[Pregnancy and psychiatry: a description of patients and the conducted interventions seen at a POP-clinic]. / Zwangerschap en psychiatrie; beschrijving van patiënten en interventies op een POP-poli.

BACKGROUND: Pregnancy and the postpartum period is a vulnerable phase in life for women and can influence the development or course of a psychiatric disorder. These patients can receive extra guidance during this period by the POP-collaboration (Psychiatry, Obstetrics and Pediatrics) in many hospitals. AIM: To describe the characteristics of patients who received psychiatric consultation by the POP-collaboration at the LUMC and the interventions that were conducted. METHOD: Data of patients who were seen at the psychiatric (outpatient) clinic for POP-guidance between 1 January 2016 and 1 April 2020 were analyzed. RESULTS: 292 patients were seen in 310 guidance programs at the psychiatric (outpatient) clinic. Patients referred preconceptionally or during the pregnancy mostly suffered anxiety or unipolar mood disorders. Postpartum it concerned mostly psychotic disorders and bipolar mood disorders. A majority had two or more psychiatric disorders. Interventions were psycho-education, supportive contact, collaboration with their own health-professionals, adjustment of the current treatment, making a prevention plan, a prolonged stay at hospital after childbirth or (rarely) an admission to the psychiatric ward. CONCLUSION: Patients seen for guidance by the POP-collaboration at the LUMC are a vulnerable patient population with frequently complex psychopathology, and need personalized psychoeducation, supervision and treatment.

Clinical and sociodemographic associations with treatment selection in major depression.

OBJECTIVE: To investigate treatment selection in a naturalistic sample of MDD outpatients and the factors influencing treatment selection in specialized psychiatric care. METHOD: Multinomial Logistic Regression analysis investigated associations between treatment selection and patients' sociodemographic and clinical characteristics, using retrospective chart review data and Routine Outcome Monitoring (ROM) data of MDD outpatients. RESULTS: Of the patients included for analyses (N = 263), 34% received psychotherapy, 32% received an antidepressant (AD) and 35% received a combination. Men were more likely than women to receive AD with reference to psychotherapy (ORAD = 5.57, 95% CI 2.38-13.00). Patients with severe depression and patients with AD use upon referral, prescribed by their general practitioner, were more likely to receive AD (ORsevere depression = 5.34, 95% CI 1.70-16.78/ORAD GP = 9.26, 95% CI 2.53-33.90) or combined treatment (ORsevere depression = 6.32, 95% CI 1.86-21.49/ORAD GP = 22.36, 95% CI 5.89-83.59) with respect to psychotherapy. More severe patients with AD upon referral received combined treatment less often compared to psychotherapy (OR = 0.14, 95% CI 0.03-0.68). CONCLUSION: AD prescriptions in primary care, severity and gender influenced treatment selection for depressive disorders in secondary psychiatric care. Other factors such as the accessibility of treatment and patient preferences may have played a role in treatment selection in this setting and need further investigation.

[Long-term follow-up of psychogenic pseudosyncope]. / Het beloop van psychogene pseudosyncope na meedelen van de diagnose.

BACKGROUND: Patients with psychogenic pseudosyncope (PPS) are frequently seen by neurologists and psychiatrists. As of yet, there has been no follow-up study of patients with PPS after communicating the diagnosis. AIM: To determine the outcome of patients with psychogenic pseudosyncope (PPS) after communicatingthe diagnosis. METHOD: A retrospective cohort study of patients with PPS referred to a tertiary referral center for syncope from 2007 to 2015. We reviewed patient records, studying attack frequency, factors possibly affecting attack frequency, health care use and quality of life using questionnaires. We explored influences on absence of attack and attack frequency in the six months before follow-up for age, sex, level of education, duration until a diagnosis was made, probability of diagnosis, additional syncope and acceptance of diagnosis. RESULTS: 47 out 57 PPS cases could be traced, of these 35 (74%) participated. Twelve (34%) were attack free for at least six months. The median time from diagnosis to follow-up was 50 months (range 6-103 months). Communication and explanation of the diagnosis resulted in immediate reduction of attack frequency (p=0.007) from the month before diagnosis (median one attack, range 0-156) to the month afterwards (median one attack, range 0-16). In the six months before follow-up the number of admissions decreased from 19/35 to 0/35 (p = 0.002). Furthermore, the demand for somatic health care shifted to psychiatric care (p < 0.0001). Quality of life at follow-up (Short Form Health Survey 36; SF-36) showed lower scores for seven of the eight domains compared to matched Dutch control values. The quality of life was not significantly influenced by absence of attack. CONCLUSION: After communicating the diagnosis of PPS, attack frequency decreased and health care use shifted toward mental care. Low quality of life underlines the fact that PPS is a serious condition. Improvement of quality of life probably requires both a longer treatment and longer follow-up.

[Views of psychiatrists on patients' responsibility for their own health. A qualitative study]. / Denkbeelden van psychiaters over de verantwoordelijkheid van patiënten voor hun gezondheid; een kwalitatief onderzoek.

BACKGROUND: In the Netherlands patients are increasingly being required to take responsibility for their own their health. However, an important problem not yet resolved is whether psychiatric patients are able or well enough to shoulder this responsibility. AIM: To explore the normative views of psychiatrists concerning their responsibility of their patients' health. METHOD: We performed a qualitative research in which 15 psychiatrists were interviewed with the help of a list of topics. The verbatim accounts of the interviews were analysed and interpreted by two researchers. RESULTS: Psychiatrists differed in their views on the responsibility of patients for their own health. Some psychiatrists defined patient responsibility as a personal quality or disposition and regarded patients as being in principle responsible; others considered patient responsibility to be a construct or result of the therapeutic relationship. These two groups had different views about the moments and the ways in which patient responsibility becomes problematical. In addition, they had opposing views on current developments in government policies. CONCLUSION: Psychiatrists differ in their interpretation of patient responsibility. This means they differ not only in their views on government policy but also probably in the attitudes they adopt in their daily practice. These differing attitudes to patient responsibility need to be looked at critically because they have a bearing on the observance of ethical norms and on the need to respect patients' autonomy.

The clinical effectiveness of concise cognitive behavioral therapy with or without pharmacotherapy for depressive and anxiety disorders; a pragmatic randomized controlled equivalence trial in clinical practice.

BACKGROUND: Depressive and anxiety disorders contribute to a high disease burden. This paper investigates whether concise formats of cognitive behavioral- and/or pharmacotherapy are equivalent with longer standard care in the treatment of depressive and/or anxiety disorders in secondary mental health care. METHODS: A pragmatic randomized controlled equivalence trial was conducted at five Dutch outpatient Mental Healthcare Centers (MHCs) of the Regional Mental Health Provider (RMHP) 'Rivierduinen'. Patients (aged 18-65 years) with a mild to moderate anxiety and/or depressive disorder, were randomly allocated to concise or standard care. Data were collected at baseline, 3, 6 and 12 months by Routine Outcome Monitoring (ROM). Primary outcomes were the Brief Symptom Inventory (BSI) and the Web Screening Questionnaire (WSQ). We used Generalized Estimating Equations (GEE) to assess outcomes. RESULTS: Between March 2010 and December 2012, 182 patients, were enrolled (n=89 standard care; n=93 concise care). Both intention-to-treat and per-protocol analyses demonstrated equivalence of concise care and standard care at all time points. Severity of illness reduced, and both treatments improved patient's general health status and subdomains of quality of life. Moreover, in concise care, the beneficial effects started earlier. DISCUSSION: Concise care has the potential to be a feasible and promising alternative to longer standard secondary mental health care in the treatment of outpatients with a mild to moderate depressive and/or anxiety disorder. For future research, we recommend adhering more strictly to the concise treatment protocols to further explore the beneficial effects of the concise treatment. The study is registered in the Netherlands Trial Register, number NTR2590. Clinicaltrials.gov identifier: NCT01643642.

An evaluation of irreversible psychosurgical treatment of patients with obsessive-compulsive disorder in the Netherlands, 2001-2008.

Admissions for irreversible psychosurgical treatment of obsessive-compulsive disorder (OCD) by the Working Group for Indication Psychosurgery in the Netherlands were analyzed, and the postsurgical effects on symptom severity and quality of life were evaluated. The data were extracted from patient records in the period 2001-2008, and there was a postoperative assessment with a semistructured interview. Fourteen patients applied, having severe OCD with mostly one or more comorbid disorders. The mean Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 32 points. Four of seven patients in whom psychosurgery was deemed useful were operated on. The decrease of the Y-BOCS score from registration to after surgery was 9 points (range, 3-17 points). An improvement in social function was present in three of four patients. In conclusion, psychosurgery can be a valuable treatment option for patients with severe OCD in whom other treatments fail.

[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.

[Empirical evidence for the effectiveness of Routine Outcome Monitoring. A study of the literature]. / Empirische evidence voor de effectiviteit van routine outcome monitoring; een literatuuronderzoek.

BACKGROUND: Routine Outcome Monitoring ROM is an important instrument for measuring the effectiveness of treatment and has been implemented in the Dutch mental health care system. AIM: To review the effectiveness of ROM with regard to diagnosis, treatment, and other outcomes. METHOD: The literature study focused on randomised controlled trials RCT's of ROM performed on patients of all age groups, some being general patients, others being psychiatric patients. The main search words were 'routine outcome monitoring' or 'routine outcome measurement'. RESULTS: 52 RCTs on adult patients were included in the study; 45 of these trials were performed on patients with mental health problems, but not always in a psychiatric setting or as primary outcome measure. rom appears to have positive effects on diagnosis and treatment and on the communication between patient and therapist. Other results were less clear. CONCLUSION: ROM seems to be particularly effective for the monitoring of treatments which have not been entirely successful. Further research needs to be done into the clinical and cost-effectiveness of ROM when used with adults and children who have mental health problems.

[Update of the multidisciplinary guidelines for anxiety and depression]. / Herziening van de multidisciplinaire richtlijnen angst en depressie.

The multidisciplinary guidelines for depression, panic disorder and post-traumatic stress disorder have been revised. They incorporate some important changes: algorithms are now based on the severity of the disorders, a 'stepped-care' approach is promoted, so-called basic interventions are required for each algorithm and so-called first-step interventions are advocated for mild disorders. Antidepressants are no longer indicated for mild disorders.

Elevated alpha-amylase but not cortisol in generalized social anxiety disorder.

Stress-system dysregulation is thought to increase the risk for anxiety disorders. Here we describe both hypothalamic pituitary adrenal (HPA) axis and autonomic nervous system (ANS) activity in basal non-challenging conditions and after 0.5mg dexamethasone in generalized social anxiety disorder (gSAD) patients. To ensure stress-free sampling we collected saliva and determined cortisol and alpha-amylase (sAA), the latter a relative new marker of autonomic activity. Forty-three untreated gSAD patients without comorbidity were compared with 43 age and gender matched controls in non-stressed conditions on sAA and cortisol after awakening, during the day (including late evening), and after a low dose (0.5mg) of dexamethasone. Cortisol and sAA were analyzed with mixed models. Additional analyses were done with paired t-tests. Apart from the assessments in the morning, gSAD patients had significantly higher diurnal and post-dexamethasone 1600h sAA levels. No differences between gSAD and controls in any cortisol measurements were found. In conclusion, in gSAD in basal, non-stimulated conditions and after dexamethasone, we found hyperactivity of the ANS, as measured with sAA, but not of the HPA-axis. This suggests a relative increased activity of the ANS as compared to the HPA-axis, in line with the observed hyperarousal in gSAD.

Need for alternative ways of phenotyping of mood, anxiety, and somatoform disorders in biological research.

Variation in psychiatric symptomatology is continuous and does not coalesce into fairly well-defined categorical DSM-IV clusters. As a consequence, DSM-IV fails to meaningfully integrate information generated by neuroendocrine research. Continuous psychological dimensions selected for their predictiveness with respect to endophenotypes, as biological intermediate factors, are proposed to be the best ways in reaching an understanding of the causations in mood, anxiety, and somatoform disorders.

[The MINI-International Neuropsychiatric Interview. A brief structured diagnostic psychiatric interview for DSM-IV en ICD-10 psychiatric disorders]. / Het Mini Internationaal Neuropsychiatrisch Interview (MINI). Een kort gestructureerd diagnostisch psychiatrisch interview voor DSM-IV- en ICD-10-stoornissen.

The MINI-International Neuropsychiatric Interview (MINI(-Plus)) is a structured diagnostic interview, developed to assess the diagnoses of psychiatric patients according to DSM-IV and ICD-10 criteria in less time than other diagnostic interviews such as the Structured Clinical Interview for DSM-IV disorders (SCID), the Composite International Diagnostic Interview (CIDI) or the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) tend to take. The good psychometric characteristics of the MINI (-Plus) make it a good choice for research purposes. Because of its brevity (20-30 minutes) the interview seems to be especially convenient for diagnosing psychiatric patients in everyday clinical practice. Initial experiences and results with the MINI-Plus in a selected group of Dutch psychiatric patients are described.

Behavioural effects of rapid intravenous administration of meta-chlorophenylpiperazine (m-CPP) in patients with generalized social anxiety disorder, panic disorder and healthy controls.

Findings from epidemiological, pharmacotherapeutical, genetic and neurobiological studies suggest a possible overlap in the neurobiology of generalized social anxiety disorder (gSAD) and panic disorder (PD). Previously we have found a rapid intravenous m-CPP challenge of 0.1 mg/kg to be highly sensitive and selective in the provocation of panic attacks in patients with PD. We therefore directly compared the behavioural, neuroendocrine and physiological effects of this rapid m-CPP challenge in a small sample of patients with gSAD, patients with PD and matched healthy controls. Panic attacks were significantly more provoked in patients with PD (85%), but not in patients with gSAD (14%) as compared to healthy controls (0%). Effects on the other behavioural parameters, but not on the neuroendocrine and physiological parameters, were significantly greater in patients with PD compared to patients with gSAD and controls. Our preliminary data do not support a shared neurobiology of gSAD and PD.

[Prediction of effectiveness of electroconvulsive therapy in major depression with routinely collected data]. / Voorspelling van de effectiviteit van elektroconvulsietherapie bij een depressieve stoornis met routinematig verzamelde data.

BACKGROUND: Little is known about the possibility to predict response to electroconvulsive therapy (ECT) in patients with major depression. AIM: To create an indexforthe prediction ofresponse to ECT in an individual patient. METHOD: Fifty-three depressive patients referred for ECT were included. Poor response was defined as a decrease in Hamilton Rating Depression Scale less than 50%. With multivariable analyses a simple index of independent predictors was constructed. RESULTS: Thirty-one patients (58%) showed poor response. The index comprised age < 65 years, psychotic depression, refractory to antidepressant medication, and personality disorder. It discriminated poor response patients reasonably well with an area under the receiver operating characteristic curve of 0.76 (95% confidence interval 0.63-0.89). CONCLUSION: Response to ECT may be predicted using an index with four patient characteristics. Before implementation, however, validation of the index in future patients is mandatory.

[The practice guideline 'Anxiety disorders' (first revision) from the Dutch College of General Practitioners; a response from the perspective of psychiatry]. / De standaard 'Angststoornissen' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de psychiatrie.

The revised version of the practice guideline 'Anxiety disorders' from the Dutch College of General Practitioners largely agrees with the Dutch interdisciplinary guidelines. It was agreed that the interdisciplinary guidelines would function as the standard and the professional guidelines would be derived from these. Differences concern the need to distinguish anxiety disorders as distinct conditions, the need to question about psychiatric disorders in the family, the status of tricyclic anti-depressants (TCAs) and selective serontonin re-uptake inhibitors (SSRIs), the medicinal possibilities, and the possibility of an one-offconsultation with a psychologist or psychiatrist.

[Withdrawal symptoms of antidepressants]. / Onttrekkingsverschijnselen van antidepressiva.

Withdrawal symptoms are encountered with both the classical anti-depressants, i.e. the tricyclic antidepressants and monoamineoxidase inhibitors, the modern antidepressants, i.e. the selective serotonin re-uptake inhibitors, and the new antidepressants such as venlafaxine and mirtazapine. The symptoms that are reported following the withdrawal of these drugs can be classified into 8 groups: influenza-like symptoms, psychic symptoms, gastrointestinal symptoms, sleep disorders, equilibrium disorders, sensory disturbances, extrapyramidal symptoms and other symptoms. It is characteristic of these symptoms that they appear 1-4 days after reduction of the dose or the last administration of the drug. They may also appear in the infants of mothers who used an antidepressant during the last phase of the pregnancy. It is important that the patient be informed accurately and carefully at the start and termination of any treatment with an antidepressant. In order to prevent withdrawal symptoms, it is advisable to reduce the dosage slowly if possible when the treatment is to be terminated.

['Hyperventilation syndrome': often an easy to treat panic disorder]. / 'Hyperventilatiesyndroom': veelal goed behandelbare paniekstoornis.

Three patients, 2 men aged 35 and 26 years and 1 woman aged 41 years, had acutely occurring attacks, accompanied by diverse somatic complaints, and were diagnosed with hyperventilation syndrome. They recovered only when the complaints were recognised and treated as a panic disorder. Hyperventilation and the decrease of CO2 in the blood do not explain the symptoms and complaints in patients with panic disorder, a psychiatric disorder with a good prognosis. Treatment consists of cognitive behavioural therapy or a selective serotonin re-uptake inhibitor in the case of panic disorder and of a combination of those two treatments in the case of panic disorder with agoraphobia. Breathing exercises can form part of the behavioural therapy but not because the disorder is due to faulty breathing habits.

Mirtazapine in social anxiety disorder: a pilot study.

Fourteen patients with social anxiety disorder (generalized type), according to DSM-IV criteria, were treated with mirtazapine 30 mg for 12 weeks. Twelve patients completed the study. Two patients (14.3%) dropped out due to side-effects. Generally, mirtazapine was well tolerated. Five out of 12 patients (41.7%) were classified as responders, based on a Clinical Global Improvement score of 1 or 2 and a reduction of the Liebowitz Social Anxiety Scale (LSAS) of 40%. The mean total score on the LSAS, as well as the anxiety and avoidance subscores, decreased significantly. This open pilot study suggests that further investigations are warranted to prove the efficacy of mirtazapine in generalized social anxiety disorder.

Characteristics of patients with social phobia and their treatment in specialized clinics for anxiety disorders in the Netherlands.

BACKGROUND: Social phobia frequently occurs in the general population but is probably underreported due to comorbid disorders which mask the social phobia. Another reason might be that patients do not consult their general pratitioner due to embarrassment or an estimation of their condition. There are several treatments available for social phobia, but not enough is known about the efficacy of the different treatments strategies. METHODS: A retrospective, medical record-based study was carried out in four outpatient clinics specializing in treatment of anxiety disorders to investigate the characteristics of 64 patients with a DSM-IV axis diagnosis of social phobia who seeked help for their problems. Therapies for social phobia within these clinics and differences between these clinics were evaluated. RESULTS: Men with a high educational level tended to seek more help and comorbid disorders tended to cause more impairment in functioning. Further, there is a large delay between onset and therapy attendance (mean 14 years). Finally, there was consistency in the treatment of social phobia in these four clinics which consisted of cognitive behavioral therapy and/or medication. LIMITATIONS: The study is retrospective and based on medical records which means there was no objective measurement of the effectiveness of the therapies. CONCLUSIONS: Seventy-five percent of patients improved after treatment independent of the kind of therapy, the occurrence of comorbid disorders and the type of social phobia.

Relapse prevention in major depressive disorder after successful ECT: a literature review and a naturalistic case series.

OBJECTIVE: Medication-resistance in major depressive disorder (MDD) may be related to high relapse rates after successful ECT when continued medication (C-MED) is used to prevent relapse. An alternative could be to continue ECT (C-ECT). METHOD: Patients with medication-resistant MDD responding to ECT were offered C-ECT without medication. Follow-up was 6 months. Publications from a literature search were screened against prespecified criteria. RESULTS: With C-ECT the 6-month relapse-rate was 50% (6/12, 95% CI:21-79) in our medication-resistant group. In the review we found with C-ECT 29% (7/24,CI:13-51) in 'unknown' medication resistance and no data about medication-resistant depression. With C-MED at 6 months: no data were found concerning medication-resistant depression, 28% (35/124,CI:20-36) in 'unknown' resistance and 13% (2/15,CI:2-41) in non-resistance. With C-MED at 12 months, 73% (16/22,CI:50-90), 50% (16/32,CI:32-68) and 27% (8/30,CI:12-46) were found, respectively. CONCLUSION: The efficacy of C-MED is related negatively to medication resistance before ECT. This may also be the case for C-ECT. Further studies with C-ECT are urgently needed.