Richel Lousberg

Higher incidence of depression preceding the onset of Parkinson's disease: a register study.

Although case histories of depression preceding Parkinsons disease (PD) point to a possible pathophysiological relationship between these two disorders, there is as yet no epidemiological evidence to support this view. We compared the incidence of depression in patients later diagnosed with PD with that of a matched control population. Using data from an ongoing general practice‐based register study, the lifetime incidence of depressive disorder was calculated for patients until their diagnosis of PD and compared with that of a matched control population from the same register. At the time of analysis, the register held information on 105,416 people. At the time of their diagnosis of PD, 9.2% of the patients had a history of depression, compared with 4.0% of the control population (χ2 = 22.388, df = 1, P < 0.001). The odds ratio for a history of depression for these patients was 2.4 (95% CI: 2.1–2.7). We concluded that the higher incidence of depression in patients who were later diagnosed with PD supports the hypothesis of there being a biological risk factor for depression in these patients.

The validity of the Hamilton and Montgomery‐Åsberg depression rating scales as screening and diagnostic tools for depression in Parkinson's disease

The concurrent validity of the Hamilton Rating Scale for Depression (HAMD‐17) and the Montgomery‐Åsberg Depression Rating Scale (MADRS) against the DSM‐IV diagnosis ‘depressive disorder’ was assessed in patients with Parkinsons disease (PD). Sixty‐three non‐demented Parkinsons Disease (PD) patients who attended the outpatient department of an academic hospital were diagnosed according to a standardised research protocol. This protocol consisted of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) to establish the presence or absence of ‘depressive disorder’ according to the DSM‐IV criteria, as well as the HAMD‐17 and the MADRS. Receiver Operating Characteristics curves (ROC curves) were obtained and the positive and negative predictive values (PPV, NPV) were calculated for different cut‐off scores. Maximum discrimination between depressed and non‐depressed patients was reached at a cut‐off score of 13/14 for the HAMD‐17, and at 14/15 for the MADRS. At lower cut‐offs, like 11/12 for the HAMD‐17 and 14/15 for the MADRS, the high sensitivity and NPV make these scales good screening instruments. At higher cut‐offs, such as 16/17 for the HAMD‐17 and 17/18 for the MADRS, the high specificity and PPV make these instruments good diagnostic instruments. The diagnostics performance of the HAMD‐17 is slightly better than that of the MADRS. This study shows that it is justified to use the HAMD‐17 and the MADRS to measure depressive symptoms in both non‐depressed and depressed PD patients, to diagnose depressive disorder in PD, and to dichotomize patient samples into depressed and non‐depressed groups. Copyright

Behavioral Problems in Dementia: A Factor Analysis of the Neuropsychiatric Inventory

The aim of this study was to detect behavioral subsyndromes of the 12-item Neuropsychiatric Inventory (NPI). Cross-sectional data of 199 patients with dementia living in the community were collected. Principal component analysis (with Varimax rotation) was used for factor analysis. Results showed the presence of three behavioral subsyndromes: mood/apathy, psychosis, and hyperactivity. Anxiety was regarded as a separate symptom. The subsyndrome mood/apathy was the most common, occurring in almost 80% of the patients, versus psychosis and hyperactivity, which occurred in 37 and 60% of the patients, respectively.

Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial.

Objectives:Radiofrequency facet joint denervation procedures have been common practice for 2 decades in treatment of chronic low back pain. We designed this multicenter, randomized, double-blind, sham treatment controlled trial to determine the efficacy of radiofrequency facet joint denervation, as it is routinely performed. Methods:Inclusion criteria were low back pain, duration more than 6 months, and ≥50% Visual Analog Scale (VAS) reduction on diagnostic block. Exclusion criteria were prior radiofrequency treatment, radicular syndrome, coagulopathies, specific allergies, cancer, and pregnancy. A total of 81 out of 462 patients were randomized to undergo radiofrequency facet joint denervation or sham treatment. The first evaluation was carried out 3 months after treatment. Primary outcome was determined with a combined outcome measure comprising VAS, physical activities, and analgesic intake, from a twice-weekly recorded diary. Secondary outcome measures were the separate diary parameters, global perceived effect (complete relief, >50% relief, no effect, pain increase), and SF-36 Quality of Life Questionnaire. Results:There were no dropouts before the first evaluation. The combined outcome measure showed no differences between radio- frequency facet joint denervation (n = 40; success 27.5%) and sham (n = 41; success 29.3%) (P = 0.86). The VAS in both groups improved (P < 0.001). Global perceived effect improved after radiofrequency facet joint denervation (P < 0.05). The other secondary outcome parameters showed no significant differences. Relevant costs were evaluated. Discussion:The combined outcome measure and VAS showed no difference between radiofrequency and sham, though in both groups, significant VAS improvement occurred. The global perceived effect was in favor of radiofrequency. In selected patients, radiofrequency facet joint denervation appears to be more effective than sham treatment.

Predictive Accuracy of MCI Subtypes for Alzheimer’s Disease and Vascular Dementia in Subjects with Mild Cognitive Impairment: A 2-Year Follow-Up Study

Aim: The aim of this study was to investigate the prognostic accuracy of different subtypes of mild cognitive impairment (MCI): amnestic MCI, multiple domain MCI, and single non-memory domain MCI, for the development of Alzheimer’s dementia (AD) and vascular dementia (VaD). Patients: Nondemented patients from a memory clinic cohort (n = 118), and a stroke cohort (n = 80, older than 55 years and with a cognitive impairment). Results: ‘Multiple domain MCI’ had the highest sensitivity for both AD (80.8%) and VaD (100%), and ‘amnestic MCI’ had the highest specificity (85.9% for AD, 100% for VaD). The positive predictive value was low for all subtypes (0.0–32.7%), whereas the negative predictive value was high (72.8–100%). Discussion: The subtype ‘multiple domain MCI’ has high sensitivity in identifying people at risk for developing AD or VaD. The predictive accuracy of the MCI subtypes was similar for both AD and VaD.

The association between motor subtypes and psychopathology in Parkinson's disease

BACKGROUND In Parkinsons disease (PD) it has been suggested that various motor subtypes are also characterized by a different prevalence and severity of specific non-motor symptoms such as cognitive deterioration, depression, apathy and hallucinations. The aim of this study was to investigate the association between motor subtypes and psychopathology in PD. METHODS An exploratory and confirmatory cluster analysis of motor and psychopathological symptoms was performed with a randomized sample of 173 patients each, stemming from two research databases: one from Stavanger University Hospital and one from Maastricht University Hospital. These databases contained data of standardized assessments of patients with the Unified Parkinsons Disease Rating Scale, the Montgomery-Asberg Depression Rating Scale, and the Mini-Mental State Examination. RESULTS PD patients can be accurately and reliably classified into four different subtypes: rapid disease progression subtype, young-onset subtype, non-tremor-dominant subtype with psychopathology and a tremor-dominant subtype. Cognitive deterioration, depressive and apathetic symptoms, and hallucinations all cluster within the non-tremor-dominant motor subtype, that is characterized by hypokinesia, rigidity, postural instability and gait disorder. CONCLUSIONS This study shows that non-tremor-dominant PD is associated with cognitive deterioration, depression, apathy, and hallucinations, which has implications for future research into the pathophysiology of psychopathology in PD.

A comparative study into the one year cumulative incidence of depression after stroke and myocardial infarction

Background: The high incidence of post-stroke depression has been claimed to reflect a specific, stroke related pathogenesis in which lesion location plays an important role. To substantiate this claim, post-stroke depression should occur more often than depression after another acute, life threatening, disabling disease that does not involve cerebrovascular damage. Objectives: To compare the cumulative one year incidence of depression after stroke and after myocardial infarction, taking into consideration differences in age, sex, and the level of handicap. Methods: In a longitudinal design, 190 first ever stroke patients and 200 first ever myocardial infarction patients were followed up for one year. Depression self rating scales were used as a screening instrument to detect patients with depressive symptoms. Major and minor depression was assessed at one, three, six, nine, and 12 months after stroke or myocardial infarction according to DSM-IV criteria, using the structured clinical interview from DSM-IV. The severity of depressive symptoms was measured with the Hamilton depression rating scale. Level of disability and handicap was rated with the Rankin handicap scale. Results: The cumulative one year incidence of major and minor depression was 37.8% in stroke patients and 25% in patients with myocardial infarction (hazard ratio 1.6; p = 0.06). This difference disappeared after controlling for sex, age, and level of handicap. In addition, no differences were found in the severity of depressive symptoms or in the time of onset of the depressive episode after stroke or myocardial infarction. Conclusions: Depression occurs equally often during the first year after stroke and after myocardial infarction when non-specific factors such as sex, age, and level of handicap are taken into account. Thus the relatively high incidence of post-stroke depression seems not to reflect a specific pathogenic mechanism. Further research is needed to investigate whether vascular factors play a common role in the development of depression after stroke and myocardial infarction.

One year cumulative incidence of depression following myocardial infarction and impact on cardiac outcome

BACKGROUND Major depression has been identified as an independent risk factor for increased morbidity and mortality in mixed patients populations with first and recurrent myocardial infarction (MI). The aim of this study was to evaluate whether incidence of major and minor depression is as high in a population with merely first-MI patients as in recurrent MI populations. Furthermore, it was evaluated whether in first-MI patients major and minor depression, and depressive symptoms, had an impact on cardiac mortality and morbidity up to 3 years post MI. METHODS A consecutive cohort of 206 patients with a first MI were included in this study. One month following MI, all patients were interviewed using the Structured Clinical Interview for DSM-IV (SCID-I-R). Three, six, nine and twelve months following MI, patients filled out three psychiatric self-rating scales for depression, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), and the 90-item Symptom Checklist (SCL-90). Patients, exceeding a previously defined cut-off value on at least one of these scales, were reinterviewed using the SCID. The BDI was applied to assess depressive symptoms in relation to cardiac outcome as the SCL-90 and HADS showed similar results. Cardiac outcome was defined as major cardiac event, i.e., death or recurrent MI, and health care consumption, i.e., cardiac rehospitalisation and/or frequent visits at the cardiac outpatient clinic. Depression outcome was assessed from 1 month post MI up to 1 year post MI whereas cardiac outcome was assessed between 1 month and 3 years post MI. RESULTS A 1-year incidence of 31% of major and minor depression was found in first-MI patients. The highest incidence rate for both major and minor depression was found in the first month after MI. Compared with nondepressed patients, depressed patients were younger (P=.001), female (P=.04) and were known with a previous depressive episode (P=.002). Neither major/minor depression nor depressive symptoms significantly predicted major cardiac events, but did predict health care consumption (P=.04 and P<.001, respectively). CONCLUSIONS Incidence of major and minor depression is similar in this first-MI patients population as in recurrent MI populations. Major/minor depressive disorder nor depressive symptoms predicted neither mortality nor reinfarction.

Treatment of post-myocardial infarction depressive disorder: a randomized, placebo-controlled trial with mirtazapine.

Objective: To examine the antidepressant efficacy of a dual-acting antidepressant (mirtazapine) in patients with post-myocardial infarction (MI) depressive disorder. Antidepressants used in post MI trials with a randomized, double-blind, placebo-controlled design have been restricted to selective serotonin reuptake inhibitors (SSRIs). Antidepressant effects have been limited. Methods: In a prospective multicenter study, 2177 patients with MI were evaluated for depressive disorder during the first year post MI. Ninety-one patients who met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for major or minor depressive disorder were randomized to a 24-week, double-blind, placebo-controlled trial. Antidepressant efficacy was tested using last-observation-carried-forward procedure and repeated measurements analysis using the SPPS mixed models approach, with as primary outcome reduction in depressive symptomatology on the 17-item Hamilton-Depression Rating Scale (Ham-D), and secondary outcomes the Beck Depression Inventory (BDI) and depression subscale of the Symptom Check List 90 items (dSCL-90) as well as the Clinical Global Impression (CGI) scale. Results: Using the “last observation carried forward” (LOCF) method, mirtazapine did not show to be superior to placebo on the Ham-D, but did on the BDI, dSCL-90, and CGI scale over the acute treatment phase of 8 weeks (n = 91). Using mixed models analysis over the entire 24 weeks of treatment (n = 40), we did find a significant difference favoring mirtazapine to placebo on the Ham-D, BDI, and CGI, but on the dSCL-90, this difference was not significant. Conclusions: This trial shows efficacy of mirtazapine on primary and secondary depression measures. Mirtazapine seems to be safe in the treatment of post-MI depression. MI = myocardial infarction; RCT = randomized controlled trial; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders; CAD = coronary artery disease; SSRI = selective serotonin reuptake inhibitors; TCA = tricyclic antidepressant; Ham-D = Hamilton-Depression Rating Scale; BDI = Beck Depression Inventory; CGI = Clinical Global Impression; dSCL-90 = Symptom Check List 90 items, depression subscale; SES = standardized effect size.

Recognizing Increased Risk of Depressive Comorbidity after Myocardial Infarction: Looking for 4 Symptoms of Anxiety-Depression

Background: Screening for depression in myocardial infarction (MI) patients must be improved: (1) depression often goes unrecognized and (2) anxiety has been largely overlooked as an essential feature of depression in these patients. We therefore examined the co-occurrence of anxiety and depression after MI, and the validity of a brief mixed anxiety-depression index as a simple way to identify post-MI patients at increased risk of comorbid depression. Methods: One month after MI, 176 patients underwent a psychiatric interview and completed the Beck Depression Inventory (BDI) and the Symptoms of Anxiety-Depression index (SAD4) containing four symptoms of anxiety (tension, restlessness) and depression (feeling blue, hopelessness). Results: Thirty-one MI patients (18%) had comorbid depression and 37 (21%) depressive or anxiety disorder. High factor loadings and item-total correlations (SAD4, α = 0.86) confirmed that symptoms of anxiety and depression co-occurred after MI. Mixed anxiety-depression (SAD4≧3) was present in 90% of depressed MI patients and in 100% of severely depressed patients. After adjustment for standard depression symptoms (BDI; OR = 4.4, 95% CI 1.6–12.1, p = 0.004), left ventricular ejection fraction, age and sex, mixed anxiety-depression symptomatology was associated with an increased risk of depressive comorbidity (OR = 11.2, 95% CI 3.0–42.5, p < 0.0001). Mixed anxiety-depression was also independently associated with depressive or anxiety disorder (OR = 9.2, 95% CI 3.0–27.6, p < 0.0001). Conclusions: Anxiety is underrecognized in post-MI patients; however, the present findings suggest that anxiety symptomatology should not be overlooked in these patients. Depressive comorbidity after MI is characterized by symptoms of mixed anxiety-depression, after controlling for standard depression symptoms. The SAD4 represents an easy way to recognize the increased risk of post-MI depression.