M.W.M. de Waal

Depression, disability and somatic diseases among elderly

OBJECTIVE Depression among older adults is associated with both disability and somatic disease. We aimed to further understand this complicated relationship and to study the possible modifying effect of increasing age. DESIGN Cross sectional survey. SETTING Outpatient and inpatient clinics of regional facilities for mental health care and primary care. PARTICIPANTS Elderly people, 60 years and older, 378 persons meeting DSM-IV criteria for a depressive disorder and 132 non-depressed comparisons. MEASUREMENTS Depression diagnoses were assessed with the CIDI version 2.1. Disability was assessed with the WHO Disability Assessment Schedule (WHODAS). Social-demographic information and somatic diseases were assessed by self-report measurements. RESULTS Disability, in general and on all its subscales, was strongly related to depression. Presence of somatic disease did not contribute independently to variance in depression. The relationship was stronger for people of 60-69 years old than for those older than 70 years. Important aspects of disability that contributed to depression were disability in participation, self-care and social activities. LIMITATIONS Results are based on cross sectional data. No inferences about causal relationships can be drawn. CONCLUSION Disability, especially disability regarding participation, self-care, or social activities is strongly related to late-life depression. Somatic diseases in itself are less of a risk for depression, except that somatic diseases are related to disability.

Depression in later life: a more somatic presentation?

BACKGROUND Depression later in life may have a more somatic presentation compared with depression earlier in life due to chronic somatic disease and increasing age. This study examines the influence of the presence of chronic somatic diseases and increasing age on symptom dimensions of late-life depression. METHODS Baseline data of 429 depressed and non-depressed older persons (aged 60-93 years) in the Netherlands Study of Depression in Old Age were used, including symptom dimension scores as assessed with the mood, somatic and motivation subscales of the Inventory of Depressive Symptomatology-Self Report (IDS-SR). Linear regression was performed to investigate the effect of chronic somatic diseases and age on the IDS-SR subscale scores. RESULTS In depressed older persons a higher somatic disease burden was associated with higher scores on the mood subscale (B = 2.02, p = 0.001), whereas higher age was associated with lower scores on the mood (B = -2.30, p < 0.001) and motivation (B = -1.01, p = 0.006) subscales. In depressed compared with non-depressed persons, a higher somatic disease burden showed no different association with higher scores on the somatic subscale (F(1,12) = 9.2; p = 0.003; partial η(2)=0.022). LIMITATIONS Because the IDS-SR subscales are specific for old age, it was not feasible to include persons aged < 60 years to investigate differences between earlier and later life. CONCLUSIONS It seems that neither higher somatic disease burden nor higher age contributes to more severe somatic symptoms in late-life depression. In older old persons aged ≥ 70 years, late-life depression may not be adequately recognized because they may show less mood and motivational symptoms compared with younger old persons.

Hoe up-to-date is het medisch dossier?

SamenvattingInleiding In het elektronisch medisch dossier van huisartsen wordt in toenemende mate gebruik gemaakt van episodegewijze registratie. Wanneer de titel van een zorgepisode in de loop van de tijd verandert, dient deze ‘transitie’ te worden geregistreerd in de episodelijst. Wij onderzochten hoe up-to-date de episodelijsten van de huisartsen van het Registratie Netwerk Universitaire Huisartspraktijken Leiden en Omstreken in dit opzicht zijn.Methode Uit het databestand van het RNUH-LEO werd een selectie gemaakt van verwijzingen naar interne geneeskunde in de periode januari 1998 t/m juni 1999 (n=505). In de gevallen waarbij sprake was van een transitie van werkdiagnose naar definitieve diagnose, werd nagegaan of deze diagnose adequaat in het medisch dossier was geregistreerd (n=218).Resultaten Bij bijna een derde van de onderzochte verwijzingen was de titel van de zorgepisode niet veranderd, hoewel de internist wel een definitieve diagnose had gesteld. In 71% van de gevallen was de definitieve diagnose als episodetitel geregistreerd. In 57% van de gevallen was dit adequaat gebeurd: de episodetitel was veranderd van werkdiagnose naar definitieve diagnose. In 14% van de gevallen was een nieuwe episode in de episodelijst aangemaakt.Conclusie In de praktijk blijkt dat het adequaat bijhouden van de episodelijst te wensen overlaat. Eén blik op de episodelijst is voor (collega-)huisartsen soms nog niet voldoende om op de hoogte te zijn van de actuele situatie van de patiënt.

The effect of pain on presence and severity of depressive disorders in older persons: The role of perceived control as mediator.

BACKGROUND The relation between pain and depression is reported repeatedly. It is suggested that pain by itself is not sufficient for the development of depression. We aim to study the role of perceived control as mediating factor in the relation between pain and depressive disorders at old age. METHODS Baseline data of the Netherlands Study of Depression in Older Persons (NESDO) were used, including 345 persons with DSM-IV depressive disorders (CIDI) and 125 control persons without depressive disorders, aged 60 years and over. Measures included severity of depression (Inventory of Depressive Symptomatology), presence and intensity of pain and pain-related disability (Chronic Graded Pain scale), and a general measure of perceived control over life (Pearlin Mastery Scale). In mediation analyses direct and indirect effects were estimated. RESULTS Older persons with depressive disorders reported pain more frequently with higher intensity than controls. After controlling for confounding, the direct effect of pain intensity and the indirect effect through perceived control on depression were OR=1.10 (CI 95% .98;1.25) and OR=1.24 (1.15;1.35). For pain-related disability these were OR=1.14 (1.02;1.29) and OR=1.21 (1.13;1.29). In depressed persons there was a strong direct effect of pain intensity and disability and a smaller indirect effect through perceived control on severity of depressive symptoms. LIMITATIONS This cross-sectional study cannot give evidence on causal direction. CONCLUSIONS Perceived control plays an important role as mediator in the association between pain and presence of depression. In depressed persons however, the direct role of pain seems more important in the association with depression severity.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

BACKGROUND There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people. AIM To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics. DESIGN AND SETTING Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand. METHOD The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L). RESULTS A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]). CONCLUSION GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.

Depressive subtypes in an elderly cohort identified using latent class analysis

BACKGROUND Clinical findings indicate heterogeneity of depressive disorders, stressing the importance of subtyping depression for research and clinical care. Subtypes of the common late life depression are however seldom studied. Data-driven methods may help provide a more empirically-based classification of late-life depression. METHODS Data were used from the Netherlands Study of Depression in Older People (NESDO) derived from 359 persons, aged 60 years or older, with a current diagnosis of major depressive disorder. Latent class analysis (LCA) was used to identify subtypes of depression, using ten CIDI-based depression items. Classes were then characterized using various sociodemographic and clinical characteristics. RESULTS The most prevalent class, as identified by LCA, was a moderate-severe class (prevalence 46.5%), followed by a severe melancholic class (prevalence 38.4%), and a severe atypical class (prevalence 15.0%). The strongest distinguishing features between the three classes were appetite and weight and, to a lesser extent, psychomotor symptoms and loss of interest. Compared with the melancholic class, the severe atypical class had the highest prevalence of females, the lowest mean age, the highest BMI, and highest prevalence of both cardiovascular disease, and metabolic syndrome. LIMITATIONS The strongest distinguishing symptoms, appetite and weight, could be correlated. Further, only longitudinal studies could demonstrate whether the identified classes are stable on the long term. DISCUSSION In older persons with depressive disorders, three distinct subtypes were identified, similar to subtypes found in younger adults. The strongest distinguishing features were appetite and weight; moreover, classes differed strongly on prevalence of metabolic syndrome and cardiovascular disease. These findings suggest differences in the involvement of metabolic pathways across classes, which should be considered when investigating the pathogenesis and (eventually) treatment of depression in older persons.

Physician's Prescribing Preference as an Instrumental Variable: Exploring Assumptions Using Survey Data.

Background: Physician’s prescribing preference is increasingly used as an instrumental variable in studies of therapeutic effects. However, differences in prescribing patterns among physicians may reflect differences in preferences or in case-mix. Furthermore, there is debate regarding the possible assumptions for point estimation using physician’s preference as an instrument. Methods: A survey was sent to general practitioners (GPs) in The Netherlands, the United Kingdom, New Zealand, Ireland, Switzerland, and Germany, asking whether they would prescribe levothyroxine to eight fictitious patients with subclinical hypothyroidism. We investigated (1) whether variation in physician’s preference was observable and to what extent it was explained by characteristics of GPs and their patient populations and (2) whether the data were compatible with deterministic and stochastic monotonicity assumptions. Results: Levothyroxine prescriptions varied substantially among the 526 responding GPs. Between-GP variance in levothyroxine prescriptions (logit scale) was 9.9 (95% confidence interval: 8.0, 12) in the initial mixed effects logistic model, 8.3 (6.7, 10) after adding a fixed effect for country and 8.2 (6.6, 10) after adding GP characteristics. The occurring prescription patterns falsified the deterministic monotonicity assumption. All cases in all countries were more likely to receive levothyroxine if a different case of the same GP received levothyroxine, which is compatible with the stochastic monotonicity assumption. The data were incompatible with this assumption for a different definition of the instrument. Conclusions: Our study supports the existence of physician’s preference as a determinant in treatment decisions. Deterministic monotonicity will generally not be plausible for physician’s preference as an instrument. Depending on the definition of the instrument, stochastic monotonicity may be plausible.

Telefonische behandeling bij chronische pijn

controlegroep 8%, voor de TCGT-groep 33%, voor de CT-groep 24% en voor de gecombineerde interventiegroep 37%. Ook na controle nificant verschillend ten gunste van de actieve therapieën, met bijbehorende NNT’s (respectievelijk 4,6 en 3). Geen van de actieve therapieën bleek kosteneffectief na 6 maanden. Na 9 maanden had TCGT de voorkeur, met 70% kans om kosteneffectief te zijn ten opzichte van gebruikelijke zorg. Beschouwing De auteurs concluderen dat telefonische CGT leidt tot blijvende en klinisch relevante verbetering van zelfgerapporteerde gezondheid voor patiënten met chronische verspreide pijn in de huisartsenpraktijk.