Marten de Haan

The four-dimensional symptom questionnaire (4DSQ): measuring distress and other mental health problems in a working population

In non-clinical (working) populations it is important to differentiate between general distress, on the one hand, and psychiatric symptoms—depression, anxiety and somatization—on the other hand. The Four-Dimensional Symptom Questionnaire (4DSQ) is a new instrument that measures these four symptom dimensions (Terluin, 1996). This study aimed to investigate the psychometric properties of the 4DSQ in a working population. A postal stress and health survey was sent to all employees of a Dutch telecom company, 51% of whom responded (N=3852). The mailing included the 4DSQ, a set of questionnaires concerning job stress (e.g. psychological demands), coping style (e.g. problem-focused coping, avoidant coping), and indicators of strain (e.g. emotional exhaustion, fatigue). Cronbachs α for the four sub-scales of the 4DSQ ranged from .79 to .90. Factor analysis showed four factors corresponding to the four scales of the 4DSQ: distress, depression, anxiety, and somatization. The validity of the 4DSQ was assessed using (partial) correlations with job stress, coping, and strain. As expected, the distress scale showed the strongest correlations with the indicators of strain, as well as with job stress and coping. In conclusion, the 4DSQ is a reliable and valid instrument that can be used in a working population to distinguish between stress-related symptoms and psychiatric illness.

Gender Differences in Health-Related Quality of Life Among Asthma Patients

Objective. To identify and explain differences between men and women with asthma regarding health-related quality of life (HRQoL). Methods. A cross-sectional study was performed among 967 asthma patients recruited from general practice. Data were collected by means of a pulmonary function assessment, a face-to-face interview, and a written questionnaire. Results. Women with asthma reported lower scores on HRQoL in the age groups 16–34 and 56–75 years but not in the age group 35–55 years. In all age groups, women reported more severe dyspnea but had higher levels of pulmonary function. The poorer HRQoL reported by women could be explained by a more severe dyspnea and a higher level of medication use in women. Conclusions. The finding that women with asthma aged 16–34 and 56–75 years report poorer HRQoL than men is not due to a more severe disease state in terms of pulmonary obstruction but does seem to be related to a more severe subjective disease state in women than in men.

The prognosis of undetected depression in older general practice patients. A one year follow-up study.

BACKGROUND Late-life depression often remains undetected in primary care. However, as there is evidence that GPs do identify those with the most severe and persistent disorders, it is important to know more about the prognosis of depressive disorders that are not detected by GPs. METHODS A one-year follow-up study of depressed patients of 55 years and older consulting their GP in The Netherlands. A two-stepped screening procedure was used to diagnose depression using the GDS-15 and PRIME-MD. GPs and patients were not informed about the results. The course of depression was measured with the MADRS and PRIME-MD, at six and twelve months. Remission was defined by no longer fulfilling DSM-criteria for depressive disorder and a MADRS-score below 10. The prognosis of those not detected by GPs was compared to those that were detected. RESULTS 73 patients were followed for one year. Among the 49 (67%) patients that were not detected by their GP as being depressed, 33% had remitted after one year. Of the 24 (33%) depressed patients that were detected by their GP, 37% had remitted after one year. Detected patients tended to have more serious depression and more comorbid anxiety than undetected patients. CONCLUSIONS Although GPs identify older depressed patients who are most in need of treatment, the prognosis of patients that go undetected is poor.

Antidepressant prescription for depression in general practice in The Netherlands.

Objective: To evaluate diagnoses and the prescription of antidepressants drugs for depression, based on data from 1993 to 1998 related to consultations for depression in general practice in the Netherlands. Method: An exploratory analysis of data provided by IMS Health. Consecutive annual representative samples of 640 GPs regularly registered data on morbidity and (drug) treatment for specific medical problems in special booklets for a period of one week. The data refer to consultations for depression. The diagnoses were initially based on ICD‐9 criteria and later ICD‐10 criteria for depression.Main outcome measures: Number of diagnoses of depression and number of prescriptions for antidepressants.Results: The number of first consultations for depression rose gradually, from 909 in 1993 (95% CI: 774 to 1043), to 1,482 (CI: 1292 to 1672) in 1998: an increase of 63%. For an individual GP, this represents an increase from 18 to 30 in first consultations for depression. The number of prescriptions for antidepressants also increased, mainly during repeat consultations: a 278% increase, from 3,708 in 1993 to 14,024 in 1998 (CIs: 3,504 to 3,912 and 13,252 to 14,796). Antidepressants were prescribed during the first consultation 564 times in 1993 compared with 1,080 times in 1998. The first contact with a GP for depression led to an antidepressant prescription in 62% of cases in 1993 and 73% in 1998. Although the guidelines issued by the Dutch College of General Practitioners in 1994 recommended tricyclic antidepressants (TCAs) for the treatment of depression, paroxetin, fluoxetin, and mirtazapin (SSRIs) accounted for 56% of the prescribed antidepressants.Conclusion:Between 1993 and 1998, GPs in the Netherlands prescribed increasingly more antidepressants, and they prescribed more SSRIs than TCAs. Furthermore, GPs diagnose depression more frequently and the number of repeat consultations has increased.

Effectiveness of disease management programmes for recognition, diagnosis and treatment of depression in primary care.

Objectives: Screening is advocated to improve the recognition of patients with major depression in primary care. Furthermore, disease management programmes are advocated to improve the quality of care and outcome for these patients. But is screening and the subsequent implementation of a disease management programme more effective than usual care? Methods: Review of the literature on the effects of disease management programmes that include screening for major depression in general practice. Results: Six randomised controlled trials were identified in which the effectiveness of disease management programmes were studied in patients with major depression in primary care and compared with usual care. The majority of these, and especially the largest, showed positive effects on the recognition, diagnosis, treatment and outcome of patients. Populations in the US seem to benefit most. Conclusion: The results of disease management programmes for depression in primary care that include screening are positive and are more effective than usual care. Therefore, if preceded by screening, attention to the whole process of care for patients with major depression instead of paying attention to isolated elements of the process is justified.

Primary care management of major depression in patients aged ≥55 years:: outcome of a randomised clinical trial

BACKGROUND Late-life depression is associated with chronic illness, disability, and a poor prognosis. Primary care management may be in need of improvement. AIM To compare the effects of an intervention programme that aims to improve the identification, diagnosis, and treatment of depression in patients aged > or =55 years with the effects of usual care. DESIGN OF STUDY Cluster randomised controlled trial. SETTING General practices in the Netherlands. METHOD Trained GPs performed the intervention and their practice assistants conducted the screenings. Patients were screened with the 15-item Geriatric Depression Scale (GDS-15) and given a consultation with the GP who diagnosed depression with the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Antidepressant treatment was proposed. Primary outcomes were measured with the Montgomery Asberg Depression Rating Scale (MADRS). Trained independent research assistants performed independent evaluations in both arms. RESULTS Eighteen practices (23 GPs) were allocated to the intervention and 16 practices (20 GPs) to usual care. From June 2000 to September 2002, 3937 patients were screened; 579 patients had a positive score on the GDS-15, 178 had major depression, of whom 145 participated in the trial. MADRS scores for the intervention group dropped from 21.66 at baseline to 9.23 at 6 months, and the usual care group from 20.94 at baseline to 11.45 at 6 months. MADRS scores decreased during the year in both arms. For the intervention group, these scores increased between 6 and 12 months. CONCLUSION The programme resulted in lower MADRS scores in the intervention group than in the usual care group, but only at the end of the intervention, at 6 months after baseline.

Effects of coaching by community pharmacists on psychological symptoms of antidepressant users; a randomised controlled trial

BACKGROUND Community pharmacists strive to deliver pharmaceutical care to patients. At the moment, coaching of depressive primary care patients on taking their antidepressants (ADs) is not yet part of their standard care package. AIMS To investigate the effects of coaching by community pharmacists on psychological symptoms. METHOD A randomised controlled trial with a 6-month follow-up. OUTCOMES psychological symptoms with the Hopkins Symptom Checklist (SCL). Intention-to-treat (ITT) was performed with (1) last observation carried forward and (2) with group mean imputation (GMI). RESULTS Analyses with LOCF and GMI resulted in different findings. The LOCF method revealed that at the 6-month follow-up, the intervention patients were less depressed and less anxious than the controls. The intervention was particularly effective in patients with lower levels of education who received pharmacists coaching. However, ITT with the GMI method showed no differences in psychological symptoms. Differences between LOCF and GMI were explained by the selective attrition in the intervention arm (attrition intervention patients had lower initial SCL-item scores on depression and anxiety than the completers) and by the higher attrition rate in controls. CONCLUSIONS Our study indicates that the interpretation of the effects of an intervention on psychological symptoms can differ substantially by the way missing values are imputed. If both LOCF and GMI produce significant differences, efficacy can be concluded. If not, the effects based on ITT analyses with LOCF are based on artefacts. We recommend that positive intervention effects should only be reported when findings with LOCF and GMI are in accordance.

Reliability and validity of the assessment of depression in general practice: the Short Depression Interview (SDI).

General practitioners (GPs) are recommended to use DSM-IV criteria to diagnose major depression in daily clinical practice. This implies the assessment of nine depressive symptoms and four additional criteria. A short structured interview has been developed to assess these symptoms and criteria, and a study was carried out to investigate the reliability and validity with which GPs can assess these symptoms and criteria and the DSM-IV diagnosis of major depression. In 14 general practices, 52 patients with symptoms of distress and depression were interviewed twice by their GP, with an interval of one to four days. Furthermore, the patients filled out three depression questionnaires. The reproducibility of eight symptoms and three additional criteria was moderate to good (kappa >0.40). The reproducibility of the depressive symptom count, that is necessary to arrive at a diagnosis of major depression, was such that in 75 percent of the patients the test-retest difference did not exceed one symptom. The reproducibility of the diagnosis of major depression was good (kappa 0.63). The validity of the diagnosis of major depression assessed by the GPs, as compared to results of the self-report depression questionnaires, was satisfactory (r 0.35-0.61). Diagnosing major depression in patients with depressive symptomatology just above or below the threshold of major depression warrants a certain amount of caution in general practice.

Disease management voor depressieve patiënten van 55

SamenvattingVan Marwijk HWJ, Ader H, De Haan M, Beekman A. Disease management voor depressieve patiënten van 55+. Uitkomsten van een gerandomiseerd onderzoek. Huisarts Wet 2009;52(6):281-6.Doel Wij evalueerden de gevolgen van een interventieprogramma dat probeerde de identificatie, diagnose en behandeling van depressie te verbeteren bij patiënten van ≥ 55 jaar, versus gebruikelijke zorg.Methode Het betreft een clustergerandomiseerde, gecontroleerde trial in huisartsenpraktijken in West-Friesland. Getrainde huisartsen en hun praktijkmedewerkers screenden de patiënten met de uit 15 items bestaande Geriatrische Depressie Schaal (GDS15). De patiënten kregen een consult bij de huisarts, die de depressie beoordeelde met de stemmingsmodule van de Primary Care Evaluation of Mental Disorders (PRIME-MD). De huisarts stelde antidepressieve behandeling voor indien hij dat nodig achtte. Primaire uitkomst was de Montgomery Åsberg Depression Rating Scale (MÅDRS). Onderzoekmedewerkers voerden in beide onderzoeksgroepen onafhankelijke evaluaties uit.Resultaten We wezen 18 praktijken (23 huisartsen) toe aan de interventie en 16 (20 huisartsen) aan de gebruikelijke zorg. Vanaf juni 2000 tot september 2002 onderzochten de huisartsen 3937 patiënten; 579 patiënten hadden een positieve score op de GDS15, 178 hadden een depressie, van wie er 145 aan het project deelnamen. MÅDRS-scores in de interventiegroep daalden van 21,66 bij de nulmeting naar 9,23 bij 6 maanden, en in de gebruikelijke zorggroep van 20,94 bij de nulmeting naar 11,45 bij 6 maanden. De MÅDRS-scores verminderden tijdens het jaar in beide onderzoeksgroepen. Voor de interventiegroep stegen de scores tussen 6 en 12 maanden.Conclusie Het programma resulteerde bij de interventiegroep aan het eind van de interventie en bij 6 maanden na de nulmeting in lagere MÅDRS-scores dan bij de controlegroep, maar niet bij 12 maanden.

Helpen antidepressiva bij depressieve klachten of lichte depressieve stoornissen

SamenvattingHermens MLM, Van Hout HPJ, Terluin B, Adèr HJ, Penninx BWJH, Van Marwijk HWJ, Bosmans JE, Van Dyck R, De Haan M. Helpen antidepressiva bij depressieve klachten of lichte depressieve stoornissen? Huisarts Wet 2008;51(8):361-9.Achtergrond Depressieve klachten en lichte depressieve stoornissen komen in de huisartsenpraktijk veel voor. Er is onvoldoende bewijs dat antidepressiva effectief zijn bij het behandelen van depressieve klachten en lichte depressieve stoornissen in de huisartsenpraktijk.Methode We voerden een pragmatisch gerandomiseerd equivalentieonderzoek uit. Negenenvijftig huisartsen behandelden in totaal 181 volwassen patiënten met depressieve klachten of lichte depressieve stoornissen. Patiënten kregen de gebruikelijke huisartsenzorg met of zonder antidepressiva (respectievelijk GZplusAD of GZgeenAD). We vergeleken de effectiviteit van beide behandelingen. Veranderingen in de ernst van de depressieve symptomen werden met de Montgomery åsberg Depression Rating Scale (MADRS) gemeten na 6, 13, 26 en 52 weken follow-up.Resultaten Zowel in de intention-to-treat- als in de per-protocolanalyse werd alleen na 6 weken equivalentie van GZplusAD en GZgeenAD aangetoond. We vonden in de intention-to-treatanalyse geen verschil in effectiviteit tussen de behandelgroepen. Patiënten die waren toegewezen aan de behandeling van hun voorkeur (vooral als het om GZgeenAD ging) waren vaker trouw aan het behandelprotocol en hun klinische resultaten waren beter.Conclusie GZplusAD bleek even effectief als GZgeenAD na de eerste 6 weken, maar niet na 13, 26, of 52 weken. Geen van beide behandelingen bleek op enig tijdstip superieur. De vraag of antidepressiva klinische effectiviteit toevoegen aan de gebruikelijke huisartsenzorg blijft onbeantwoord.Registratie Nederlandse Trial Register ISRCN03007807.AbstractHermens MLM, Van Hout HPJ, Terluin B, Adèr HJ, Penninx BWJH, Van Marwijk HWJ, Bosmans JE, Van Dyck R, De Haan M. Are antidepressants helpful in minor and mild-major depression? Huisarts Wet 2008;51(8):361-9.Background Minor and mild–major depression are highly prevalent in primary care. There is insufficient evidence that antidepressants are effective in the treatment of minor and mild–major depression. We compared the effectiveness of usual primary care treatment, with or without antidepressants, in minor and mild–major depression.Method We conducted a pragmatic randomised equivalence trial. Ninety-five GPs treated a total of 181 adult patients with minor or mild–major depression. Patients received the usual GP care with or without antidepressants (respectively UCandAD or UCnoAD). We compared the effectiveness of both types of treatment. The Montgomery Ǻsberg Depression Rating Scale (MADRS) was used to assess changes in severity of the depressive symptoms.Results Equivalence of UCandAD and UCnoAD was demonstrated in the intention-to-treat analyses as well as the per-protocol analysis after 6 weeks only. No differences in effectiveness between treatment groups were found in the intention-to-treat analysis. Patients who were assigned to the treatment of their preference (in particular to UCnoAD), were more often compliant to the treatment protocol and had better clinical outcomes.Conclusion UCandAD was as effective as UCnoAD over the first 6 weeks, but not after 13, 26 or 52 weeks. Superiority of either treatment could not be demonstrated at any time. Thus, the question as to whether antidepressants add clinical effectiveness to usual care given by the GP remains unanswered.