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The course over time of religious delusions (RDs) in late-life schizophrenia and psychotic depression may be relevant to know how long certain aspects of RDs may affect treatment. The present study examines (1) the 1-year follow-up of RDs and other prevalent delusions, (2) the association between RDs and the clinical course of psychotic depression and schizophrenia compared to those without RDs, and (3) associations of RDs and other prevalent delusions with “indicators of complexity” (e.g., suicidality, refusing medication).
Prospective study (half year and 1-year follow-up combined).
Outpatients and inpatients in Geriatric Psychiatry Institution of Yulius, South-Holland, the Netherlands.
One hundred and thirty seven older adult patients, mean age 76.3 (s.d. 8.1).
Natural follow-up study.
Diagnostic interview measures included Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1), positive psychosis items of the Community Assessment of Psychic Experiences-42 (CAPE), and the 20-item measures from the Centre for Epidemiologic Studies Depression Scale (CES-D).
Although RDs in older adults decline in the clinical course of psychotic depression, the course is unfavorable compared to psychotic depression without RDs with regard to depressive symptom severity as measured by CES-D. No significant differences were noted in relation to clinical course of positive psychotic symptoms for both psychotic depression and schizophrenia. In schizophrenia, RDs persist more frequently compared to the most prevalent delusions. No significant difference was observed between patients with RDs compared to patients without RDs regarding indicators of clinical complexity.
RDs predicting a less favorable course over time in psychotic depression. In schizophrenia, RDs appears to be relatively pervasive.
The Netherlands has few financial barriers to access mental healthcare. However, in 2012, a sharp rise in co-payments was introduced.
We tested whether these increased co-payments coincided with less guideline-recommended continuous out-patient psychiatric care and more crisis interventions for patients with bipolar disorder.
A retrospective longitudinal cohort study on a health insurance registry was performed to examine trends, and deviations from these trends, in the healthcare received by patients with bipolar disorder. Deviations of trends were tested by time-series analyses (autoregressive integrated moving average). Subsequently, the relationship between significant deviations of trends and rise in co-payments was examined. Outcome measures were the level of standard out-patient care (out-patient psychiatric care and/or medication), crisis psychiatric care and somatic care.
The cohort comprised 3210 patients. During follow-up, the use of psychiatric care decreased and somatic care increased. The high rise in co-payments from 2012 onward coincided with decreases in standard out-patient care and increases in medication-only treatment, crisis psychiatric care and somatic care. Crisis intervention was highest when patients received only bipolar disorder medication. Patients receiving continuous standard out-patient care (62%) had less crisis intervention compared with the other patients.
Our data suggest that the rise of co-payments decreased guideline-recommended continuous out-patient psychiatric care among patients with bipolar disorder, and increased crisis psychiatric care.
Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders.
In this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy.
Patients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (n = 693).
The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who’s course should be monitored actively as they are at increased risk (21<26).
By using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring.
Dietary interventions did not prevent depression onset nor reduced depressive symptoms in a large multi-center randomized controlled depression prevention study (MooDFOOD) involving overweight adults with subsyndromal depressive symptoms. We conducted follow-up analyses to investigate whether dietary interventions differ in their effects on depressive symptom profiles (mood/cognition; somatic; atypical, energy-related).
Baseline, 3-, 6-, and 12-month follow-up data from MooDFOOD were used (n = 933). Participants received (1) placebo supplements, (2) food-related behavioral activation (F-BA) therapy with placebo supplements, (3) multi-nutrient supplements (omega-3 fatty acids and a multi-vitamin), or (4) F-BA therapy with multi-nutrient supplements. Depressive symptom profiles were based on the Inventory of Depressive Symptomatology.
F-BA therapy was significantly associated with decreased severity of the somatic (B = −0.03, p = 0.014, d = −0.10) and energy-related (B = −0.08, p = 0.001, d = −0.13), but not with the mood/cognition symptom profile, whereas multi-nutrient supplementation was significantly associated with increased severity of the mood/cognition (B = 0.05, p = 0.022, d = 0.09) and the energy-related (B = 0.07, p = 0.002, d = 0.12) but not with the somatic symptom profile.
Differentiating depressive symptom profiles indicated that food-related behavioral interventions are most beneficial to alleviate somatic symptoms and symptoms of the atypical, energy-related profile linked to an immuno-metabolic form of depression, although effect sizes were small. Multi-nutrient supplements are not indicated to reduce depressive symptom profiles. These findings show that attention to clinical heterogeneity in depression is of importance when studying dietary interventions.
In research and clinical practice, familial risk for depression and anxiety is often constructed as a simple Yes/No dichotomous family history (FH) indicator. However, this measure may not fully capture the liability to these conditions. This study investigated whether a continuous familial loading score (FLS), incorporating family- and disorder-specific characteristics (e.g. family size, prevalence of depression/anxiety), (i) is associated with a polygenic risk score (PRS) for major depression and with clinical/psychosocial vulnerabilities and (ii) still captures variation in clinical/psychosocial vulnerabilities after information on FH has been taken into account.
Data came from 1425 participants with lifetime depression and/or anxiety from the Netherlands Study of Depression and Anxiety. The Family Tree Inventory was used to determine FLS/FH indicators for depression and/or anxiety.
Persons with higher FLS had higher PRS for major depression, more severe depression and anxiety symptoms, higher disease burden, younger age of onset, and more neuroticism, rumination, and childhood trauma. Among these variables, FH was not associated with PRS, severity of symptoms, and neuroticism. After regression out the effect of FH from the FLS, the resulting residualized measure of FLS was still associated with severity of symptoms of depression and anxiety, rumination, and childhood trauma.
Familial risk for depression and anxiety deserves clinical attention due to its associated genetic vulnerability and more unfavorable disease profile, and seems to be better captured by a continuous score that incorporates family- and disorder-specific characteristics than by a dichotomous FH measure.
Both attention-deficit/hyperactivity disorder (ADHD) and insomnia have been independently related to poorer quality of life (QoL), productivity loss, and increased health care use, although most previous studies did not take the many possible comorbidities into account. Moreover, ADHD and insomnia often co-occur. Symptoms of ADHD and insomnia together may have even stronger negative effects than they do separately. We investigated the combined effects of symptoms of ADHD and insomnia, in addition to their independent effects, on QoL, productivity, and health care use, thereby controlling for a wide range of possible comorbidities and confounders.
Data from the third wave of the Netherlands Mental Health Survey and Incidence Study-2 were used, involving N = 4618 from the general population. Both the inattention and the hyperactivity ADHD symptom dimensions were studied, assessed by the ASRS Screener.
Mental functioning and productivity were negatively associated with the co-occurrence of ADHD and insomnia symptoms, even after adjusting for comorbidity and confounders. The results show no indication of differences between inattention and hyperactivity. Poorer physical functioning and health care use were not directly influenced by the interaction between ADHD and insomnia.
People with both ADHD and sleep problems have increased risk for poorer mental functioning and productivity loss. These results underscore the importance of screening for sleep problems when ADHD symptoms are present, and vice versa, and to target both disorders during treatment.
Major depressive disorder (MDD), represent a major source of risk for suicidality. However, knowledge about risk factors for future suicide attempts (SAs) within MDD is limited. The present longitudinal study examined a wide range of putative non-clinical risk factors (demographic, social, lifestyle, personality) and clinical risk factors (depressive and suicidal indicators) for future SAs among persons with MDD. Furthermore, we examined the relationship between a number of significant predictors and the incidence of a future SA.
Data are from 1713 persons (18–65 years) with a lifetime MDD at the baseline measurement of the Netherlands Study of Depression and Anxiety who were subsequently followed up 2, 4 and 6 years. SAs were assessed in the face-to-face measurements. Cox proportional hazard regression analyses were used to examine a wide range of possible non-clinical and clinical predictors for subsequent SAs during 6-year follow-up.
Over a period of 6 years, 3.4% of the respondents attempted suicide. Younger age, lower education, unemployment, insomnia, antidepressant use, a previous SA and current suicidal thoughts independently predicted a future SA. The number of significant risk factors (ranging from 0 to 7) linearly predicted the incidence of future SAs: in those with 0 predictors the SA incidence was 0%, which increased to 32% incidence in those with 6+ predictors.
Of the non-clinical factors, particularly socio-economic factors predicted a SA independently. Furthermore, preexisting suicidal ideation and insomnia appear to be important clinical risk factors for subsequent SA that are open to preventative intervention.
Although the importance and advantages of measurement-based care in mental healthcare are well established, implementation in daily practice is complex and far from optimal.
To accelerate the implementation of outcome measurement in routine clinical practice, a government-sponsored National Quality Improvement Collaborative was initiated in Dutch-specialised mental healthcare.
To investigate the effects of this initiative, we combined a matched-pair parallel group design (21 teams) with a cluster randomised controlled trial (RCT) (6 teams). At the beginning and end, the primary outcome ‘actual use and perceived clinical utility of outcome measurement’ was assessed.
In both designs, intervention teams demonstrated a significant higher level of implementation of outcome measurement than control teams. Overall effects were large (parallel group d=0.99; RCT d=1.25).
The National Collaborative successfully improved the use of outcome measurement in routine clinical practice.
Studying secular trends in the exposure to risk and protective factors of depression and whether these trends are associated with secular trends in the prevalence of depression is important to estimate future healthcare demands and to identify targets for prevention.
Three birth cohorts of 55–64-year olds from the population-based Longitudinal Aging Study Amsterdam were examined using identical methods in 1992 (n = 944), 2002 (n = 964) and 2012 (n = 957). A two-stage screening design was used to identify subthreshold depression (SUBD) and major depressive disorder (MDD). Multinomial logistic regression analyses were used to identify secular trends in depression prevalence and to identify factors from the biopsychosocial domains of functioning that were associated with these trends.
Compared with 1992, MDD became more prevalent in 2002 (OR 1.90, 95% CI 1.10–3.28, p = 0.022) and 2012 (OR 1.80, 95% CI 1.03–3.14, p = 0.039). This was largely attributable to an increase in the prevalence of chronic diseases and functional limitations. Socioeconomic and psychosocial improvements, including an increase in labor market participation, social support and mastery, hampered MDD rates to rise more and were also associated with a 32% decline of SUBD-rates in 2012 as compared with 2002 (OR 0.68, 95% CI 0.48–0.96, p = 0.03).
Among late middle-aged adults, there is a substantial net increase of MDD, which is associated with deteriorating physical health. If morbidity and disability continue to increase, a further expansion of MDD rates may be expected. Improving socioeconomic and psychosocial conditions may benefit public health, as these factors were protective against a higher prevalence of both MDD and SUBD.
Loneliness is highly prevalent among older people, has serious health consequences and is an important predictor of mortality. Loneliness and depression may unfavourably interact with each other over time but data on this topic are scarce.
To determine whether loneliness is associated with excess mortality after 19 years of follow-up and whether the joint effect with depression confers further excess mortality.
Different aspects of loneliness were measured with the De Jong Gierveld scale and depression with the Centre for Epidemiologic Studies Depression Scale in a cohort of 2878 people aged 55–85 with 19 years of follow-up. Excess mortality hypotheses were tested with Kaplan–Meier and Cox proportional hazard analyses controlling for potential confounders.
At follow-up loneliness and depression were associated with excess mortality in older men and women in bivariate analysis but not in multivariate analysis. In multivariate analysis, severe depression was associated with excess mortality in men who were lonely but not in women.
Loneliness and depression are important predictors of early death in older adults. Severe depression has a strong association with excess mortality in older men who were lonely, indicating a lethal combination in this group.
Patients with a severe mental illness (SMI) are more likely to experience
victimisation than the general population.
To examine the prevalence of victimisation in people with SMI, and the
relationship between symptoms, treatment facility and indices of
substance use/misuse and perpetration, in comparison with the general
Victimisation was assessed among both randomly selected patients with SMI
(n = 216) and the general population
Compared with the general population, a high prevalence of violent
victimisation was found among the SMI group (22.7% v.
8.5%). Compared with out-patients and patients in a sheltered housing
facility, in-patients were most often victimised (violent crimes: 35.3%;
property crimes: 47.1%). Risk factors among the SMI group for violent
victimisation included young age and disorganisation, and risk factors
for property crimes included being an in-patient, disorganisation and
cannabis use. The SMI group were most often assaulted by someone they
Caregivers should be aware that patients with SMI are at risk of violent
victimisation. Interventions need to be developed to reduce this
Psychosocial stress has been associated with an increased risk for mental and somatic health problems across the life span. Some studies in younger adults linked this to accelerated cellular aging, indexed by shortened telomere length (TL). In older adults, the impact of psychosocial stress on TL may be different due to the lifetime exposure to competing causes of TL-shortening. This study aims to assess whether early and recent psychosocial stressors (childhood abuse, childhood adverse events, recent negative life events, and loneliness) were associated with TL in older adults.
Data were from the Netherlands Study of Depression in Older Persons (NESDO) in which psychosocial stressors were measured in 496 persons aged 60 and older (mean age 70.6 (SD 7.4) years) during a face-to-face interview. Leukocyte TL was determined using fasting blood samples by performing quantitative polymerase chain reaction (qPCR) and was expressed in base pairs (bp).
Multiple regression analyses, adjusted for age, sex, and chronic diseases, showed that childhood abuse, recent negative life events and loneliness were unrelated to TL. Only having experienced any childhood adverse event was weakly but significantly negatively associated with TL.
Our findings did not consistently confirm our hypothesis that psychosocial stress is associated with shorter TL in older adults. Healthy survivorship or other TL-damaging factors such as somatic health problems seem to dominate a potential effect of psychosocial stress on TL in older adults.
Anxiety is an adaptive human experience that may occur at all ages and serves to
help draw attention to, avoid or cope with immanent threat and danger. Given its
evolutionary importance, it has strong genetic and biological underpinnings, and
when it serves that adaptive function for the organism, anxiety may be viewed as
useful. However, complex adaptive systems, such as our adaptation to threat or
stress, by definition provide many and often interrelated points of breakdown or
dysregulation, which, if sustained, may lead to psychopathology. Anxiety has
been described as a common currency for psychopathology, indicating that it is a
first line and universal way for us to respond to stress and threat. It is more
or less prominent in patients diagnosed with practically all psychiatric or
neurodegenerative disorders. This has lead to the inclusion of anxiety as a
cross-cutting symptom measure in the development of DSM-5 (APA, 2013). Given
that they are rooted in a complex adaptive system that has many potential points
of impact to develop pathology, it is not surprising that anxiety disorders are
extremely heterogeneous. This heterogeneity of anxiety disorders pertains to
symptomatology, etiology and outcomes, and poses great challenges to both
research and clinical practice.
Clinical staging and profiling is a diagnostic strategy that goes beyond the traditional dichotomy in medicine of merely focusing on the presence or absence of a disease. Disease staging extends this traditional dichotomy by defining where a patient lies along the continuum of the course of his or her particular illness. Successful examples include the general tumor, node, metastasis (TNM) classification in oncology, as well as the New York Heart Association (NYHA classes I–IV) functional classification system for patients with congestive heart failure. It enables clinicians to select treatments relevant to earlier stages because such interventions may be more effective and less harmful than treatments delivered later in the illness course. Profiling is a further refinement, as well as a necessary component of staging. Profiling refers to the characterization of a patient within a specific disease stage, which is relevant for its course and treatment choice. An example of profiling is estrogen receptor positivity in patients with breast cancer.
Little is known about the prevalence of attention-deficit hyperactivity
disorder (ADHD) among older adults.
To estimate the prevalence of the syndromatic and symptomatic DSM-IV ADHD
diagnosis in older adults in The Netherlands.
Data were used from the Longitudinal Aging Study Amsterdam (LASA). At
baseline, 1494 participants were screened with an ADHD questionnaire and
in 231 respondents a structured diagnostic interview was administered.
The weighted prevalence of ADHD was calculated.
The estimated prevalence rate of syndromatic ADHD in older adults was
2.8%; for symptomatic ADHD the rate was 4.2%. Younger elderly adults
(60–70 years) reported significantly more ADHD symptoms than older
elderly adults (71–94 years).
This is the first epidemiological study on ADHD in older persons. With a
prevalence of 2.8% the study demonstrates that ADHD does not fade or
disappear in adulthood and that it is a topic very much worthy of further
Background: In this paper, we aim to test the long-term benefit of an integrative reactivation and rehabilitation (IRR) program compared to usual care in terms of improved psychogeriatric patients on multiple psychiatric symptoms (MPS) and of caregivers on burden and competence. Improvement was defined as >30% improvement (≥ a half standard deviation) compared to baseline.
Methods: We used the following outcome variables: difference in the number of improved patients on MPS (Neuropsychiatric Inventory, NPI) and improved caregivers on burden (Caregiver Burden, CB) and competence (Caregiver Competence List, CCL). Assessments were taken after intake (T1) and after six months of follow-up (T3). Risk ratios (RR), number needed to treat (NNT), and odds ratios (ORs) were calculated.
Results: IRR had a significant positive effect on NPI-cluster hyperactivity (RR 2.64; 95% CI: 1.26–5.53; NNT 4.07). In the complete cases analysis, IRR showed significant ORs of 2.80 on the number of NPI symptoms and 3.46 on the NPI-sum-severity; up to 76% improved patients. For caregivers, competence was a significant beneficiary in IRR (RR 2.23; 95% CI: 1.07–4.62; NNT 5.07). In the complete cases analysis, the ORs were significantly in favor of IRR on general burden and competence (ORs range: 2.40–4.18), with up to 71% improved caregivers.
Conclusion: IRR showed a significantly higher probability of improvement with a small NNT of four on multiple psychiatric symptoms in psychogeriatric patients. The same applies to the higher probability to improve general burden and competence of the caregiver with an NNT of five. The results were even more pronounced for those who fully completed the IRR program. (Inter)national psychogeriatric nursing home care and ambulant care programs have to incorporate integrative psychotherapeutic interventions.
Inconsistent findings have been reported on the role of comorbid alcohol
use disorders as risk factors for a persistent course of depressive and
To determine whether the course of depressive and/or anxiety disorders is
conditional on the type (abuse or dependence) or severity of comorbid
alcohol use disorders.
In a large sample of participants with current depression and/or anxiety
(n = 1369) we examined whether the presence and
severity of DSM-IV alcohol abuse or alcohol dependence predicted the
2-year course of depressive and/or anxiety disorders.
The persistence of depressive and/or anxiety disorders at the 2-year
follow-up was significantly higher in those with remitted or current
alcohol dependence (persistence 62% and 67% respectively), but not in
those with remitted or current alcohol abuse (persistence 51% and 46%
respectively), compared with no lifetime alcohol use disorder
(persistence 53%). Severe (meeting six or seven diagnostic criteria) but
not moderate (meeting three to five criteria) current dependence was a
significant predictor as 95% of those in the former group still had a
depressive and/or anxiety disorder at follow-up. This association
remained significant after adjustment for severity of depression and
anxiety, psychosocial factors and treatment factors.
Alcohol dependence, especially severe current dependence, is a risk
factor for an unfavourable course of depressive and/or anxiety disorders,
whereas alcohol abuse is not.
Past episodes of depressive or anxiety disorders and subthreshold
symptoms have both been reported to predict the occurrence of depressive
or anxiety disorders. It is unclear to what extent the two factors
interact or predict these disorders independently.
To examine the extent to which history, subthreshold symptoms and their
combination predict the occurrence of depressive (major depressive
disorder, dysthymia) or anxiety disorders (social phobia, panic disorder,
agoraphobia, generalised anxiety disorder) over a 2-year period.
This was a prospective cohort study with 1167 participants: the
Netherlands Study of Depression and Anxiety. Anxiety and depressive
disorders were determined with the Composite International Diagnostic
Interview, subthreshold symptoms were determined with the Inventory of
Depressive Symptomatology–Self Report and the Beck Anxiety Inventory.
Occurrence of depressive disorder was best predicted by a combination of
a history of depression and subthreshold symptoms, followed by either one
alone. Occurrence of anxiety disorder was best predicted by both a
combination of a history of anxiety disorder and subthreshold symptoms
and a combination of a history of depression and subthreshold symptoms,
followed by any subthreshold symptoms or a history of any disorder
A history and subthreshold symptoms independently predicted the
subsequent occurrence of depressive or anxiety disorder. Together these
two characteristics provide reasonable discriminative value. Whereas
anxiety predicted the occurrence of an anxiety disorder only, depression
predicted the occurrence of both depressive and anxiety disorders.