Hein van Hout

Stepped-Care Prevention of Anxiety and Depression in Late Life: A Randomized Controlled Trial

CONTEXT Given the public health significance of late-life depression and anxiety, and the limited capacity of treatment, there is an urgent need to develop effective strategies to prevent these disorders. OBJECTIVE To determine the effectiveness of an indicated stepped-care prevention program for depression and anxiety disorders in the elderly. DESIGN Randomized controlled trial with recruitment between October 1, 2004, and October 1, 2005. SETTING Thirty-three primary care practices in the northwestern part of the Netherlands. PARTICIPANTS A total of 170 consenting individuals, 75 years and older, with subthreshold symptom levels of depression or anxiety who did not meet the full diagnostic criteria for the disorders. INTERVENTION Participants were randomly assigned to a preventive stepped-care program (n = 86) or to usual care (n = 84). Stepped-care participants sequentially received a watchful waiting approach, cognitive behavior therapy-based bibliotherapy, cognitive behavior therapy-based problem-solving treatment, and referral to primary care for medication, if required. MAIN OUTCOME MEASURES The cumulative incidence of DSM-IV major depressive disorder or anxiety disorder after 12 months as measured using the Mini International Neuropsychiatric Interview. RESULTS The intervention halved the 12-month incidence of depressive and anxiety disorders, from 0.24 (20 of 84) in the usual care group to 0.12 (10 of 86) in the stepped-care group (relative risk, 0.49; 95% confidence interval, 0.24 to 0.98). CONCLUSIONS Indicated stepped-care prevention of depression and anxiety in elderly individuals is effective in reducing the risk of onset of these disorders and is valuable as seen from the public health perspective.

Depression is associated with decreased blood pressure, but antidepressant use increases the risk for hypertension

The present study compared blood pressure levels between subjects with clinical anxiety and depressive disorders with healthy controls. Cross-sectional data were obtained in a large cohort study, the Netherlands Study of Depression and Anxiety (N=2981). Participants were classified as controls (N=590) or currently or remittedly depressed or anxious subjects (N=2028), of which 1384 were not and 644 were using antidepressants. Regression analyses calculated the contributions of anxiety and depressive disorders and antidepressant use to diastolic and systolic blood pressures, after controlling for multiple covariates. Heart rate and heart rate variability measures were subsequently added to test whether effects of anxiety/depression or medication were mediated by vagal control over the heart. Higher mean diastolic blood pressure was found among the current anxious subjects (β=0.932; P=0.03), although anxiety was not significantly related to hypertension risk. Remitted and current depressed subjects had a lower mean systolic blood pressure (β=−1.74, P=0.04 and β=−2.35, P=0.004, respectively) and were significantly less likely to have isolated systolic hypertension than controls. Users of tricyclic antidepressants had higher mean systolic and diastolic blood pressures and were more likely to have hypertension stage 1 (odds ratio: 1.90; 95% CI: 0.94 to 3.84; P=0.07) and stage 2 (odds ratio: 3.19; 95% CI: 1.35 to 7.59; P=0.008). Users of noradrenergic and serotonergic working antidepressants were more likely to have hypertension stage 1. This study shows that depressive disorder is associated with low systolic blood pressure and less hypertension, whereas the use of certain antidepressants is associated with both high diastolic and systolic blood pressures and hypertension.

What do community-dwelling people with dementia need? A survey of those who are known to care and welfare services

BACKGROUND The aging society will bring an increase in the number of people with dementia living in the community. This will mean a greater demand on care and welfare services to deliver efficient and customized care, which requires a thorough understanding of subjective and objective care needs. This study aims to assess the needs of community-dwelling people with dementia as reported by themselves and by their informal carers. The study also aims to give insight into the service use and gaps between needs and the availability of services. METHODS 236 community-dwelling people with dementia and 322 informal carers were interviewed separately. (Un)met needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE). RESULTS Most unmet needs were experienced in the domains of memory, information, company, psychological distress and daytime activities. People with dementia reported fewer (unmet) needs than their carers. Type and severity of dementia, living situation and informal carer characteristics were related to the number of reported needs. CONCLUSIONS This study showed a large number of unmet needs in dementia. Reasons for unmet needs are lack of knowledge about the existing service offer, a threshold to using services and insufficient services offer. These results provide a good starting point for improving community care for people with dementia.

Cardiovascular disease in persons with depressive and anxiety disorders

BACKGROUND Associations between depression, and possibly anxiety, with cardiovascular disease have been established in the general population and among heart patients. This study examined whether cardiovascular disease was more prevalent among a large cohort of depressed and/or anxious persons. In addition, the role of specific clinical characteristics of depressive and anxiety disorders in the association with cardiovascular disease was explored. METHODS Baseline data from the Netherlands Study of Depression and Anxiety were used, including persons with a current (i.e. past year) or remitted DSM-IV depressive or anxiety disorder (N=2315) and healthy controls (N=492). Additional clinical characteristics (subtype, duration, severity, and psychoactive medication) were assessed. Cardiovascular disease (stroke and coronary heart disease) was assessed using algorithms based on self-report and medication use. RESULTS Persons with current anxiety disorders showed an about three-fold increased prevalence of coronary heart disease (OR anxiety only=2.70, 95%CI=1.31-5.56; OR comorbid anxiety/depression=3.54, 95%CI=1.79-6.98). No associations were found for persons with depressive disorders only or remitted disorders, nor for stroke. Severity of depressive and anxiety symptoms--but no other clinical characteristics--most strongly indicated increased prevalence of coronary heart disease. LIMITATIONS Cross-sectional design. CONCLUSIONS Within this large psychopathology-based cohort study, prevalence of coronary heart disease was especially increased among persons with anxiety disorders. Increased prevalence of coronary heart disease among depressed persons was largely owing to comorbid anxiety. Anxiety-alone as well as comorbid to depressive disorders-as risk indicator of coronary heart disease deserves more attention in both research and clinical practice.

Incidence of Depression and Anxiety in the Spouses of Patients With Dementia: A Naturalistic Cohort Study of Recorded Morbidity With a 6-Year Follow-Up

OBJECTIVE Living with a demented person has been associated with high levels of clinical depression and anxiety. However, there are no prospective studies that allow good estimates of the incidence of depression and anxiety. In this study, the authors assess the long-term incidence of depression and anxiety in the spouses of patients with dementia as recorded by general practitioners. DESIGN Prospective naturalistic cohort study with a comparison group. Data from medical records in 2001-2007 were analyzed. PARTICIPANTS Two hundred eighteen spouses of patients with dementia and 353 age and gender-matched spouses of nondemented persons. SETTING Seventy-one general practices in the Netherlands with a listed source population of 320,309 patients. MEASUREMENTS Incidence rates (IRs) per 1,000 person-years and hazard ratios (HRs) of depression and anxiety; prescription rates (per 1,000 person-years) for antidepressants and anxiolytics. RESULTS A new episode of depression was diagnosed in 18 spouses and 7 comparison spouses (IRs of 18.8/1,000 person-years and 4.4/1,000 person-years, respectively). Spouses of patients with dementia were far more likely to be diagnosed with depression than the comparison spouses (HR, 4.16; 95% CI: 1.73-9.98). Spouses did not have a higher incidence of anxiety than the comparison group (HR, 1.26; 95% CI: 0.58-2.71). The prescription rates for both antidepressants and anxiolytics were significantly higher for spouses than for the comparison group. CONCLUSION The spouses of patients with dementia have a fourfold higher risk of a diagnosis of depression than the spouses of nondemented persons. The authors could not establish this for anxiety.

The identification of frail older adults in primary care: comparing the accuracy of five simple instruments

BACKGROUND many instruments are available to identify frail older adults who may benefit from geriatric interventions. Most of those instruments are time-consuming and difficult to use in primary care. OBJECTIVE to select a valid instrument to identify frail older adults in primary care, five simple instruments were compared. METHODS instruments included clinical judgement of the general practitioner, prescription of multiple medications, the Groningen frailty indicator (GFI), PRISMA-7 and the self-rated health of the older adult. Frieds frailty criteria and a clinical judgement by a multidisciplinary expert panel were used as reference standards. Data were used from the cross-sectional Dutch Identification of Frail Elderly Study consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. In this study, frail older adults were oversampled. We estimated the accuracy of each instrument by calculating the area under the ROC curve. The agreement between the instruments and the reference standards was determined by kappa. RESULTS frailty prevalence rates in this sample ranged from 11.6 to 36.4%. The accuracy of the instruments ranged from poor (AUC = 0.64) to good (AUC = 0.85). CONCLUSION PRISMA-7 was the best of the five instruments with good accuracy. Further research is needed to establish the predictive validity and clinical utility of the simple instruments used in this study.

Cost-effectiveness of a stepped care intervention to prevent depression and anxiety in late life: randomised trial

BACKGROUND There is an urgent need for the development of cost-effective preventive strategies to reduce the onset of mental disorders. AIMS To establish the cost-effectiveness of a stepped care preventive intervention for depression and anxiety disorders in older people at high risk of these conditions, compared with routine primary care. METHOD An economic evaluation was conducted alongside a pragmatic randomised controlled trial (ISRCTN26474556). Consenting individuals presenting with subthreshold levels of depressive or anxiety symptoms were randomly assigned to a preventive stepped care programme (n = 86) or to routine primary care (n = 84). RESULTS The intervention was successful in halving the incidence rate of depression and anxiety at euro563 ( pound412) per recipient and euro4367 ( pound3196) per disorder-free year gained, compared with routine primary care. The latter would represent good value for money if the willingness to pay for a disorder-free year is at least euro5000. CONCLUSIONS The prevention programme generated depression- and anxiety-free survival years in the older population at affordable cost.

Impact of coaching by community pharmacists on drug attitude of depressive primary care patients and acceptability to patients; a randomized controlled trial.

OBJECTIVE To investigate whether an intervention by Dutch community pharmacists improves the drug attitude of depressive patients, who are prescribed a nontricyclic antidepressant by their general practitioner (GP). METHOD A randomized controlled trial with a 3-month follow-up was conducted among consecutive general practice patients who go to 19 pharmacists for antidepressants. The trial consisted of a control group (n=79) that received usual care and an intervention group (n=69) that received three drug coaching contacts at the pharmacy and a 25-min take-home video on the background of depression and the effects of medication. OUTCOME MEASURE Drug attitude (DAI). RESULTS At the baseline measurement there were no significant differences between the intervention and control group on any demographic and health status variables or on clinical symptoms. At the 3-month follow-up intervention patients had a better drug attitude (P=0.03) than their controls and evaluated the coaching of their pharmacist as more positive. They also felt the video to be useful. It had changed their ideas about medication. CONCLUSIONS Coaching by community pharmacists is an effective way to improve drug attitude of depressive primary care patients and it is acceptable to them.

Cost effectiveness of a pharmacy-based coaching programme to improve adherence to antidepressants.

IntroductionThe efficacy of antidepressants in the treatment of depression has been convincingly demonstrated in randomised trials. However, non-adherence to antidepressant treatment is common.ObjectiveTo evaluate, from a societal perspective, the cost effectiveness of a pharmacy-based intervention to improve adherence to antidepressant therapy in adult patients receiving treatment in primary care.MethodsAn economic evaluation was performed alongside a 6-month randomised controlled trial in The Netherlands.Patients who came to 19 pharmacies with a new prescription for a non-tricyclic antidepressant, i.e. those who had not received any prescription for an antidepressant in the past 6 months, were invited to participate. They were then randomly allocated to education and coaching by the pharmacist or to usual care. The coaching programme consisted of three contacts with the pharmacist, with a mean duration of between 13 and 20 minutes, and a take-home video reviewing important facts on depression and antidepressant treatment.The clinical outcome measures were adherence to antidepressant treatment measured using an electronic pill container (eDEM) and improvement in depressive symptoms measured using the Hopkins Symptom Checklist (SCL). Resource use was measured by means of questionnaires. The uncertainty around differences in costs and cost effectiveness between the treatment groups was evaluated using bootstrapping.ResultsSeventy patients were randomised to the intervention group and 81 to the usual care group; of these, 40 in the intervention group and 48 in the control group completed all of the follow-up questionnaires.There were no significant differences in adherence, improvements in the SCL depression mean item score and costs over 6 months between the two treatment groups. Mean total costs (2002 values) were €3275 in the intervention group and €2961 in the control group (mean difference €315; 95% CI —1922, 2416). The incremental cost-effectiveness ratio associated with the pharmacist intervention was €149 per 1% improvement in adherence and €2550 per point improvement in the SCL depression mean item score. Cost-effectiveness planes and acceptability curves indicated that the pharmacist intervention was not likely to be cost effective compared with usual care.ConclusionIn patients starting treatment with antidepressants, there were no significant differences in adherence, severity of depression, costs and cost effectiveness between patients receiving coaching by a pharmacist and patients receiving usual care after 6 months. Considering the resources needed to implement an intervention like this in clinical practice, based on these results, the continuation of usual care is recommended.

Does a family meetings intervention prevent depression and anxiety in family caregivers of dementia patients? A randomized trial

Background Family caregivers of dementia patients are at increased risk of developing depression or anxiety. A multi-component program designed to mobilize support of family networks demonstrated effectiveness in decreasing depressive symptoms in caregivers. However, the impact of an intervention consisting solely of family meetings on depression and anxiety has not yet been evaluated. This study examines the preventive effects of family meetings for primary caregivers of community-dwelling dementia patients. Methods A randomized multicenter trial was conducted among 192 primary caregivers of community dwelling dementia patients. Caregivers did not meet the diagnostic criteria for depressive or anxiety disorder at baseline. Participants were randomized to the family meetings intervention (n = 96) or usual care (n = 96) condition. The intervention consisted of two individual sessions and four family meetings which occurred once every 2 to 3 months for a year. Outcome measures after 12 months were the incidence of a clinical depressive or anxiety disorder and change in depressive and anxiety symptoms (primary outcomes), caregiver burden and quality of life (secondary outcomes). Intention-to-treat as well as per protocol analyses were performed. Results A substantial number of caregivers (72/192) developed a depressive or anxiety disorder within 12 months. The intervention was not superior to usual care either in reducing the risk of disorder onset (adjusted IRR 0.98; 95% CI 0.69 to 1.38) or in reducing depressive (randomization-by-time interaction coefficient = −1.40; 95% CI −3.91 to 1.10) or anxiety symptoms (randomization-by-time interaction coefficient = −0.55; 95% CI −1.59 to 0.49). The intervention did not reduce caregiver burden or their health related quality of life. Conclusion This study did not demonstrate preventive effects of family meetings on the mental health of family caregivers. Further research should determine whether this intervention might be more beneficial if provided in a more concentrated dose, when applied for therapeutic purposes or targeted towards subgroups of caregivers. Trial Registration Controlled-Trials.com ISRCTN90163486