Fatigue among Long-Term Breast Cancer Survivors: A Controlled Cross-Sectional Study.

BACKGROUND: Fatigue is the most common and persistent symptom among women in the first five years after a breast cancer diagnosis. However, long-term prevalence of fatigue, among breast cancer survivors, needs further investigation. AIM: To compare fatigue experienced by long-term breast cancer survivors with that in a reference population and to evaluate the determinants of that fatigue. DESIGN AND SETTING: A cross-sectional cohort study of 350 breast cancer survivors ≥5 years after diagnosis and a reference population of 350 women matched by age and general practitioner. METHOD: Fatigue was measured using the Multidimensional Fatigue Inventory (MFI-20), and a sum score of >60 (multidimensional fatigue) was the primary outcome. Logistic regression was applied to compare the prevalence of multidimensional fatigue between the survivor and reference populations, adjusted for body mass index (BMI) and for cardiovascular and psychological variables. Odds ratios (ORs) and 95% confidence intervals (95%CIs) were estimated. Logistic regression was applied to evaluate the determinants of multidimensional fatigue among the survivors. RESULTS: Breast cancer survivors (median 10 years after diagnosis), more often experienced multidimensional fatigue than the reference population (26.6% versus 15.4%; OR, 2.0 [95%CI, 1.4-2.9]), even after adjusting for confounders. The odds of multidimensional fatigue were also higher among survivors with symptoms of depression (32.2% versus 2.7%; OR, 17.0 [95%CI, 7.1-40.5]) or anxiety (41.9% versus 10.1%; OR, 6.4 [95%CI, 3.6-11.4]). CONCLUSION: One in four breast cancer survivors experience multidimensional fatigue and fatigue occurs more frequently than in women of the same age and general practitioner. This fatigue appears to be associated with symptoms of depression and anxiety.

Trajectories and determinants of functional limitations in late-life depression: A 2-year prospective cohort study.

BACKGROUND: In mental health research, functional recovery is increasingly valued as an important outcome in addition to symptomatic remission. METHODS: Course types of functional limitations among depressed older patients and its relation with symptomatic remission were explored in a naturalistic cohort study (Netherlands Study of Depression in Older persons). 378 depressed older patients (≥60 years) and 132 non-depressed persons were included. Depressive disorders were assessed with Composite International Diagnostic Interview at baseline and two-year follow-up. Functional limitations were assessed every 6 months with the World Health Organization Disability Assessment II. RESULTS: Depressed patients had more functional limitations compared to their non-depressed counterparts. Growth Mixture Modeling among depressed patients identified two trajectories of functional limitations, both starting at a high disability level. The largest subgroup (81.2%) was characterized by a course of high disability levels over time. The smaller subgroup (18.8%) had an improving course (functional recovery). After two years, the main predictor of functional recovery was the remission of depression. Among symptomatic remitted patients, female sex, higher level of education, higher gait speed, and less severe depression were associated with no functional recovery. Non-remitted patients without functional recovery were characterized by the presence of more chronic somatic diseases, a lower sense of mastery, and a higher level of anxiety. CONCLUSIONS: 1 in 5 depressed older patients have a course with functional recovery. Combining functional and symptomatic recovery points to a subgroup of older patients that might profit from more rigorous psychiatric treatment targeted at psychiatric comorbidity and a group of frail depressed older patients that might profit from integrated geriatric rehabilitation.

What proportion of initially prescribed antidepressants is still being prescribed chronically after 5 years in general practice? A longitudinal cohort analysis.

OBJECTIVES: Antidepressant prescribing almost doubled in the Netherlands between 1996 and 2012, which could be accounted for by longer continuation after the first prescription. This might be problematic given a growing concern of large-scale antidepressant dependence. We aimed to assess the extent and determinants of chronic antidepressant prescribing among patient aged 18 years and older. We hypothesise a relatively large prevalence of chronic (>2 years) prescription. DESIGN: A longitudinal observational study based on routinely registered prescription data from general practice. SETTING: 189 general practices in the Netherlands. PARTICIPANTS: 326 025 patients with valid prescription data for all 5 years of the study. OUTCOME MEASURES: Primary outcome measure: the number of patients (N) receiving at least four antidepressant prescriptions in 2011, as well as during each of the four subsequent years. Secondary outcome measure: the above, but specified for selective serotonin reuptake inhibitors and for tricyclic antidepressants. RESULTS: Antidepressants were prescribed to almost 7% of our 326 025 participants each year. They were prescribed for depression (38%), anxiety (17%), other psychological disorders (20%) and non-psychological indications (25%). Antidepressants were prescribed in all 5 years to the 42% of the population who had at least four prescriptions dispensed in 2011. Chronic prescribing was higher among women than men, for those aged 45-64 years than for those aged >65 years and for those treated for depression or anxiety than for non-psychological indications (eg, neuropathic pain). Chronic prescribing also varied markedly among general practices. CONCLUSION: Chronic antidepressant use is common for depression and for anxiety and non-psychological diagnoses. Once antidepressants have been prescribed, general practitioners and other prescribers should be aware of the risks associated with long-term use and should provide annual monitoring of the continued need for therapy.

Non-adherence to antidepressants among older patients with depression: a longitudinal cohort study in primary care.

Background: Depression is common among older adults and is typically treated with antidepressants. Objective: To determine the non-adherence rates to antidepressants among older adults in primary care, based on non-initiation, suboptimal implementation or non-persistence. Methods: We selected all patients aged ≥60 years and diagnosed with depression in 2012, from the Netherlands Institute for Health Services Research (NIVEL) Primary Care Database. Non-initiation was defined as no dispensing within 14 days of the first prescription; suboptimal implementation, as fewer than 80% of the days covered by dispensed dosages; and non-persistence, as discontinuation within 294 days after first dispense. First, we determined the antidepressant non-initiation, suboptimal implementation and non-persistence rates. Second, we examined whether comorbidity and chronic drug use were associated with non-adherence by mixed-effects logistic regression (non-initiation or suboptimal implementation as dependent variables) and a clustered Cox regression (time to non-persistence). Results: Non-initiation, suboptimal implementation and non-persistence rates were 13.5%, 15.2% and 37.1%, respectively. As the number of chronically used drugs increased, the odds of suboptimal implementation (odds ratio, 0.89; 95% confidence interval, 0.83-0.95) and of non-persistence (hazard ratio, 0.87; 95% confidence interval, 0.82-0.92) reduced. Conclusions: Non-adherence to antidepressants is high among older patients with depression in primary care settings. Adherence is better when patients are accustomed to taking larger numbers of prescribed drugs, but this only provides partial explanation of the variance. GPs should be aware of the high rates of non-adherence. Emphasizing the importance of adhering to the optimal length of antidepressant therapy might be prudent first steps to improving adherence.

Non-pharmacological treatment for depressed older patients in primary care: A systematic review and meta-analysis.

BACKGROUND: Late-life depression is most often treated in primary care, and it usually coincides with chronic somatic diseases. Given that antidepressants contribute to polypharmacy in these patients, and potentially to interactions with other drugs, non-pharmacological treatments are essential. In this systematic review and meta-analysis, we aimed to present an overview of the non-pharmacological treatments available in primary care for late-life depression. METHOD: The databases of PubMed, PsychINFO, and the Cochrane Central Register of Controlled Trials were systematically searched in January 2017 with combinations of MeSH-terms and free text words for "general practice," "older adults," "depression," and "non-pharmacological treatment". All studies with empirical data concerning adults aged 60 years or older were included, and the results were stratified by primary care, and community setting. We narratively reviewed the results and performed a meta-analysis on cognitive behavioral therapy in the primary care setting. RESULTS: We included 11 studies conducted in primary care, which covered the following five treatment modalities: cognitive behavioral therapy, exercise, problem-solving therapy, behavioral activation, and bright-light therapy. Overall, the meta-analysis showed a small effect for cognitive behavioral therapy, with one study also showing that bright-light therapy was effective. Another 18 studies, which evaluated potential non-pharmacological interventions in the community suitable for implementation, indicated that bibliotherapy, life-review, problem-solving therapy, and cognitive behavioral therapy were effective at short-term follow-up. DISCUSSION: We conclude that the effects of several treatments are promising, but need to be replicated before they can be implemented more widely in primary care. Although more treatment modalities were effective in a community setting, more research is needed to investigate whether these treatments are also applicable in primary care. TRIAL REGISTRATION: PROSPERO CRD42016038442.

Late-life depression and the association with multimorbidity and polypharmacy: a cross-sectional study.

Background: Late-life depression often coincides with chronic somatic diseases and, consequently, with polypharmacy, which may complicate medical treatment. Objective: To determine the associations between patients diagnosed with late-life depression in primary care and multimorbidity and polypharmacy. Methods: This cross-sectional observational study was performed using 2012 primary care data. Depressed patients aged ≥60 years were compared to age and gender matched patients diagnosed with other psychological diagnoses and mentally healthy controls. Morbidity and prescription data were combined, and regression analyses were performed for the associations between depression and chronic disease and chronic drug use. Results: We included 4477 patients; 1512 had a record of depression, 1457 of other mental health or psychological diagnoses and 1508 were controls. Depressed patients had a 16% [Prevalence Ratio (PR) 1.16; 95% confidence interval (95% CI) 10%-24%] higher rate of chronic somatic disease and higher odds for multimorbidity (OR 1.55; 95% CI 1.33-1.81) compared with controls. No differences existed between depressed patients and patients with other psychological diagnoses. Compared with controls, depressed patients had a 46% (95% CI 39-53%) higher rate of chronic drug use and higher odds for polypharmacy (OR 2.89; 95% CI 2.41-3.47). Depressed patients also had higher rates of chronic drug use and higher odds for polypharmacy compared with patients with other psychological diagnoses (PR 1.26; OR 1.75; both P < 0.001). Conclusions: Late-life depression in primary care patients is associated with more chronic drug use, even beyond the increased rates of comorbid somatic diseases. General practitioners should consider medication reviews to prevent unnecessary drug-related problems in these patients.

Patients' readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study.

BACKGROUND: Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations. However, detection rates appeared to be strikingly low. OBJECTIVES: Our study aimed to examine patients' readiness to discuss psychosocial problems with nurses during diabetes consultations. DESIGN: A mixed methods design was used in which qualitative data collection was followed up by quantitative data collection. SETTING: Diabetes care in a regional group of family practices in the south of the Netherlands. PARTICIPANTS: Type 2 diabetes patients with psychosocial problems, determined by a self-administered questionnaire. METHODS: First, in-depth interviews (n=12) were conducted about patients' experiences with routine diabetes consultations and their perspective on a biopsychosocial care approach. Based on a qualitative content analysis, a structured questionnaire was designed to further explore the findings among a larger group of patients. This questionnaire was completed by 205 patients. The questionnaire included 14 items measuring patients' agreement with statements about diabetes care and the role of the nurse to focus on patients' emotional and social functioning. RESULTS: The interviews showed that patients view a diabetes consultation primarily as a biomedical check-up, and do not perceive discussion of psychosocial well-being as an integral part of diabetes management. More than 90% of the sample showed a positive attitude towards current diabetes consultations. Patients' intentions and perceived needs regarding a biopsychosocial care approach of the nurse were variable. Younger patients seemed more open to discussing psychosocial problems with the nurse than patients over 65. Patients' openness to discussing psychosocial problems was not significantly (p<0.05) associated with the nurses being trained in the biopsychosocial self-management approach. CONCLUSION: Patients see primary care nurses primarily as specialists regarding the biomedical management of diabetes. Although patients seemed to support the ideal of integrated care, they did not expect a discussion about psychosocial problems in diabetes consultations. The incorporation of systematic detection of patients with psychosocial problems in diabetes care requires endeavours to make patients acquainted with the new role of the nurse.

Development and preliminary validation of an Observation List for detecting mental disorders and social Problems in the elderly in primary and home care (OLP).

OBJECTIVE: Even though the prevalence of mental disorders and social problems is high among elderly patients, it is difficult to detect these in a primary (home) care setting. Goal was the development and preliminary validation of a short observation list to detect six problem areas: anxiety, depression, cognition, suspicion, loneliness, and somatisation. METHODS: A draft list of indicators identified from a short review of the literature and the opinions of 22 experts was evaluated by general practitioners (GPs) and home care organisations for feasibility. It was then used by GPs and home care personnel to observe patients, who also completed validated tests for psychological disorders (General Health Questionnaire 12 item version (GHQ-12)), depression (Geriatric Depression Scale 15-item version (GDS-15)), anxiety and suspicion (Symptom Checklist-90 (SCL-90)), loneliness (University of California, Los Angeles (UCLA)), somatisation (Illness Attitude Scale (IAS)), and cognition (Mini-Mental State Examination (MMSE)). RESULTS: GPs and home care personnel observed 180 patients (mean age 78.4 years; 66% female) and evaluated the draft list during a regular visit. Cronbach's α was 0.87 for the draft list and ≥0.80 for the draft problem areas (loneliness and suspicion excepted). Principal component analysis identified six components (cognition, depression + loneliness, somatisation, anxiety + suspicion, depression (other signs), and an ambiguous component). Convergent validity was shown for the indicators list as a whole (using the GHQ-12), and the subscales of depression, anxiety, loneliness, cognition, and somatisation. Using pre-set agreed criteria, the list was reduced to 14 final indicators divided over five problem areas. CONCLUSION: The Observation List for mental disorders and social Problems (OLP) proved to be preliminarily valid, reliable, and feasible for use in primary and home care settings. Copyright © John Wliey & Sons, Ltd.

A new approach to child mental healthcare within general practice.

BACKGROUND: Child and adolescent mental health problems are frequently not identified and properly treated within general practice. Politicians in the Netherlands are promoting more primary healthcare treatment for mental health problems. The current study aims to evaluate an integrated primary mental healthcare approach for child and adolescent emotional and behavioural problems. This integrated approach allows general practitioners (GPs) to comprehensively explore the request for help, followed by an informed decision to refer, offer short-term treatment within general practice or postpone a decision by asking for additional consultations with youth mental health specialists. METHOD: The study is a naturalistic evaluation of Dutch general practices with pre-test and post-test comparison with controls based on data from Electronic Medical Records (EMR). The intervention started in September 2010. EMR data of all GP contacts with children aged 4 to 18 (including diagnosis, prescriptions, referrals) from practices involved in the intervention was used from 1 January 2009 to 31 December 2012. Extra codes were added to the EMR to record aspects of the intervention. Comparable EMR data was used in control practices in 2011. RESULTS: GPs in the intervention group were able to identify more emotional and behavioural problems after the integrated service had started. They also identified more problems than GPs in the control practices. They were already reluctant to prescribe psychopharmacological medication to children before the intervention, and levels of prescription at intervention GP practices remained low for psychotropic drugs compared to control practices. Referral rates to mental healthcare remained relatively steady after the introduction of the integrated service, but referrals switched from specialized to primary mental healthcare. CONCLUSION: An integrated mental healthcare approach within general practice may lead to an increase in detected psychosocial problems among children, and these problems can mainly be treated within the primary care setting.

Changes in general practitioners' sensitivity to patients' distress in low back pain consultations.

OBJECTIVE: We aim to study GPs' sensitivity to patients' distress and communication on psychosocial factors prior to and after the introduction of the clinical guideline for low back pain. METHODS: Consultations from previous studies on doctor-patient communication in the Netherlands were available for secondary analyses. We selected consultations in which patients presented low back pain complaints (N=168; 25 from 1989, 6 from 1995, 116 from 2001, 21 from 2008) and analyzed these consultations using the Roter Interaction Analysis System (RIAS) and the Verona Coding Definitions of Emotional Sequences (VR-CoDES). RESULTS: GPs more often acknowledged psychosocial factors during consultations after implementation of the guideline for non-specific low back pain. Moreover, patients more often voiced their worries, while GPs put more emphasis on providing biomedical information and counseling during these consultations. CONCLUSIONS: GPs tend to emphasize biomedical factors rather than supporting their patients emotionally. Patients are likely to voice their worries implicitly, indicating they have a need for emotional support from their GPs. PRACTICE IMPLICATIONS: GPs now face the challenge of not only recognizing psychosocial aspects during consultations with low back pain, but also actively eliciting concerns regarding these psychosocial aspects.

Loneliness is associated with poor prognosis in late-life depression: Longitudinal analysis of the Netherlands study of depression in older persons.

BACKGROUND: Although depression and loneliness are common among older adults, the role of loneliness on the prognosis of late-life depression has not yet been determined. Therefore, we examined the association between loneliness and the course of depression. METHODS: We conducted a 2-year follow-up study of a cohort from the Netherlands Study of Depression in Older Persons (NESDO). This included Dutch adults aged 60-90 years with a diagnosis of major depression, dysthymia, or minor depression according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. We performed regression analyses to determine associations between loneliness at baseline and both severity and remission of depression at follow-up. We controlled for potential confounders and performed multiple imputations to account for missing data. RESULTS: Of the 285 respondents, 48% were still depressed after 2 years. Loneliness was independently associated with more severe depressive symptoms at follow-up (beta 0.61; 95% CI 0.12-1.11). Very severe loneliness was negatively associated with remission after 2 years compared with no loneliness (OR 0.25; 95% CI 0.08-0.80). LIMITATIONS: Despite using multiple imputation, the large proportion of missing values probably reduces the study's precision. Generalizability to the general population may be limited by the overrepresentation of ambulatory patients with possibly more persistent forms of depression. CONCLUSION: In this cohort, the prognosis of late-life depression was adversely affected by loneliness. Health care providers should seek to evaluate the degree of loneliness to obtain a more reliable assessment of the prognosis of late-life depression.

The role of frailty in the association between depression and somatic comorbidity: results from baseline data of an ongoing prospective cohort study.

BACKGROUND: Depression and physical frailty in older persons are both associated with somatic diseases, but are hardly examined in concert. OBJECTIVES: To examine whether depression and physical frailty act independently and/or synergistically in their association with somatic diseases. DESIGN: Baseline data of an ongoing observational cohort study including depressed cases and non-depressed comparison subjects. SETTINGS: Netherlands Study of Depression in Older persons (NESDO). PARTICIPANTS: 378 depressed older persons confirmed by the Composite International Diagnostic Interview (CIDI), version 2.1, and 132 non-depressed comparison subjects. METHODS: Multiple linear regression analyses adjusted for socio-demographic and life-style characteristics were conducted with the number of somatic diseases as the dependent variable and depression and physical frailty as independent variables. Physical frailty was defined as ≥3 of the following characteristics, slowness, low physical activity, weight loss, exhaustion, and weakness. RESULTS: Depression and physical frailty did not interact in explaining variance in the number of somatic diseases (p=.57). Physical frailty, however, partly mediated the association between depression and somatic diseases, as the strength of this association decreased by over 10% when frailty was added to the model (B=0.47, p=.003, versus B=0.41, p=.01). The mediation effect was primarily driven by the frailty criterion exhaustion. Of the remaining frailty components, only slowness was associated with the number of somatic diseases; but this association was fully independent of depression. CONCLUSIONS: Our results suggest that depression and physical frailty have common pathways towards somatic diseases, as well as unique pathways. As no high-risk group was identified (no significant interaction), mental health nurses should regularly monitor for physical frailty within their caseload of depressed patients.

Concerns voiced by patients and GPs' responses during psychosocial visits in primary care: a historical cross-sectional study.

BACKGROUND: In a recent study comparing psychosocial consultations prior to and after the implementation of national clinical guidelines in the Netherlands, we found that general practitioners (GPs) showed less empathy in the more recent consultations. As a consequence, patients possibly have less scope to express their worries. The objective is to investigate whether patients have become more reluctant to open up about their concerns during psychosocial consultations and how GPs respond. METHODS: Consultations from previous study samples videotaped between 1977 and 2008 and categorized by GPs as 'completely psychosocial' were selected for the present study. These consultations were observed using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to capture cues and concerns expressed by patients and GPs' immediate responses. We compared consultations prior to (N = 121) and after (N = 391) introduction of national clinical guidelines in the 1990s. RESULTS: In 92% of the consultations, patients presented at least one worry. These were most often expressed implicitly. However, the proportion of consultations containing at least one explicit concern changed from 24% to 37% over time. The increased number of expressed cues and concerns was partly explained by a change in GP characteristics; the latter sample contained more female and more experienced GPs. Furthermore, cues and concerns were more often expressed during later phases of consultations in recent years. CONCLUSIONS: Our study shows that patients have become somewhat more explicit in expressing their worries. However, GPs need to be aware that, still, most worries are expressed implicitly and that new concerns may appear towards the end of consultations.

Healthcare utilization in general practice before and after psychological treatment: a follow-up data linkage study in primary care.

OBJECTIVE: Literature suggests that serious mental health problems increase the use of health services and psychological interventions can reduce this effect. This study investigates whether this effect is also found in primary care patients with less serious mental health problems. DESIGN/SETTING: Routine electronic health records (EHR) from a representative sample of 128 general practices were linked to patient files from 150 primary care psychologists participating in the NIVEL Primary Care Database, using a trusted third party. Data were linked using the date of birth, gender, and postcode. This yielded 503 unique data pairs that were listed in one of the participating GP practices in 2008-2010, for people who had psychological treatment from a psychologist that ended in 2009. MAIN OUTCOME MEASURES: The number of contacts, health problems presented, and prescribed medication in general practice were analysed before and after the psychological treatment. RESULTS: Nearly all 503 patients consulted their GP during the six months preceding the psychological treatment (90.9%) and also in the six months after this treatment had ended (83.7%). The frequency of contacts was significantly higher before than after the psychological treatment (6.1 vs. 4.8). Fewer patients contacted their GPs specifically for psychological or social problems (46.3% vs. 38.8%) and fewer patients had anxiolytic drug prescriptions (15.5% vs. 7.6%) after psychological treatment. CONCLUSION: After psychological treatment, patients contact their GPs less often and present fewer psychological or social problems. Although contact rates seem to decrease, clients of psychologists are still frequent GP attenders.

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation.

BACKGROUND: Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing. METHODS: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network. RESULTS: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92). CONCLUSIONS: An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

Correlates of alcohol abstinence and at-risk alcohol consumption in older adults with depression: the NESDO study.

OBJECTIVES: To compare alcohol use between depressed and nondepressed older adults, and to investigate correlates of alcohol abstinence and at-risk alcohol consumption in depressed older adults. DESIGN: Cross-sectional study. SETTING: Netherlands Study of Depression in Older Persons (NESDO). PARTICIPANTS: A total of 373 participants (mean [standard deviation] age: 70.6 [7.3] years; 66% women) diagnosed with a depressive disorder, and 128 nondepressed participants. MEASUREMENTS: Alcohol use was assessed with the Alcohol Use Disorders Identification Test (AUDIT). Participants were categorized into abstainers (AUDIT score: 0), moderate drinkers (AUDIT score: 1-4), and at-risk drinkers (AUDIT score: ≥5). Multinomial logistic regression analysis was performed with AUDIT categories as outcome, and demographic, social, somatic, and psychological variables as determinants. RESULTS: The depressed group consisted of 40.2% abstainers, 40.8% moderate drinkers, and 19.0% at-risk drinkers. The depressed participants were more often abstinent and less often moderate drinkers than the nondepressed participants; they did not differ in at-risk drinking. Depressed abstainers more often used benzodiazepines but less often used antidepressants, and they had a poorer cognitive function than depressed moderate drinkers. Depressed at-risk drinkers were more often smokers and had fewer functional limitations but more severe depressive symptoms than depressed moderate drinkers. CONCLUSIONS: Although alcohol abstinence was more common in depressed than in nondepressed older adults, 19% of depressed persons were at-risk drinkers. Because at-risk drinking is associated with more severe depression and may have a negative impact on health and treatment outcome, it is important that physicians consider alcohol use in depressed older adults.

Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008.

OBJECTIVE: To examine whether GPs' communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s. METHODS: From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as 'completely psychosocial' were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time. RESULTS: We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9-3.2 to 1.4-1.6 between periods). CONCLUSION: Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy. PRACTICE IMPLICATIONS: GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients' personal contexts and giving room to their emotions.

[Cutting costs in mental health care: how do we divide the sheep from the goats?]. / Triage in de geestelijke gezondheidszorg: hoe scheiden we de bokken van de schapen?

Dutch Mental Health Services are in the process of being reformed. Specialist Mental Health Services have to be restricted. The realization of these restrictions will need a more fundamental shift in criteria than the DSM classification will be able to provide.

Mental health treatment provided by primary care psychologists in The Netherlands.

OBJECTIVE: The study examined outcomes of clients treated by primary care psychologists in 2010 in the Netherlands. METHODS: Data for 55,067 clients treated by 613 primary care psychologists were analyzed for three outcomes: regular conclusion of treatment, improvement of >10 points on the Global Assessment of Functioning (GAF), and treatment conclusion in eight or fewer sessions. Logistic regression analyses examined relationships between client characteristics and outcome. RESULTS: For 73% of clients, treatment reached a regular conclusion, and for 71% of these clients treatment was concluded in eight or fewer sessions. An improvement of >10 GAF points was achieved by 47%. Women, clients with more years of education, those born in the Netherlands, and those with adjustment problems or child problems were more likely to have a regular treatment conclusion and an improvement of >10 GAF points. CONCLUSIONS: Clients with psychopathology of a low or moderate severity were treated successfully by primary care psychologists.

Perceived need for care and health care utilization among depressed and anxious patients with and without suicidal ideation.

BACKGROUND: Information is scarce concerning the perceived needs and the amount of health-care utilization of persons with suicidal ideation (SI) compared to those without SI. AIMS: To describe the needs and health care use of persons with and without SI and to investigate whether these differences are associated with the severity of the axis-I symptomatology. METHOD: Data were obtained from 1,699 respondents with a depressive and/or anxiety disorder who participated in the Netherlands Study of Depression and Anxiety. Persons with and without SI were distinguished. Outcome variables were perceived needs and health-care utilization. We used multivariate regression in two models: (1) adjusted only for sociodemographic variables and (2) adjusted additionally for severity of axis-I symptomatology. RESULTS: Persons with SI had higher odds for both unmet and met needs in almost all domains and made more intensive use of mental-health care. Differences in needs and health-care utilization of persons with and without SI were strongly associated with severity of axis I symptomatology. CONCLUSIONS: Our results validate previous findings about perceived needs and health-care use of persons with SI. The results also suggest that suicidal persons are more seriously ill, and that they need more professional care, dedication, and specialized expertise than anxious and depressed persons without SI, especially in the domains of information and referral.