Effectiveness of the implementation of guidelines for anxiety disorders in specialized mental health care.

OBJECTIVE: To examine the effect of implementing anxiety disorders guidelines on guideline adherence and patient outcomes in specialized mental health care. METHOD: A treatment setting in which guidelines were implemented (intervention condition) was compared with one in which guidelines were only disseminated (control condition). RESULTS: Of 61.7% of 81 intervention-condition patients received treatment according to the guidelines vs. 40.6% of 69 control-condition patients (P = 0.01). At 1-year follow-up, intervention-condition patients showed a greater decrease in anxiety symptoms (d = 0.48, P < 0.05); higher percentages of response (52.6% vs. 33.8%; P = 0.025) and remission (33.3% vs.16.9%; P = 0.026); and a greater decrease in the rate of phobic avoidance (d = 0.34, P < 0.05). At 2-year follow-up, control-condition patients had experienced a longer period of treatment, which had eroded most of these differences, except for phobic avoidance. CONCLUSION: Systematic guideline implementation results in earlier gains and shorter treatment times.

[The characterisation of anxiety disorders: staging and profiling based on common sense]. / De karakterisering van angststoornissen: stageren en profileren met gezond verstand.

BACKGROUND: Clinicians need to be well informed about staging and profiling so that they can divide patients with anxiety disorders into groups according to the phase and severity of their illness. The group to which the patient is assigned determines the types of treatment he or she receives. AIM: To investigate ways in which clinicians can be helped to apply staging and profiling procedures to patients with anxiety disorders. METHOD: We searched the literature for articles about the staging and profiling of anxiety disorders. RESULTS: There seems to be practically no literature relating to the staging and profiling of anxiety disorders. However, in daily practice clinicians do attempt to classify their patients and use forms of staging when deciding on special types of treatment for their patients and when assessing the length of treatment required. The revised Dutch guidelines on anxiety disorders include a generalised form of staging, called 'stepped care’. These revisions have been made on the basis of consensus decisions reached by the guideline committee. CONCLUSION: The revised guidelines on anxiety disorders assist clinicians with the application of staging in their daily practice. However, because of the lack of scientific data, our article closes with the presentation of a research agenda.

[Do guidelines lead to better clinical practice?]. / Leiden richtlijnen tot een betere klinische praktijk?

It appears from a review of the literature that at present a considerable number of psychiatric patients are being deprived of evidence-based treatment. However, Australian theoretical research has shown that if patients were to be treated entirely in accordance with evidence-based guidelines they would derive considerably more benefit from their treatment. This conclusion has been corroborated by various randomised controlled trials (RCT's) in which the effect of evidence-based treatment according to guidelines is compared with the effect of 'treatment as usual'. Studies carried out under less controlled circumstances than those prevailing in RCT's yield slightly less positive results. The literature stresses the difficulties of improving the quality of patient care. Studies on the implementations of guidelines show that carefully constructed, tailor-made interventions are needed to ensure that professionals adhere to guidelines. More research is required into effective ways of implementing guidelines in an adequate manner.

The placebo response in social phobia.

The placebo response forms a growing problem in randomized, placebo-controlled clinical trials in psychiatry. Research into the placebo response is on the increase, but remains very limited in relation to social phobia. Together with the dropout rate, the placebo effect is an important factor limiting the discriminative properties of any study. In this study, we reviewed 15 placebo-controlled studies in social phobia, focussing on patients and study characteristics. In social phobia, the placebo effect has turned out to be moderately large and has shown no increase over the past decade. Placebo response was highest in large, multicentred trials and was independent of study duration. No validation for a placebo run-in was found. Taking into account both response to placebo and active drug, as well as dropout rate, the most discriminative results are probably to be expected in a sample of patients who are moderately to severely impaired. More research in the field of the placebo response is needed.

An open study of paroxetine in hypochondriasis.

1. Despite the high prevalence of hypochondriasis, this disorder is found to be the focus of research only minimally. 2. This open study evaluates the efficacy and tolerance of paroxetine in 11 patients with DSM-III-R hypochondriasis. 3. Using paired samples t-test, a significant reduction on measures of hypochondriasis was found after 12 weeks of treatment compared to baseline. Two patients dropped out prematurely. At post-test, eight out of nine patients who completed the study had improved to a clinically relevant degree. Of these, five attained scores in the reach of the normal population. 4. In one patient who completed the study and one patient who dropped out, tolerance of paroxetine was poor, whereas in remaining patients tolerance was moderate to good. 5. The results of this study suggest that patients with hypochondriasis may be responsive to paroxetine. A controlled study is recommended.

[Hypochondriasis]. / Hypochondrie.

In a female patient aged 33 years and suffering from excessive concern with her physical health, hypochondriasis was diagnosed. By cognitive behavioural therapy the obsessive thoughts, controlling behaviour and avoidance behaviour were alleviated. After treatment the patient needed fewer consultations. In general practice hypochondriasis is a common problem. Patients will ask for a lot of diagnostic tests. Nothing will give them enough reassurance and there can be irritation. The general practitioner must confront them with the fact that their main problem is hypochondriasis and search for solutions. Cognitive and behavioural therapy as well as treatment with antidepressive drugs may be helpful. The earlier the diagnosis and the start of treatment, the better the prognosis.