Predictors of the 6-year outcome of obsessive-compulsive disorder: Findings from the Netherlands Obsessive-Compulsive Disorder Association study.

OBJECTIVE: Obsessive-compulsive disorder is characterized by a chronic course that can vary between patients. The knowledge on the naturalistic long-term outcome of obsessive-compulsive disorder and its predictors is surprisingly limited. The present research was designed to identify clinical and psychosocial predictors of the long-term outcome of obsessive-compulsive disorder. METHODS: We included 377 individuals with a current diagnosis of obsessive-compulsive disorder, who participated in the Netherlands Obsessive Compulsive Disorder Association study, a multicenter naturalistic cohort study. Predictors were measured at baseline using self-report questionnaires and clinical interviews. Outcome was assessed using the Yale-Brown Obsessive Compulsive Scale at 2-, 4- and 6-year follow-up. RESULTS: The overall course of obsessive-compulsive disorder was characterized by two prominent trends: the first reflected an improvement in symptom severity, which was mitigated by the second, worsening trend in the long term. Several determinants affected the course variations of obsessive-compulsive disorder, namely, increased baseline symptom severity, late age of onset, history of childhood trauma and autism traits. CONCLUSION: The long-term outcome of obsessive-compulsive disorder in naturalistic settings was characterized by an overall improvement in symptom severity, which was gradually halted to the point of increased worsening. However, after 6 years, the severity of symptoms remained below the baseline level. While certain determinants predicted a more favorable course, their effect diminished over time in correspondence to the general worsening trend. The results highlight the importance of a regular and continuous monitoring for symptom exacerbations as part of the management of the obsessive-compulsive disorder, regardless of the presence of putative predictors.

Cannabidiol enhancement of exposure therapy in treatment refractory patients with social anxiety disorder and panic disorder with agoraphobia: A randomised controlled trial.

Preclinical research suggests that enhancing CB1 receptor agonism may improve fear extinction. In order to translate this knowledge into a clinical application we examined whether cannabidiol (CBD), a hydrolysis inhibitor of the endogenous CB1 receptor agonist anandamide (AEA), would enhance the effects of exposure therapy in treatment refractory patients with anxiety disorders. Patients with panic disorder with agoraphobia or social anxiety disorder were recruited for a double-blind parallel randomised controlled trial at three mental health care centres in the Netherlands. Eight therapist-assisted exposure in vivo sessions (weekly, outpatient) were augmented with 300 mg oral CBD (n = 39) or placebo (n = 41). The Fear Questionnaire (FQ) was assessed at baseline, mid- and post-treatment, and at 3 and 6 months follow-up. Primary analyses were on an intent-to-treat basis. No differences were found in treatment outcome over time between CBD and placebo on FQ scores, neither across (ß = 0.32, 95% CI [-0.60; 1.25]) nor within diagnosis groups (ß = -0.11, 95% CI [-1.62; 1.40]). In contrast to our hypotheses, CBD augmentation did not enhance early treatment response, within-session fear extinction or extinction learning. Incidence of adverse effects was equal in the CBD (n = 4, 10.3%) and placebo condition (n = 6, 15.4%). In this first clinical trial examining CBD as an adjunctive therapy in anxiety disorders, CBD did not improve treatment outcome. Future clinical trials may investigate different dosage regimens.

Usage Intensity of a Relapse Prevention Program and Its Relation to Symptom Severity in Remitted Patients With Anxiety and Depression: Pre-Post Study.

BACKGROUND: Given that relapse is common in patients in remission from anxiety and depressive disorders, relapse prevention is needed in the maintenance phase. Although existing psychological relapse prevention interventions have proven to be effective, they are not explicitly based on patients' preferences. Hence, we developed a blended relapse prevention program based on patients' preferences, which was delivered in primary care practices by mental health professionals (MHPs). This program comprises contact with MHPs, completion of core and optional online modules (including a relapse prevention plan), and keeping a mood and anxiety diary in which patients can monitor their symptoms. OBJECTIVE: The aims of this study were to provide insight into (1) usage intensity of the program (over time), (2) the course of symptoms during the 9 months of the study, and (3) the association between usage intensity and the course of symptoms. METHODS: The Guided E-healTh for RElapse prevention in Anxiety and Depression (GET READY) program was guided by 54 MHPs working in primary care practices. Patients in remission from anxiety and depressive disorders were included. Demographic and clinical characteristics, including anxiety and depressive symptoms, were collected via questionnaires at baseline and after 3, 6, and 9 months. Log data were collected to assess the usage intensity of the program. RESULTS: A total of 113 patients participated in the study. Twenty-seven patients (23.9%) met the criteria for the minimal usage intensity measure. The core modules were used by ≥70% of the patients, while the optional modules were used by <40% of the patients. Usage decreased quickly over time. Anxiety and depressive symptoms remained stable across the total sample; a minority of 15% (12/79) of patients experienced a relapse in their anxiety symptoms, while 10% (8/79) experienced a relapse in their depressive symptoms. Generalized estimating equations analysis indicated a significant association between more frequent face-to-face contact with the MHPs and an increase in both anxiety symptoms (ß=.84, 95% CI .39-1.29) and depressive symptoms (ß=1.12, 95% CI 0.45-1.79). Diary entries and the number of completed modules were not significantly associated with the course of symptoms. CONCLUSIONS: Although the core modules of the GET READY program were used by most of the patients and all patients saw an MHP at least once, usage decreased quickly over time. Most patients remained stable while participating in the study. The significant association between the frequency of contact and the course of symptoms most likely indicates that those who received more support had more symptoms, and thus, it is questionable whether the support offered by the program was sufficient to prevent these patients from relapsing. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12888-019-2034-6.

A clinical staging approach to improving diagnostics in anxiety disorders: Is it the way to go?

BACKGROUND: Clinical staging is a paradigm in which stages of disease progression are identified; these, in turn, have prognostic value. A staging model that enables the prediction of long-term course in anxiety disorders is currently unavailable but much needed as course trajectories are highly heterogenic. This study therefore tailored a heuristic staging model to anxiety disorders and assessed its validity. METHODS: A clinical staging model was tailored to anxiety disorders, distinguishing nine stages of disease progression varying from subclinical stages (0, 1A, 1B) to clinical stages (2A-4B). At-risk subjects and subjects with anxiety disorders (n = 2352) from the longitudinal Netherlands Study of Depression and Anxiety were assigned to these nine stages. The model's validity was assessed by comparing baseline (construct validity) and 2-year, 4-year and 6-year follow-up (predictive validity) differences in anxiety severity measures across stages. Differences in depression severity and disability were assessed as secondary outcome measures. RESULTS: Results showed that the anxiety disorder staging model has construct and predictive validity. At baseline, differences in anxiety severity, social avoidance behaviors, agoraphobic avoidance behaviors, worrying, depressive symptoms and levels of disability existed across all stages (all p-values < 0.001). Over time, these differences between stages remained present until the 6-year follow-up. Differences across stages followed a linear trend in all analyses: higher stages were characterized by the worst outcomes. Regarding the stages, subjects with psychiatric comorbidity (stages 2B, 3B, 4B) showed a deteriorated course compared with those without comorbidity (stages 2A, 3A, 4A). CONCLUSION: A clinical staging tool would be useful in clinical practice to predict disease course in anxiety disorders.

Prevalence and course of subthreshold anxiety disorder in the general population: A three-year follow-up study.

BACKGROUND: This study examined the prevalence, course and risk indicators of subthreshold anxiety disorder to determine the necessity and possible risk indicators for interventions. METHODS: Data were derived from the 'Netherlands Mental Health Survey and Incidence Study-2' (NEMESIS-2), a psychiatric epidemiological cohort study among the general population (n = 4528). This study assessed prevalence, characteristics, and three-year course of subthreshold anxiety disorder (n = 521) in adults, and compared them to a no anxiety group (n = 3832) and an anxiety disorder group (n = 175). Risk indicators for persistent and progressive subthreshold anxiety disorder were also explored, including socio-demographics, vulnerability factors, psychopathology, physical health and functioning. RESULTS: The three-year prevalence of subthreshold anxiety disorder was 11.4%. At three-year follow-up, 57.3% had improved, 29.0% had persistent subthreshold anxiety disorder and 13.8% had progressed to a full-blown anxiety disorder. Prevalence, characteristics and course of subthreshold anxiety disorder were in between both comparison groups. Risk indicators for persistent course partly overlapped with those for progressive course and included vulnerability and psychopathological factors, and diminished functioning. LIMITATIONS: Course analysis were restricted to the development of anxiety disorders, other mental disorders were not assessed. Moreover, due to the naturalistic design of the study the impact of treatment on course cannot be assessed. CONCLUSIONS: Subthreshold anxiety disorder is relatively prevalent and at three-year follow-up a substantial part of respondents experienced persistent symptoms or had progressed into an anxiety disorder. Risk indicators like reduced functioning may help to identify these persons for (preventative) treatment and hence reduce functional limitations and disease burden.

Feasibility and impact of data-driven learning within the suicide prevention action network of thirteen specialist mental healthcare institutions (SUPRANET Care) in the Netherlands: a study protocol.

INTRODUCTION: Improvement of the quality and safety of care is associated with lower suicide rates among mental healthcare patients. In The Netherlands, about 40% of all people that die by suicide is in specialist mental healthcare. Unfortunately, the degree of implementation of suicide prevention policies and best practices within Dutch mental healthcare services is variable. Sharing and comparing outcome and performance data in confidential networks of professionals working in different organisations can be effective in reducing practice variability within and across organisations and improving quality of care. METHODS AND ANALYSIS: Using formats of professional networks to improve surgical care (Dutch Initiative for Clinical Auditing) and somatic intensive care (National Intensive Care Evaluation), 113 Suicide Prevention has taken the lead in the formation of a Suicide Prevention Action Network (SUPRANET Care), with at present 13 large Dutch specialist mental health institutions. Data on suicide, suicide attempts and their determinants as well as consumer care policies and practices are collected biannually, after consensus rounds in which key professionals define what data are relevant to collect, how it is operationalised, retrieved and will be analysed. To evaluate the impact of SUPRANET Care, standardised suicide rates will be calculated adjusted for confounding factors. Second, the extent to which suicide attempts are being registered will be analysed with the suicide attempt data. Finally, professionals' knowledge, attitude and adherence to suicide prevention guidelines will be measured with an extended version of the Professionals In Training to STOP suicide survey. ETHICS AND DISSEMINATION: This study has been approved by the Central Committee on Research Involving Human Subjects, The Netherlands. This study does not fall under the scope of the Medical Research Involving Human Subjects Act (WMO) or the General Data Protection Regulation as stated by the Dutch Data Protection Authority because data are collected on an aggregated level.

Collaborative Care for Anxiety Disorders in Primary Care: a Systematic Review and Meta-Analysis.

(Reprinted with permission from BMC Family Practice (2016) 17:62).

Long-term antidepressant use: a qualitative study on perspectives of patients and GPs in primary care.

BACKGROUND: Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission. AIM: To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use. DESIGN AND SETTING: Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands. METHOD: Patients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20). RESULTS: The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation. CONCLUSION: Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan.

Collaborative care for anxiety disorders in primary care: a systematic review and meta-analysis.

BACKGROUND: Studies evaluating collaborative care for anxiety disorders are recently emerging. A systematic review and meta-analysis to estimate the effect of collaborative care for adult patients with anxiety disorders in primary care is therefore warranted. METHODS: A literature search was performed. DATA SOURCES: PubMed, Psycinfo, Embase, Cinahl, and the Cochrane library. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials examining the effects of collaborative care for adult primary care patients with an anxiety disorder, compared to care as usual or another intervention. Synthesis methods: Standardized mean differences (SMD) on an anxiety scale closest to twelve months follow-up were calculated and pooled in a random effects meta-analysis. RESULTS: Of the 3073 studies found, seven studies were included with a total of 2105 participants. Included studies were of moderate to high quality. Collaborative care was superior to care as usual, with a small effect size (SMD = 0.35 95 % CI 0.14-0.56) for all anxiety disorders combined and a moderate effect size (SMD = 0.59, 95 % CI 0.41-0.78) in a subgroup analysis (five studies) on patients with panic disorder. CONCLUSIONS: Collaborative care seems to be a promising strategy for improving primary care for anxiety disorders, in particular panic disorder. However, the number of studies is still small and further research is needed to evaluate the effectiveness in other anxiety disorders.

Recurrence of anxiety disorders and its predictors.

BACKGROUND: The chronic course of anxiety disorders and its high burden of disease are partly due to the recurrence of anxiety disorders after remission. However, knowledge about recurrence rates and predictors of recurrence is scarce. This article reports on recurrence rates of anxiety disorders and investigates predictors of recurrence from a broad range of socio-demographic characteristics, illness-related and psychosocial putative predictors. METHODS: Baseline and 2-year follow-up data were derived from the Netherlands Study of Depression and Anxiety (NESDA). Participants who had at least one lifetime anxiety disorder (panic disorder with or without agoraphobia, agoraphobia alone, social phobia or generalized anxiety disorder), but were remitted at baseline (N=429) were included. Recurrence of anxiety disorders during the 2-year follow-up period was assessed using the Composite International Diagnostic Interview, version 2.1. RESULTS: Recurrence rates among pure and multiple anxiety disorders did not differ significantly and the overall recurrence rate of anxiety disorders was 23.5%. In those recurring, the incidence of a new anxiety disorder was common (32.7%). Disability and anxiety sensitivity remained predictive of recurrence of anxiety disorders in multivariable regression analysis. LIMITATIONS: The included participants had more severe symptoms at baseline than the non-response group and lifetime anxiety diagnoses were assessed, retrospectively. CONCLUSIONS: Recurrence of anxiety disorders is common and clinicians should be aware of the diagnostic instability within anxiety disorders. Disability and anxiety sensitivity are independent predictors of recurrence of anxiety disorders. Altering these predictors in regular cognitive behavioural therapy could contribute to the reduction of recurrence.

Implementing practice guidelines for anxiety disorders in secondary mental health care: a case study.

BACKGROUND: Recent years have seen the large-scale development of clinical practice guidelines for mental disorders in several countries. In the Netherlands, more than ten multidisciplinary guidelines for mental health care have been developed since 2003. The first dealt with the treatment of anxiety disorders. An important question was whether it is feasible to implement these guidelines because implementing practice guidelines is often difficult. Although several implementation interventions have proven effective, there seems to be no ready-made strategy that works in all circumstances. CASE DESCRIPTION: The Dutch multidisciplinary guidelines for anxiety disorders were implemented in a community mental health care centre, located in the east of the Netherlands. The centre provides secondary outpatient care. The unit within the centre that specializes in the treatment of anxiety disorders has 16 team members with diverse professional backgrounds. Important steps in the process of implementing the guidelines were analysing the care provided before start of the implementation to determine the goals for improvement, and analysing the context and target group for implementation. Based on these analyses, a tailor-made multifaceted implementation strategy was developed that combined the reorganization of the care process, the development of instruction materials, the organization of educational meetings and the use of continuous quality circles to improve adherence to guidelines. DISCUSSION AND EVALUATION: Significant improvements in adherence rates were made in the aspect of care that was targeted for change. An increase was found in the number of patients being provided with recommended forms of psychotherapeutic treatment, ranging from 43% to 54% (p < 0.01). The delivery of adequate pharmacological treatment was not explicitly targeted for change remained constant. CONCLUSION: The case study presented here shows that the implementation of practice guidelines for anxiety disorders in mental health care is feasible. Based on the results of our study, the implementation model used offers a useful approach to guideline implementation. By describing the exact steps that were followed in detail and providing some of the tools that were used in the study, we hope the replication of this implementation methodology is made more practical for others in the future.