Cost-effectiveness of a stepped care program to prevent depression among primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression in comparison with usual care.

BACKGROUND: Patients with diabetes mellitus type 2 (DM2) and/or coronary heart disease (CHD) are at high risk to develop major depression. Preventing incident major depression may be an important tool in reducing the personal and societal burden of depression. The aim of the current study was to assess the cost-effectiveness of a stepped care program to prevent major depression (Step-Dep) in diabetes mellitus type 2 and/or coronary heart disease patients with subthreshold depression in comparison with usual care. METHODS: An economic evaluation with 12 months follow-up was conducted alongside a pragmatic cluster-randomized controlled trial from a societal perspective. Participants received care as usual (n = 140) or Step-Dep (n = 96) which consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to a general practitioner. Primary outcomes were quality-adjusted life years (QALYs) and cumulative incidence of major depression. Costs were measured every 3 months. Missing data was imputed using multiple imputation. Uncertainty around cost-effectiveness outcomes was estimated using bootstrapping and presented in cost-effectiveness planes and acceptability curves. RESULTS: There were no significant differences in QALYs or depression incidence between treatment groups. Secondary care costs (mean difference €1644, 95% CI €344; €3370) and informal care costs (mean difference €1930, 95% CI €528; €4089) were significantly higher in the Step-Dep group than in the usual care group. The difference in total societal costs (€1001, 95% CI €-3975; €6409) was not statistically significant. The probability of the Step-Dep intervention being cost-effective was low, with a maximum of 0.41 at a ceiling ratio of €30,000 per QALY gained and 0.32 at a ceiling ratio of €0 per prevented case of major depression. CONCLUSIONS: The Step-Dep intervention is not cost-effective compared to usual care in a population of patients with DM2/CHD and subthreshold depression. Therefore, widespread implementation cannot be recommended. TRIAL REGISTRATION: The trial was registered in the Netherlands Trial Register ( NTR3715 ).

The association between somatization and disability in primary care patients.

BACKGROUND: Patient encounters for medically unexplained physical symptoms are common in primary health care. Somatization ('experiencing and reporting unexplained somatic symptoms') may indicate concurrent or future disability but this may also partly be caused by psychiatric disorders. The aim of this study was to examine the cross-sectional and longitudinal association between somatization and disability in primary care patients with and without anxiety or depressive disorder. METHODS: Data were obtained from 1545 primary care patients, participating in the longitudinal Netherlands Study of Depression and Anxiety (NESDA). Somatization was assessed using the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ). Disability was determined by the WHO Disability Assessment Schedule 2.0 (WHO-DAS II). The relationships between somatization and both the total and subdomain scores of the WHO-DAS II were measured cross-sectionally and longitudinally after one year of follow-up using linear regression analysis. We examined whether anxiety or depressive disorder exerted a modifying effect on the somatization-disability association. RESULTS: Cross-sectionally and longitudinally, somatization was significantly associated with disability. Somatization accounted cross-sectionally for 41.8% of the variance in WHO-DAS disability and, longitudinally, for 31.7% of the variance in disability after one year of follow-up. The unique contribution of somatization to disability decreased to 16.7% cross-sectionally and 15.7% longitudinally, when anxiety and/or depressive disorder was added to the model. CONCLUSION: Somatization contributes to the presence of disability in primary care patients, even when the effects of baseline demographic and health characteristics and anxiety or depressive disorder are taken into account.

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.

Big Five personality and depression diagnosis, severity and age of onset in older adults.

BACKGROUND: Personality may play an important role in late-life depression. The aim of this study is to examine the association between the Big Five personality domains and the diagnosis, severity and age of onset of late-life depression. METHODS: The NEO-Five Factor Inventory (NEO-FFI) was cross-sectionally used in 352 depressed and 125 non-depressed older adults participating in the Netherlands Study of Depression in Older Persons (NESDO). Depression diagnosis was determined by the Composite International Diagnostic Interview (CIDI). Severity of depression was assessed by the Inventory of Depressive Symptomatology (IDS). Logistic and linear regression analyses were applied. Adjustments were made for sociodemographic, cognitive, health and psychosocial variables. RESULTS: Both the presence of a depression diagnosis and severity of depression were significantly associated with higher Neuroticism (OR=1.35, 95% CI=1.28-1.43 and B=1.06, p<.001, respectively) and lower Extraversion (OR=.79, 95% CI=.75-.83; B=-.85, p<.001) and Conscientiousness (OR=.86, 95% CI=.81.-.90; B=-.86, p<.001). Earlier onset of depression was significantly associated with higher Openness (B=-.49, p=.026). LIMITATIONS: Due to the cross-sectional design, no causal inferences can be drawn. Further, current depression may have influenced personality measures. CONCLUSIONS: This study confirms an association between personality and late-life depression. Remarkable is the association found between high Openness and earlier age of depression onset.

[Acute otitis media: do not hesitate to treat]. / Otitis media acuta: aarzel niet te behandelen.

Recently, two randomised, double-blind, placebo-controlled trials published in The New England Journal of Medicine have stirred up discussion about the use of antibiotics in the treatment of acute otitis media (AOM). In the Netherlands, the practice guideline of the Dutch College of General Practitioners recommends withholding antibiotics in most cases and that antibiotics can be considered when a child under the age of 2 years has bilateral AOM, otorrhoea, or persistent symptoms for 3 days or more. These recommendations are mostly based on a meta-analysis published in 2006. Previous studies on AOM had important limitations such as varying diagnostic criteria and biased patient selection. The new trials, which are of high methodological quality, investigated only 'real' AOM and the results show the same efficacy as the aforementioned meta-analysis. We therefore feel it is justified to consider prescribing antibiotics for a young child with manifest symptoms and evident AOM on otoscopic examination.

Does patient feedback improve the consultation skills of general practice trainees? A controlled trial.

CONTEXT: This study aimed to assess if an additional patient feedback training programme leads to better consultation skills in general practice trainees (GPTs) than regular communication skills training, and whether process measurements (intensity of participation in the programme) predict the effect of the intervention. METHODS: We carried out a controlled trial in which two sub-cohorts of GPTs were allocated to an intervention group (n = 23) or a control group (n = 30), respectively. In 2006, allocated first-year GPTs in the VU University Medical Centre attended a patient feedback training programme in addition to the regular communication skills training. The control group attended only regular communication skills training. Trainees were assessed by simulated patients who visited the practices and videotaped the consultations at baseline and after 3 months. The videotapes were randomly assigned to eight trained staff members. The MAAS-Global Instrument (range 0-6) was used to assess (a change in) trainee consultation skills. RESULTS: were analysed using a multi-level, linear mixed-model analysis. Results Data on 50 GPTs were available for the follow-up analysis. Both intervention group and control group GPTs improved their consultation skills: mean MAAS-Global scores for all participants were 3.29 (standard deviation [SD] 0.75) at baseline and 3.54 (SD 0.66) at follow-up (P = 0.047). The improvement in MAAS-Global scores in the intervention group did not differ significantly from the improvement in the control group. The analysis showed a trend for intensity of participation in the patient feedback programme to predict greater improvement in MAAS-Global scores. DISCUSSION: Although the baseline scores were already in the high range, consultation skills in both groups improved significantly. This is reassuring for current teaching methods. The patient feedback programme did not improve consultation skills more than regular communication skills training. However, a subgroup of GPTs who participated intensively in the programme did improve their consultation skills further in comparison with the less motivated subgroup.

Outcome of depression in later life in primary care: longitudinal cohort study with three years' follow-up.

OBJECTIVES: To study the duration of depression, recovery over time, and predictors of prognosis in an older cohort (>or=55 years) in primary care. DESIGN: Longitudinal cohort study, with three years' follow-up. SETTING: 32 general practices in West Friesland, the Netherlands. PARTICIPANTS: 234 patients aged 55 years or more with a prevalent major depressive disorder. MAIN OUTCOME MEASURES: Depression at baseline and every six months using structured diagnostic interviews (primary care evaluation of mental disorders according to diagnoses in Diagnostic and Statistical Manual of Mental Disorders, fourth edition) and a measure of severity of symptoms (Montgomery Asberg depression rating scale). The main outcome measures were time to recovery and the likelihood of recovery at different time points. Multivariable analyses were used to identify variables predicting prognosis. RESULTS: The median duration of a major depressive episode was 18.0 months (95% confidence interval 12.8 to 23.1). 35% of depressed patients recovered within one year, 60% within two years, and 68% within three years. A poor outcome was associated with severity of depression at baseline, a family history of depression, and poorer physical functioning. During follow-up functional status remained limited in patients with chronic depression but not in those who had recovered. CONCLUSION: Depression among patients aged 55 years or more in primary care has a poor prognosis. Using readily available prognostic factors (for example, severity of the index episode, a family history of depression, and functional decline) could help direct treatment to those at highest risk of a poor prognosis.

[Screening for depression and anxiety in residential homes for the elderly]. / Problemen bij het opsporen van depressieve- en angststoornissen bij bewoners van verzorgingshuizen.

Elderly persons in residential homes in the Netherlands are at high risk for developing major depressive and anxiety disorders. A stepped-care protocol being used in a study for vulnerable elderly in the community may also be feasible and effective for this group. A pilot study in a residential home in Amsterdam showed more problems than expected in screening and motivating the inhabitants for this intervention protocol. This article describes the problems in our screening procedure. A personal approach, performed by familiar persons, directed at the more independent inhabitants is most likely to succeed. The need for research on effectiveness and feasibility of evidence based methods in residential care remains evident. However, the more vulnerable inhabitants need something else. For this group of inhabitants we need to look more closely to the needs and possibilities by conducting research using a qualitative design.

[The prevention of psychiatric disorders]. / Preventie van psychiatrische stoornissen.

About 450 million people all over the world suffer from psychiatric disorders. Limitations and handicaps are caused especially by unipolar depression, excessive alcohol consumption, schizophrenia and manic-depressive disorder. It is expected that the importance of psychiatric disorders for public health will increase in the coming decades. Psychiatric disorders are often the cause of death, destroy the lives of both patients and their families, have far-reaching economic consequences and are often complicated by somatic diseases. The advances in the field of treatment are impressive but can have only a limited effect on the consequences of psychiatric disorders for public health. The incidence of psychiatric disorders can be reduced by more than 25%. The greatest effects have been seen with depressive disorders, indicated prevention and the use of cognitive therapy. Indicated prevention has also been found to be effective in psychotic disorders. Debriefing is ineffective in posttraumatic stress disorder. The efficacy of universal prevention has not been investigated. There are still insufficient data to develop evidence-based guidelines for the prevention of psychiatric disorders.

Frequent attenders in general practice: problem solving treatment provided by nurses [ISRCTN51021015].

BACKGROUND: There is a need for assistance from primary care mental health workers in general practice in the Netherlands. General practitioners (GPs) experience an overload of frequent attenders suffering from psychological problems. Problem Solving Treatment (PST) is a brief psychological treatment tailored for use in a primary care setting. PST is provided by nurses, and earlier research has shown that it is a treatment at least as effective as usual care. However, research outcomes are not totally satisfying. This protocol describes a randomized clinical trial on the effectiveness of PST provided by nurses for patients in general practice. The results of this study, which currently being carried out, will be presented as soon as they are available. METHODS/DESIGN: This study protocol describes the design of a randomized controlled trial to investigate the effectiveness and cost-effectiveness of PST and usual care compared to usual care only. Patients, 18 years and older, who present psychological problems and are frequent attenders in general practice are recruited by the research assistant. The participants receive questionnaires at baseline, after the intervention, and again after 3 months and 9 months. Primary outcome is the reduction of symptoms, and other outcomes measured are improvement in problem solving skills, psychological and physical well being, daily functioning, social support, coping styles, problem evaluation and health care utilization. DISCUSSION: Our results may either confirm that PST in primary care is an effective way of dealing with emotional disorders and a promising addition to the primary care in the UK and USA, or may question this assumption. This trial will allow an evaluation of the effects of PST in practical circumstances and in a rather heterogeneous group of primary care patients. This study delivers scientific support for this use and therefore indications for optimal treatment and referral.

[Summary of the practice guideline 'Depressive disorder' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Depressieve stoornis' (eerste herziening) van het Nederlands Huisartsen Genootschap.

In the revised practice guideline for the diagnosis and treatment of patients with a depressive disorder in general practice the distinction between mild and severe depression has been removed. By paying attention to a number of risk factors, the general practitioner can detect patients with a hidden depressive disorder. The general practitioner's strategy is aimed at reducing symptoms and restoring the ability to function normally. Factors that define the strategy are in particular patient's degree of suffering and dysfunctioning, and the patient's preferences and demands. In primary care tricyclic antidepressants and specific serotonin re-uptake inhibitors are the drugs of first choice: both are equally effective; the nature of the side effects differs.

Incidence of cervical carcinoma in a high-risk, non-screened area results of a retrospective analysis on the Dutch Caribbean Antilles from 1983 to 1998.

Cancer of the uterine cervix is one of the most common malignancies worldwide. The average annual incidence of cervical cancer varies widely per geographical area. Some of the highest rates have been reported in Latin American and Caribbean countries. Previous research into the frequency of cervical carcinoma in Curaçao, the main island of the Dutch Caribbean, has reported predominantly far-advanced stages of the disease. The objectives of this study were to determine: whether there are indications of changes in the incidence of cervical carcinoma, whether these changes are a result of increased clinical attention paid by general practioners (GPs) and gynaecologists, and whether less advanced stages of cervical cancer were found, indicating earlier diagnosis. Data on patients with cervical carcinoma, obtained from records kept in the Department of Pathological Anatomy at the St Elisabeth Hospital in Curaçao were retrospectively analyzed for the period 1983 to 1998. To study the incidence rate over time, cumulative and incidence rates, standardized to the World Standard Population, were calculated and compared to the rates in other Latin American and Caribbean countries. The age-standardized incidence rate for Curaçao was 14.3 per 100 000 women. The cumulative rate up to 74-years-of-age was 1.6%. Sub-division into the three groups showed a trend towards a decrease in the incidence and cumulative rates. A comparison of clinical staging International Federation of Obstetrics and Gynaecology (FIGO) showed a trend towards an increase in time of almost 48% to 59% in stage IA (ie less severe cases). A significant increase (p < 0.0001) was found in the numbers of smears performed in the complete period of 1983-1998, compared to a previously examined period of 1972-1982. The incidence of cervical cancer in Curaçao appears to be decreasing, and is lower than in other areas in the region. The number of smears GPs performed over time increased However the incidence is still relatively high compared to western countries and cases are still presenting in relatively advanced stages of the disease. Although the introduction of a screening programme might not influence the actual incidence of cervical cancer dramatically, nonetheless it may contribute to earlier diagnosis of cervical carcinoma.

Incidence of cervical carcinoma in a high-risk, non-screened area results of a retrospective analysis on the Dutch Caribbean Antilles from 1983 to 1998

Cancer of the uterine cervix is one of the most common malignancies worldwide. The average annual incidence of cervical cancer varies widely per geographical area. Some of the highest rates have been reported in Latin American and Caribbean countries. Previous research into the frequency of cervical carcinoma in Curaçao, the main island of the Dutch Caribbean, has reported predominantly far-advanced stages of the disease. The objectives of this study were to determine: whether there are indications of changes in the incidence of cervical carcinoma, whether these changes are a result of increased clinical attention paid by general practioners (GPs) and gynaecologists, and whether less advanced stages of cervical cancer were found, indicating earlier diagnosis. Data on patients with cervical carcinoma, obtained from records kept in the Department of Pathological Anatomy at the St Elisabeth Hospital in Curaçao were retrospectively analyzed for the period 1983 to 1998. To study the incidence rate over time, cumulative and incidence rates, standardized to the World Standard Population, were calculated and compared to the rates in other Latin American and Caribbean countries. The age-standardized incidence rate for Curaçao was 14.3 per 100 000 women. The cumulative rate up to 74-years-of-age was 1.6. Sub-division into the three groups showed a trend towards a decrease in the incidence and cumulative rates. A comparison of clinical staging International Federation of Obstetrics and Gynaecology (FIGO) showed a trend towards an increase in time of almost 48 to 59 in stage IA (ie less severe cases). A significant increase (p < 0.0001) was found in the numbers of smears performed in the complete period of 1983-1998, compared to a previously examined period of 1972-1982. The incidence of cervical cancer in Curaçao appears to be decreasing, and is lower than in other areas in the region. The number of smears GPs performed over time increased However the incidence is still relatively high compared to western countries and cases are still presenting in relatively advanced stages of the disease. Although the introduction of a screening programme might not influence the actual incidence of cervical cancer dramatically, nonetheless it may contribute to earlier diagnosis of cervical carcinoma

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.

[Incidental high blood pressure in family practice: due to hypertension and/or left ventricular hypertrophy in more than half of the patients]. / Incidenteel verhoogde bloeddruk in de huisartspraktijk: bij meer dan de helft van de patiënten hypertensie en (of) linkerventrikelhypertrofie.

OBJECTIVE: To determine if patients with incidentally high blood pressure actually have hypertension and if these patients have an increased left ventricular mass. DESIGN: Cross-sectional study. SETTING: Two family practices with 8 general practitioners in Leiden and Noordwijk, the Netherlands. METHODS: From the Family Practice Network in the Leiden area 133 (67%) out of 200 patients with incidental high blood pressure, who did not receive antihypertensive medication, participated in the study. Their blood pressure was measured 6 times with a mercury manometer, an automatic, non-invasive ambulatory blood pressure monitoring during 24 hours was performed once and their left ventricular mass was measured by means of echocardiography. RESULTS: Of the 133 selected patients 46% had a mean diastolic blood pressure > 95 mmHg measured with the mercury manometer and 64% had a mean 24-hr diastolic blood pressure > 90 mmHg measured with the ambulatory blood pressure monitor. The correlation between both blood pressure measurements was moderate (correlation coefficient 0.73). Left ventricular hypertrophy was found in 53% of the patients, irrespective of their blood pressures. CONCLUSION: In this investigation 45-65% of patients with an incidentally high blood pressure had a mean diastolic pressure > 95 mmHg as measured with a mercury manometer and (or) a mean 24-hr diastolic blood pressure > 90 mmHg as measured with the ambulatory blood pressure monitor; 53% had left ventricular hypertrophy.

[Depression in the elderly in family practice]. / Depressie bij ouderen in de huisartspraktijk.

Depression among the elderly is an important problem in general practice. There is insufficient knowledge of the prevalence of this condition, of possible ways to improve diagnosis and of its course. The questions in this project were: a) how prevalent is depression in the active population of the GP, and which patients are identified as such by the GP, b) how can the depressed elderly patient be diagnosed in daily practice and which signals can be used by the GP to include or exclude the diagnosis, and c) what is the recovery of this condition among the elderly and is recovery related to recognition by the GP? a) The prevalence has been estimated in two studies (n = 384, n = 580) in 1990 en 1992 with self-report questionnaires and interviews. The samples consisted of consecutive elderly attenders of general practices. We used the Zung scale, the Geriatric Depression Scale (GDS) and the Diagnostic Interview Schedule (DIS). b) To improve diagnosis the relationship of various characteristics to depression status at interview in 1992 was analyzed, and we also evaluated whether the 30-item version of the GDS could be shortened for use in daily practice. c) Patients with depression at baseline interview in 1992 were reassessed with the DIS at 6 and 12 months to evaluate the course. a) Many elderly patients indicated depressive complaints on the self-report questionnaires for depression, respectively 11% and 13% for Zung and GDS. One in twelve elderly patients had depression according to the interview in 1992 (46/580). Not all patients who have depressive complaints or depression were recognised by the GPs. b) Vague or gastrointestinal (GI) reasons for visiting the GP or presenting symptoms and female gender were related to depression. To make suspected depression more likely or to exclude depression, 4 questions may suffice. c) At 12 months 72% of the 25 patients with depression at baseline interview were not depressed. Whether patients were depressed at follow-up interviews was not related to recognition by the GP. The conclusion is that vague complaints and GI problems may be a signal for depression in the elderly and a few short questions may make this diagnosis more likely or exclude it. The course of this condition in general practice needs further study.

A postmarketing study of flunarizine in migraine and vertigo.

This prospective, open multi-centre study on flunarizine focused on the risk/benefit ratio of the use of flunarizine in the prophylaxis of migraine and in the treatment of vertigo, due to disorder of the vestibular system. The assessment of risks focused on the incidence of new events of depression and/or extrapyramidal syndrome during flunarizine treatment. For migraine, flunarizine was compared to propranolol in 686 patients; for vertigo, flunarizine was compared to betahistine in 198 patients. The incidence of depression during follow-up in this study was significantly higher in the flunarizine group than in the propranolol group in the condition of migraine. There were no observations of an extrapyramidal syndrome. There was a suggestion that flunarizine has more benefits than propranolol in the condition of migraine, and that betahistine has more benefit than flunarizine in the condition of vertigo. Differences in dosages could possible explain these differences.

[Prescription of antidepressants in family practice]. / Voorschrijven van antidepressiva in de huisartspraktijk.

OBJECTIVE: To evaluate the prescription of antidepressants in general practice. DESIGN: Retrospective observational study. SETTING: Three health centres and one practice with two partners in the Western part of the Netherlands (near Leiden). METHOD: Medication data and daily medical records of general practitioners (GPs) were analysed in the anonymous data set of Registratie network universitaire huisartspraktijken Leiden en Omstreken (RNUH-LEO, with a total of about 23,000 patients) of patients 18 years of age and over, whom the GP issued a first prescription for an antidepressant in the period May 1994-April 1995. For indication 'depression' we also evaluated whether the prescription was repeated and a minimal effective dosage was reached. RESULTS: In one year 218 patients received a first prescription of an antidepressant (9/1,000/year), mostly a classical antidepressant. In 61% the indication 'depression' was found in the medical records. Sixty-three per cent had a repeat prescription after one month. Serotonin reuptake inhibitors were repeated more frequently than classical antidepressants, especially for patients under the age of 65. The minimally effective dosage was reached in 61% of the patients with depression for the classical antidepressants, and for 98% of patients with serotonin reuptake inhibitors. CONCLUSION: Serotonin reuptake inhibitors were not prescribed more frequently than classical antidepressants. The percentage of patients with repeat prescriptions showed that the GPs should pay continued attention to compliance with therapy when prescribing antidepressants. The effective dosage appeared to be reached most often with serotonin reuptake inhibitors.