[Clinical challenges in decision-making regarding gender-affirming medical care]. / Klinische uitdagingen in de besluitvorming rondom somatische transgenderzorg.

Background   The societal discourse concerning gender(diversity) is changing rapidly and this trickles down to our consultation rooms. Most requests for gender-affirming medical care (GAMC) are well-considered and evidently necessary. In more complex presentations, however, challenges may arise. Aim  To provide insight into clinical challenges in decision-making regarding GAMC. Method  Discussing relevant literature by means of a clinical vignette. Results   Dilemmas may arise in assessing competence to give consent to treatment. In differential diagnosis, it may be challenging to discern the interaction between gender incongruence and co-occurring mental conditions. Conclusion   It is unethical to prima facie deny access to GAMC to those presenting with co-occurring mental health concerns and/or challenges in decision-making capacity. For this population, specialist care and comprehensive deliberation are indicated. To arrive at good care and decision-making, sufficient knowledge and sensitivity among, and cooperation with other mental health services is indispensable.

Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972-2017).

OBJECTIVE: This study explored the overall suicide death rate, the incidence over time, and the stage in transition where suicide deaths were observed in transgender people. METHODS: A chart study, including all 8263 referrals to our clinic since 1972. Information on death occurrence, time, and cause of death was obtained from multiple sources. RESULTS: Out of 5107 trans women (median age at first visit 28 years, median follow-up time 10 years) and 3156 trans men (median age at first visit 20 years, median follow-up time 5 years), 41 trans women and 8 trans men died by suicide. In trans women, suicide deaths decreased over time, while it did not change in trans men. Of all suicide deaths, 14 people were no longer in treatment, 35 were in treatment in the previous two years. The mean number of suicides in the years 2013-2017 was higher in the trans population compared with the Dutch population. CONCLUSIONS: We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs.

Light therapy: is it safe for the eyes?

OBJECTIVE: Light therapy has become an increasingly popular treatment for depression and a range of other neuropsychiatric conditions. Yet, concerns have been raised about the ocular safety of light therapy. METHOD: We conducted the first systematic review into the ocular safety of light therapy. A PubMed search on January 4, 2017, identified 6708 articles, of which 161 were full-text reviewed. In total, 43 articles reporting on ocular complaints and ocular examinations were included in the analyses. RESULTS: Ocular complaints, including ocular discomfort and vision problems, were reported in about 0% to 45% of the participants of studies involving light therapy. Based on individual studies, no evident relationship between the occurrence of complaints and light therapy dose was found. There was no evidence for ocular damage due to light therapy, with the exception of one case report that documented the development of a maculopathy in a person treated with the photosensitizing antidepressant clomipramine. CONCLUSION: Results suggest that light therapy is safe for the eyes in physically healthy, unmedicated persons. The ocular safety of light therapy in persons with preexisting ocular abnormalities or increased photosensitivity warrants further study. However, theoretical considerations do not substantiate stringent ocular safety-related contraindications for light therapy.

Inflammatory markers in late-life depression: results from a population-based study.

BACKGROUND: Previous studies have reported conflicting results concerning the association between several inflammatory markers and depression. The association between inflammation and depression may depend on the presence of specific chronic diseases or be relevant in specific sub-groups of depressed patients only. OBJECTIVE: To assess associations between inflammatory markers and depression in older people, taking account of confounding and effect-modifying factors. METHOD: Population-based study of 1285 participants of the Longitudinal Aging Study Amsterdam, aged 65 and over. Plasma concentrations of Interleukin-6 (IL-6) and C-reactive protein (CRP) were measured. Major depression (first- or recurrent episode) and sub-threshold depression were assessed. Associations were adjusted for confounding variables. Associations with inflammatory markers were further studied with regard to severity and duration of depression, and with regard to specific depressive symptoms. RESULTS: High levels of IL-6 (above 5 pg/mL) were associated with major depression (odds ratio 2.49 (1.07-5.80), both in recurrent and first episodes. No significant effect of either one of the markers on specific symptom dimensions of depression was found. Mildly elevated plasma levels of CRP (above 3.2 mg/L) were associated with higher CES-D scores, but not after correction for the confounding effect of age and chronic diseases. LIMITATIONS: The cross-sectional design limits conclusions regarding causality. CONCLUSIONS: A high plasma level of IL-6, but not CRP, is associated with an increased prevalence of major depression in older people, independent of age, chronic diseases, cognitive functioning and anti-depressants. Present results suggest new directions for clinical research into the prevention of physical consequences of depression.

Change of serum albumin and risk of cardiovascular disease and all-cause mortality: Longitudinal Aging Study Amsterdam.

The aim of this longitudinal study was to investigate 3-year change in serum albumin concentration as a determinant of incident cardiovascular disease (CVD) and all-cause mortality. Data were from 713 respondents of the Longitudinal Aging Study Amsterdam initially aged 55-85 years. Serum albumin was measured at baseline (1992/1993) and after 3 years. At the 6-year follow-up, incident CVD (among 456 respondents with no prevalent CVD at the 3-year follow-up) and all-cause mortality were ascertained. Overall, 18.9% developed CVD and 10.9% died. After adjustment for potential confounders, a higher level of serum albumin at the 3-year follow-up was associated with a lower risk for incident CVD (relative risk = 0.88, 95% confidence interval (CI): 0.79, 0.98). The risk of incident CVD was 0.88 (95% CI: 0.78, 0.99) per unit (g/liter) increase in change in albumin between 3-year follow-up and baseline. Chronic low serum albumin (or=1 standard deviation (2.5 g/liter) between baseline and 3-year follow-up) tended to be associated with a twofold risk (relative risk = 2.00, 95% CI: 0.91, 4.39). For all-cause mortality, no associations were observed. These findings suggest that older persons with a decrease in serum albumin concentration, even within the normal range, might be at increased risk of incident CVD. Change in serum albumin may be used as an early marker for CVD risk.

[Explanations for the relation between depression and increased mortality]. / Verklaringen voor de relatie tussen depressie en verhoogde sterfte.

Depression is a highly prevalent disorder at all levels of health-care delivery. Depression has an unfavourable effect on the prognosis of somatic illnesses, and is associated with excess mortality. Several mechanisms may contribute to these relationships. First of all, depression affects behaviour. Depressed patients show more unhealthy living habits, less compliance with medical treatment, and a higher number of accidents and suicides. Secondly, biological aspects of depression are important. Dysregulation of the neuro-immune system, hyperactivity of the hypothalamic pituitary adrenal axis, and autonomic dysregulation may all have a negative effect on both the prognosis of somatic illnesses and the lifespan. Although studies have suggested beneficial effects of the treatment of depression in (somatic) patients, it remains unclear whether treatment may also affect survival. Further research is needed to investigate the occurrence of and to unravel the mutual influences of depression and somatic illnesses, to search for possible pathogenetic mechanisms that may underlie both depression and medical disorders, and to assess the effects of depression treatment on biological parameters and survival.

Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam.

OBJECTIVE: To study the prevalence and risk factors of anxiety disorders in the older (55-85) population of The Netherlands. METHOD: The Longitudinal Aging Study Amsterdam (LASA) is based on a random sample of 3107 older adults, stratified for age and sex, which was drawn from the community registries of 11 municipalities in three regions in The Netherlands. Anxiety disorders were diagnosed using the Diagnostic Interview Schedule in a two-stage screening design. The risk factors under study comprise vulnerability, stress and network-related variables. Both bivariate and multivariate statistical methods were used to evaluate the risk factors. RESULTS: The overall prevalence of anxiety disorders was estimated at 10.2%. Generalized anxiety disorder was the most common disorder (7.3%), followed by phobic disorders (3.1%). Both panic disorder (1.0%) and obsessive compulsive disorder (0.6%) were rare. These figures are roughly similar to previous findings. Ageing itself did not have any impact on the prevalence in both bivariate and multivariate analyses. The impact of other factors did not change much with age. Vulnerability factors (female sex, lower levels of education, having suffered extreme experiences during World War II and external locus of control) appeared to dominate, while stresses commonly experienced by older people (recent losses in the family and chronic physical illness) also played a part. Of the network-related variables, only a smaller size of the network was associated with anxiety disorders. CONCLUSIONS: Anxiety disorders are common in later life. The risk factors support using a vulnerability-stress model to conceptualize anxiety disorders. Although the prevalence of risk factors changes dramatically with age, their impact is not age-dependent. The risk factors indicate which groups of older people are at a high risk for anxiety disorders and in whom active screening and treatment may be warranted.