Search

Objective: Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient and FP characteristics were related to recognition., Method: A cross-sectional comparison was made between FPs' registration and a structured diagnostic interview, the Composite International Diagnostic Interview, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Seven definitions of recognition were tested using diagnostic codes, medication data, referral data and free text in medical records. Data were derived from the Netherlands Study of Depression and Anxiety. A total of 816 patients were included., Results: Recognition ranged between 9.1% and 85.8%. A broader definition was associated with a higher recognition rate, but led to more false positives. The best definition comprised diagnostic codes for anxiety disorders and symptoms, strong free-text indications, medication and referral to mental health care. Generalized anxiety disorder was best recognized by this definition. Recognition was better among patients with increased severity, comorbid depression and older age., Conclusion: FPs recognized anxiety disorders better than previously reported when all medical record data were taken into account. However, most patients were nonspecifically labeled as having a mental health problem., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Although most depressed patients are treated in primary care, not all are recognized as such. This study explores the determinants of (non-)recognition of depression by general practitioners (GPs), with a focus on specific depression symptoms as possible determinants., Methods: Recognition of depression by GPs was investigated in 484 primary care participants of the Netherlands Study of Depression and Anxiety, with a DSM-IV diagnosis of depression in the past year. Recognition (yes/no) by GPs was based on medical file extractions (GP diagnosis of depressive symptoms/depressive disorder and/or use of antidepressants/referral to mental health care). Potential determinants of (non-)recognition (patient, depression, patient-GP interaction, and GP characteristics) were bivariately tested and variables with a p-value ≤0.2 entered into a multilevel multivariate model. Subgroup analysis was performed on 361 respondents with more reliable GP diagnosis data., Results: 60.5% of patients were recognized by their GP. Patients who did not consult their GP for mental problems, and without comorbid anxiety disorder(s) were less often recognized. In the subgroup, where 68.7% was recognized, in addition to these, decreasing number of symptoms of depression and increased appetite were associated with decreased recognition. No GP characteristics were retained in the final model., Limitations: Some data on recognition were collected retrospectively., Conclusions: In addition to patients without a comorbid anxiety disorder or who did not consult their GP for mental problems, GPs less often recognized patients with fewer depression symptoms or with increased appetite. Recognition may be improved by informing/teaching GPs that also increased appetite can be a symptom of depression., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement., Methods: This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records., Results: 721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes., Conclusion: The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Background: Whether course trajectories of depressive and anxiety disorders are different, remains an important question for clinical practice and informs future psychiatric nosology. This longitudinal study compares depressive and anxiety disorders in terms of diagnostic and symptom course trajectories, and examines clinical prognostic factors., Methods: Data are from 1209 depressive and/or anxiety patients residing in primary and specialized care settings, participating in the Netherlands Study of Depression and Anxiety. Diagnostic and Life Chart Interviews provided 2-year course information., Results: Course was more favorable for pure depression (n=267, median episode duration = 6 months, 24.5% chronic) than for pure anxiety (n=487, median duration = 16 months, 41.9% chronic). Worst course was observed in the comorbid depression-anxiety group (n=455, median duration > 24 months, 56.8% chronic). Independent predictors of poor diagnostic and symptom trajectory outcomes were severity and duration of index episode, comorbid depression-anxiety, earlier onset age and older age. With only these factors a reasonable discriminative ability (C-statistic 0.72-0.77) was reached in predicting 2-year prognosis., Limitation: Depression and anxiety cases concern prevalent - not incident - cases. This, however, reflects the actual patient population in primary and specialized care settings., Conclusions: Their differential course trajectory justifies separate consideration of pure depression, pure anxiety and comorbid anxiety-depression in clinical practice and psychiatric nosology., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: To evaluate care received for anxiety and depression, to identify which patient-, GP- and practice factors obstruct delivery of care in accordance with Dutch College of General Practitioners' (NHG) practice guidelines, and to evaluate the costs and effects of guideline-concordant care., Design: Descriptive study., Methods: During the baseline assessment of the Netherlands study of depression and anxiety--which has followed a large number of adults with and without psychiatric complaints since 2004--various questionnaires and diagnostic interviews were completed. At one year follow-up, the severity of symptoms of anxiety and depression, overall functioning or dysfunction, healthcare use and absenteeism from employment over the past year were assessed. Data from electronic medical patient records were studied to determine whether NHG practice guidelines had been followed., Results: Of the 721 patients with an anxiety or depressive disorder, 57% (n = 413) indicated receiving some form of care; two-thirds of this group received appropriate care according to NHG practice guidelines (n = 281). At patient level the severity of depressive symptoms, the self-evaluated need for care, a high level of education and accessibility of care were most strongly associated with guideline adherence; at general practitioner level, collaboration with other mental health professionals was most strongly associated with guideline adherence. On average, all patients had symptoms that were less serious than a year previously, irrespective of which care they had received. Guideline-concordant care was significantly more expensive., Conclusion: Half of the patients who had not received care did not think that they needed it. Of those who had received care, those with more severe symptoms and greatest need for care were most likely to have received guideline-concordant care. Both patients and general practitioners seemed well able to assess whether care was needed or not.

Objective: To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care., Design: Analysis of data from the Netherlands Study of Depression and Anxiety (NESDA)., Participants: Seven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included., Measures: Diagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners., Results: Two hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%-CI = 1.05-1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%-CI = 1.84-4.85; p < 0.001), counseling (OR = 2.25; 95%-CI = 1.29-3.95; p = 0.005) or a referral (OR = 1.83; 95%-CI = 1.09-3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%-CI = 0.11-0.98; p = 0.04) of receiving guideline-concordant care., Conclusions: This study shows that education level, accessibility of care and patients' perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs' communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary care.

Background: Many anxiety and depression patients receive no care, resulting in unnecessary suffering and high costs. Specific beliefs and the absence of a perceived need for care are major reasons for not receiving care. This study aims to determine the specific perceived need for care in primary care patients with anxiety and depression, and examine to what extent these different needs are met., Methods: Cross-sectional data were derived from The Netherlands Study of Depression and Anxiety (NESDA). In 622 primary care patients with a current (6-month recency) diagnosis of depression and/or anxiety disorder who recognised their mental health problem themselves, the perceived need for mental health care was measured by the Perceived Need for Care Questionnaire (PNCQ). Possible determinants were measured in the same interview by means of a questionnaire., Results: Most patients with anxiety or depression expressed a need for counselling or information. Medication, practical support, skills training and a referral were less often perceived to be needed. Multiple logistic regression analyses revealed that after controlling for age, clinical status and disability, patients' confidence in professional help and their evaluation of received care positively influenced their perception of a need for medication and counselling., Conclusions: Although no conclusions can be made about what type of care was specifically not wanted, patients with anxiety or depression mostly want to receive information and counselling. Health professionals should be aware of the fact that there are differences in perceived need for care between subgroups of patients, based on their beliefs and their evaluation of care.

Patients' illness representations and beliefs about treatment for depression and anxiety, as well as their perceived needs, are important for treatment. A systematic review was conducted of 71 studies describing the beliefs or perceived needs of patients and non-patients. Patients give multi-dimensional explanations for depression and see both psychological and medication treatment as helpful. People who suffer from depression have more positive beliefs about biological etiology and medication treatment than healthy people, or those with less severe depressive symptoms. Anxiety patients view psychological interventions as their best treatment option. Between 49% and 84% of the patients with depression or anxiety perceive a need for treatment, mostly for counseling and medication. All patients prefer psychological treatment forms to medication. A majority of patients view antidepressants as addictive and many perceive stigma and see practical and economic barriers to care. The most vulnerable groups in terms of seeking and receiving mental health care for depression and anxiety seem to be minority groups, as well as younger and older patients. More research is required into the specific needs of anxiety and depression patients. Open communication between patient and provider could lead to valuable improvements in treatment.

Several predictors of the course of depression and generalized anxiety have been identified. Whether these predictors provide a solid basis for primary care physicians (PCPs) to give an accurate prognosis remains unclear. A parallel study showed modest agreement between PCP prognosis and observed course (kappa< or = 0.21). It is the aim of the present study to establish the extent to which the one-year course of depression and generalized anxiety in primary care is in fact predictable. Predictability is operationalized as the combined predictive power of major prognostic factors identified in the literature. We identified 269 cases of ICD-10 depression and 134 of generalized anxiety among consecutive PCP attenders. For these patients a statistical model was built that provided optimal predictions of the one-year course of the disorder, based on the prognostic factors discerned. The predictions were compared with the actual course observed. Reasonable agreement (kappa = 0.37 for depression, kappa = 0.35 for anxiety) and good association (gamma = 0.66 for depression, gamma=0.67 for anxiety) were found between predicted and observed course. Nevertheless, the combined predictive power of the prognostic factors remains limited. A realistic evaluation of the accuracy of the PCP prognosis should take this limited predictability into account.

This article presents a new development on the field of psychotherapy: Eye-Movement Desensitization and Reprocessing (EMDR). This recently developed procedure promises rapid and effective treatment of anxiety related complaints, including post-traumatic stress disorders (DSM-III-R). In essence the therapist induces a series of rapid and rhythmic eye-movements. EMDR facilitates cognitive changes and lasting decrease of anxiety. As indicated by research and illustrated by case histories, EMDR can be effective in one session. Until now there is no definitive explanation for the effectiveness of this method.