen van deze stoornis voor het functioneren op diverse levensterreinen kunnen groot zijn. Toch staat de problematiek pas recent in de belangstelling bij de bevolking en de gezondheidszorg. Onbehandeld hebben de klachten een chronisch beloop dat vaak gecompliceerd wordt door depressie of alcoholproblematiek. De laatste jaren zijn effectieve medicamenteuze en psychotherapeutische behandelmethoden ontwikkeld. De huisarts kan een cruciale rol spelen bij het signaleren van deze zorgmijdende patiënten.