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Major depressive disorder (MDD) represents a leading cause of disability. This study examines the course of disability in patients with chronic, recurrent and remitting MDD compared to healthy controls and identifies predictors of disability in remitting MDD.
We included 914 participants from the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV MDD and WHO DAS II disability were assessed at baseline and at 2, 4 and 6 years. Six-year total and domain-specific disability were analysed and compared in participants with chronic (n = 57), recurrent (n = 120), remitting (n = 127) MDD and in healthy controls (n = 430). Predictors of residual disability were identified using linear regression analysis.
At baseline, most disability was found in chronic MDD, followed by recurrent MDD, remitting MDD and healthy controls. Across diagnostic groups, most disability was found in household activities, interpersonal functioning, participation in society and cognition. A chronic course was associated with chronic disability. Symptom remission was associated with a decrease in disability, but some disability remained. In remitting MDD, higher residual disability was predicted by older age, more severe avoidance symptoms, higher disability at baseline and late symptom remission. Severity of residual disability correlated with the severity of residual depressive symptoms.
Symptomatic remission is a prerequisite for improvements in disability. However, disability persists despite symptom remission. Therefore, treatment of MDD should include an explicit focus on disability, especially on the more complex domains. To this end, treatments should promote behavioural activation and address subthreshold depressive symptoms in patients with remitted MDD.
Watching videotaped personal compulsions together with a therapist might enhance the effect of cognitive–behavioural therapy in obsessive–compulsive disorder (OCD) but little is known about how patients experience this.
To performed a qualitative study that describes how watching these videos influences motivation for treatment and whether patients report any adverse events.
In this qualitative study, data were gathered in semi-structured interviews with 24 patients with OCD. The transcripts were coded by two researchers. They used a combination of open and thematic coding and discrepancies in coding were discussed.
The experience of watching videos with personal compulsions helped patients to realise that these compulsions are aberrant and irrational. Patients report increased motivation to resist their OCD and to adhere to therapy. No adverse events were reported.
Videos with personal compulsions create more awareness in patients with OCD that compulsions are irrational, leading to enhanced motivation for treatment.
The course of illness in obsessive–compulsive disorder (OCD) varies significantly between patients. Little is known about factors predicting a chronic course of illness. The aim of this study is to identify factors involved in inducing and in maintaining chronicity in OCD.
The present study is embedded within the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, an ongoing multicenter naturalistic cohort study designed to identify predictors of long-term course and outcome in OCD. For this study, 270 subjects with a current diagnosis of OCD were included. Chronicity status at 2-year follow-up was regressed on a selection of baseline predictors related to OCD, to comorbidity and to stress and support.
Psychotrauma [odds ratio (OR) 1.98, confidence interval (CI) 1.22–3.22, p = 0.006], recent negative life events (OR 1.42, CI 1.01–2.01, p = 0.043), and presence of a partner (OR 0.28, CI 0.09–0.85, p = 0.025) influenced the risk of becoming chronic. Longer illness duration (OR 1.46, CI 1.08–1.96, p = 0.013) and higher illness severity (OR 1.09, CI 1.03–1.16, p = 0.003) increased the risk of remaining chronic.
External influences increase the risk of becoming chronic, whereas the factors involved in maintaining chronicity are illness-related. As the latter are potentially difficult to modify, treatment should be devoted to prevent chronicity from occurring in the first place. Therapeutic strategies aimed at alleviating stress and at boosting social support might aid in achieving this goal.
General anxiety and depressive symptoms following a myocardial infarction are associated with a worse cardiac prognosis. However, the contribution of specific aspects of anxiety within this context remains unclear.
To evaluate the independent prognostic association of cardiac anxiety with cardiac outcome after myocardial infarction.
We administered the Cardiac Anxiety Questionnaire (CAQ) during hospital admission (baseline, n = 193) and 4 months (n = 147/193) after discharge. CAQ subscale scores reflect fear, attention, avoidance and safety-seeking behaviour. Study end-point was a major adverse cardiac event (MACE): readmission for ischemic cardiac disease or all-cause mortality. In Cox regression analysis, we adjusted for age, cardiac disease severity and depressive symptoms.
The CAQ sum score at baseline and at 4 months significantly predicted a MACE (HRbaseline = 1.59, 95% CI 1.04–2.43; HR4-months = 1.77, 95% CI 1.04–3.02) with a mean follow-up of 4.2 (s.d. = 2.0) years and 4.3 (s.d. = 1.7) years respectively. Analyses of subscale scores revealed that this effect was particularly driven by avoidance (HRbaseline = 1.23, 95% CI 0.99–1.53; HR4-months = 1.77, 95% CI 1.04–1.83).
Cardiac anxiety, particularly anxiety-related avoidance of exercise, is an important prognostic factor for a MACE in patients after myocardial infarction, independent of cardiac disease severity and depressive symptoms.
Anxiety has been associated with new-onset cardiovascular disease (CVD),
but the quality of this relationship is unclear. Only if anxiety is a
causal, independent cardiovascular risk factor might it be a target for
To determine and examine the independent association and causality
between anxiety and incident CVD.
PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A
review of Hill's criteria for causality and random effects meta-analysis
were conducted of prospective, population-based studies examining anxiety
and incident CVD in people free from CVD at baseline.
The meta-analysis comprised 37 papers (n = 1 565 699).
The follow-up ranged from 1 to 24 years. Anxiety was associated with a
52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36–1.71).
The risk seemed independent of traditional risk factors and depression.
The evaluation of Hill's criteria largely argued in favour of
Anxiety may be of interest for CVD prevention. Future research should
examine biological and behavioural underpinnings of the association in
order to identify targets for intervention.
Thus far collaborative stepped care (CSC) studies have not incorporated self-help as a first step.
To evaluate the effectiveness of CSC in the treatment of common mental disorders.
An 8-month cluster randomised controlled trial comparing CSC to care as usual (CAU) (Dutch Trial Register identifier NTR1224). The CSC consisted of a stepped care approach guided by a psychiatric nurse in primary care with the addition of antidepressants dependent on the severity of the disorder, followed by cognitive–behavioural therapy in mental healthcare.
Twenty general practitioners (GPs) and 8 psychiatric nurses were randomised to provide CSC or CAU. The GPs recruited 163 patients of whom 85% completed the post-test measurements. At 4-month mid-test CSC was superior to CAU: 74.7% (n = 68) v. 50.8% (n = 31) responders (P = 0.003). At 8-month post-test and 12-month follow-up no significant differences were found as the patients in the CAU group improved as well.
Treatment within a CSC model resulted in an earlier treatment response compared with CAU.
The need for symmetry and ordering objects related to a “just right”-feeling is a common symptom in Tourette's syndrome (TS) and resembles symmetry behavior in obsessive-compulsive disorder, but its pathophysiology is unknown. We used a symptom provocation paradigm to investigate the neural correlates of symmetry behavior in TS and hypothesized the involvement of frontal-striatal and limbic brain areas.
Pictures of asymmetrically and symmetrically arranged objects were presented in randomized blocks (4 blocks of each condition) to 14 patients with TS and 10 matched healthy controls (HC). A H215O positron emission tomography scan was acquired during each stimulus block, resulting in 8 scans per subject. After each scan, state anxiety and symmetry behavior (the urge to rearrange objects) were measured using a visual analogue scale.
During the asymmetry condition, TS patients showed increased regional cerebral blood flow (rCBF) in the anterior cingulate cortex, supplementary motor area, and inferior frontal cortex, whereas HC showed increased rCBF in the visual cortex, primary motor cortex, and dorsal prefrontal cortex. Symmetry ratings during provocation correlated positively with orbitofrontal activation in the TS group and sensorimotor activation in the HC group, and negatively with dorsal prefrontal activity in HC.
Results suggest that both motor and limbic circuits are involved in symmetry behavior in TS. Motor activity may relate to an urge to move or perform tics, and limbic activation may indicate that asymmetry stimuli are salient for TS patients. In contrast, symmetry provocation in HC resulted in activation of brain regions implicated in sensorimotor function and cognitive control.
This chapter emphasizes the importance of adequate care of pharmacological evidence on treating panic disorder. It focuses on the optimal first-line pharmacotherapy of panic disorder. The chapter discusses the optimal duration of maintenance therapy, and describes the optimal approach to pharmacotherapy in the treatment-refractory patient. It reviews the antidepressants and benzodiazepines with regard to efficacy in acute and long-term treatment, the side-effects and risks involved, drop-out rates, onset of action and efficacy in comorbid conditions. Given the comparable efficacy of the pharmacological classes described in acute phase treatment and the efficacy in long-term treatment, other considerations determine which agent should be considered the first-line pharmacotherapy of panic disorder. The first-line pharmacotherapy for panic disorder has been selective serotonin reuptake inhibitor (SSRIs) for some time, and there is now sufficient evidence to indicate that the SNRI venlafaxine should also be considered as a first-line agent.
The prevalence of benzodiazepine consumption in European countries
remains at 2–3% of the general population despite the well-documented
disadvantages of long-term use.
To review systematically the success rates of different benzodiazepine
Meta-analysis of comparable intervention studies.
Twenty-nine articles met inclusion criteria. Two groups of interventions
were identified; minimal intervention (e.g. giving simple advice in the
form of a letter or meeting to a large group of people;
n=3), and systematic discontinuation (defined as
treatment programmes led by a physician or psychologist;
n=26). Both were found to be significantly more
effective than treatment as usual: minimal interventions (pooled OR=2.8,
95% CI 1.6–5.1); systematic discontinuation alone (one study, OR=6.1, 95%
CI 2.0–18.6). Augmentation of systematic discontinuation with imipramine
(two studies, OR=3.1, 95% CI 1.1–9.4) or group cognitive-behavioural
therapy for patients with insomnia (two studies, OR=5.5, 95% CI 2.3–14.2)
was superior to systematic discontinuation alone.
Evidence was found for the efficacy of stepped care (minimal intervention
followed by systematic discontinuation alone) in discontinuing long-term
Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition.
To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive–behavioural therapy (CBT).
A 3-month randomised, controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care.
Tapering off led to a significantly higher proportion of successful discontinuations than usual care (62% v. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibility in general practice.
Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.
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