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One in eight individuals worldwide lives with a mental health disorder. For many European countries, the prevalence is even higher, with one in four people reporting mental health problems . Three-quarters of all mental health disorders develop before age 25, with many presenting initially in undiagnosed forms already in the mid-teens and eventually manifesting as severe disorders and lasting into old age . There is also growing evidence that mental health disorder symptoms cross diagnoses and people frequently have more than one mental health disorder .
Major depressive disorder (MDD) is highly prevalent across Europe. While evidence-based treatments exist, many people with MDD have their condition undetected and/or untreated. This study aimed to assess the cost-effectiveness of reducing treatment gaps using a modeling approach.
A decision-tree model covering a 27-month time horizon was used. This followed a care pathway where MDD could be detected or not, and where different forms of treatment could be provided. Expected costs pertaining to Germany, Hungary, Italy, Portugal, Sweden, and the UK were calculated and quality-adjusted life years (QALYs) were estimated. The incremental costs per QALY of reducing detection and treatment gaps were estimated.
The expected costs with a detection gap of 69% and treatment gap of 50% were €1236 in Germany, €476 in Hungary, €1413 in Italy, €938 in Portugal, €2093 in Sweden, and €1496 in the UK. The incremental costs per QALY of reducing the detection gap to 50% ranged from €2429 in Hungary to €10,686 in Sweden. The figures for reducing the treatment gap to 25% ranged from €3146 in Hungary to €13,843 in Sweden.
Reducing detection and treatment gaps, and maintaining current patterns of care, is likely to increase healthcare costs in the short term. However, outcomes are improved, and reducing these gaps to 50 and 25%, respectively, appears to be a cost-effective use of resources.
Major depressive disorder (MDD) is a leading cause of disability worldwide, and yet delivery of care for this illness is rife with gaps. The COVID-19 pandemic has had far reaching implications for every facet of healthcare, and MDD is no exception. This scoping review aimed to ascertain the impacts of COVID-19 on the delivery of MDD care in Europe, as well as to evaluate any novel MDD care strategies trialled in this period.
We searched the PubMed and PsycINFO databases up to January 2022 with a strategy centred around COVID-19 and MDD. Full texts of eligible studies examining working-age adults and conducted in Europe were evaluated against several criteria. All outcomes were then extracted and a narrative synthesis was constructed to summarise identified themes.
Of 1,744 records identified in our search, 11 articles were eligible for inclusion in the review. In general, these studies reported a decrease in treatment rates, access to care, and perceived access to care during the COVID-19 pandemic. In addition, digital interventions trialled during the pandemic were broadly well-received by users, though their efficacy in improving MDD care was ambiguous.
Despite a limited number of pertinent studies, this scoping review identified a trend of exacerbated treatment gaps in MDD care during the pandemic. Several of our pre-specified gaps, including delays to detection or treatment of depression and rates of follow-up contacts, remained unexplored in the context of COVID-19. This highlights the need for further investigation to obtain a full understanding of the relationship between COVID-19 and MDD care in Europe.
Despite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:
1. Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and
After agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.
Four recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).
The treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.
The objective in managing patients with schizophrenia is to provide effective control of symptoms and enable the patient to reintegrate into society. Pharmacotherapy should, therefore, aim to provide optimum symptom control with minimal side effects using a simple dosage regimen. Ideally, this would be achieved through the use of a single agent. Some patients are successfully managed with a single antipsychotic drug, but it is often necessary or thought to be necessary to use a combination of agents to provide effective treatment. One European survey reported that most patients receive two to three psychotropic agents on average, but at least 5-22% receive five or more agents . Unfortunately, the addition of more agents increases the risk of drug interactions, adverse events and non-compliance. This is amplified by the paucity of evidence-based medicine currently available to guide physicians in the use of combinations of agents, and the tendency of polypharmaceutical practice to be mostly driven by personal preference, clinical experience and marketing. This article therefore briefly looks at the feasibility of using various drug classes as adjunctive therapy in patients with schizophrenia.
Researchers tried to explain the overlap between anxiety and depression by suggesting that some items of self-administered questionnaires were badly selected and that both constructs should rather be considered as multidimensional. Thus, we hypothesise that the Spielberger trait anxiety inventory (TAI) includes items related to depression.
A non-clinical sample of 193 subjects filled out the TAI and the Hospitalised Anxiety–Depression Scale. Factors were postulated on the basis of item content and submitted to confirmatory factor analysis (CFA).
We found five factors: a 10-item anxiety factor containing three factors, a four-item unsuccessfulness factor correlated with the HADS anhedonia factor, and a six-item happiness factor.
The TAI scale encompasses measures of anxiety, depression and well-being. Consequently, the overlap with other measures of depression may result from item selection. This work awaits replication in independent normal and pathological samples.
The objective of this analysis was to evaluate the short- (8 weeks) and long-term (24 weeks) efficacy of three fixed doses of venlafaxine extended release (ER) and placebo on the social adjustment of patients with generalised anxiety disorder (GAD). We analysed data from 544 outpatients who participated in a 24-week, double-blind, multicentre, parallel-group, placebo-controlled study conducted at 55 centres in five countries. All patients meet the DSM-IV criteria for GAD and were randomly assigned to receive venlafaxine ER 37.5, 75, and 150 mg or matched placebo administered orally once daily. Social adjustment was measured using the Social Adjustment Scale-Self Report, which explores social adaptation in the areas of work, social and leisure, extended family, primary relationship (marital), parental, and family unit. At baseline, the GAD patients had a high level of social dysfunction. Venlafaxine ER showed a dose-related improvement in social impairment during short-term treatment and in sustaining this improvement over the long-term. In the most severely socially impaired subgroup, placebo remission rates on the HAM-A were low, and the magnitude of the venlafaxine-placebo difference on the mean HAM-A total score was high, reaching more than 7 points. The benefits of venlafaxine ER treatment of GAD extend beyond that of improvement of anxiety symptoms to a significant improvement in the impairment of functioning that is associated with the illness.
According to human observations of a syndrome of physical activity dependence and its consequences, we tried to examine if running activity in a free activity paradigm, where rats had a free access to activity wheel, may present a valuable animal model for physical activity dependence and most generally to behavioral dependence. The pertinence of reactivity to novelty, a well-known pharmacological dependence predictor was also tested. Given the close linkage observed in human between physical activity and drugs use and abuse, the influence of free activity in activity wheels on reactivity to amphetamine injection and reactivity to novelty were also assessed. It appeared that (1) free access to wheel may be used as a valuable model for physical activity addiction, (2) two populations differing in activity amount also differed in dependence to wheel-running. (3) Reactivity to novelty did not appeared as a predictive factor for physical activity dependence (4) activity modified novelty reactivity and (5) subjects who exhibited a high appetence to wheel-running, presented a strong reactivity to amphetamine. These results propose a model of dependency on physical activity without any pharmacological intervention, and demonstrate the existence of individual differences in the development of this addiction. In addition, these data highlight the development of a likely vulnerability to pharmacological addiction after intense and sustained physical activity, as also described in man. This model could therefore prove pertinent for studying behavioral dependencies and the underlying neurobiological mechanisms. These results may influence the way psychiatrists view behavioral dependencies and phenomena such as doping in sport or addiction to sport itself.
Mood stabilising therapy is the cornerstone of treatment for bipolar disorder, a disease that is commonly associated with disabling psychosocial morbidity [37,11]. A variety of drugs have been approved for use in bipolar disorder, thus providing a wide array of options for clinicians when deciding on a course of treatment . In order to assist clinical decision-making, facilitate optimal quality of care and reduce unnecessary variation in clinical practice, several clinical practice guidelines and treatment algorithms have been developed [4,19,20,21]. As well as similarities, there are some differences between guidelines developed from an American perspective and those developed from a European perspective [4,19], and there is a pervasive view in the clinical community that treatment of patients with bipolar disorder differs substantially between the United States (US) and Europe. This article discusses what is known about the similarities and differences of treatment practices for bipolar disorder between the US and Europe.
The bipolar dimension of morningness–eveningness refers to the preferred times of day for achieving various activities (i.e. the phase of the circadian clock). It is validated from a biological point of view, associated with at least one gene and heritable through an epistatic mechanism. It has been used as a proxy to study the relationships between the circadian system, personality and psychopathology: there is a correlation between the evening orientation and depression, extraversion and, probably, impulsivity. Furthermore, there is a possible relationship with temperament in children as theorized by Thomas and Chess. In this paper, we expanded on the hypothesis that impulsive subjects are low in morningness by performing a factor analysis of the Composite Scale of Morningness, Cloninger’s temperament and character inventory, and Spielberger’s trait anxiety inventory in a sample of 129 males. The results can probably be extended to women. Morningness is negatively correlated with novelty seeking (which includes an impulsivity facet), positively correlated with persistence, and independent of character dimensions and trait anxiety. Future research may focus in the involvement of the circadian system in these personality dimensions and facets, and the benefits of adding chronotherapic manipulations in the treatment of the personality disorders.
Positive findings on early detection and early intervention services have been consistently reported from many different countries. The aim of this study, conducted within the European Brain Council project “The Value of Treatment”, was to estimate costs and the potential cost- savings associated with adopting these services within the context of the Czech mental health care reform.
Czech epidemiological data, probabilities derived from meta-analyses, and data on costs of mental health services in the Czech Republic were used to populate a decision analytical model. From the health care and societal perspectives, costs associated with health care services and productivity lost were taken into account. One-way sensitivity analyses were conducted to explore the uncertainty around the key parameters.
It was estimated that annual costs associated with care as usual for people with the first episode of psychosis were as high as 46 million Euro in the Czech Republic 2016. These annual costs could be reduced by 25% if ED services were adopted, 33% if EI services were adopted, and 40% if both, ED and EI services, were adopted in the country. Cost-savings would be generated due to decreased hospitalisations and better employment outcomes in people with psychoses.
Adopting early detection and early intervention services in mental health systems based on psychiatric hospitals and with limited access to acute and community care could generate considerable cost- savings. Although the results of this modelling study needs to be taken with caution, early detection and early intervention services are recommended for multi-centre pilot testing accompanied by full economic evaluation in the region of Central and Eastern Europe.
The aim of the European Brain Council project “The Value of Treatment” was to provide evidence-based, cost-effective policy recommendations for a patient-centered and sustainable coordinated care model for brain disorders. The first part of schizophrenia study examined the needs and gaps in the patients' care pathway.
Descriptive analysis was based on an inventory of needs and treatment opportunities, using focus group sessions, expert interviews, users’ input, and literature review. Three patient pathways were selected: indicated prevention, duration of untreated psychosis, and relapse prevention.
The analysis identified several critical barriers to optimal treatment. Available health care services often miss or delay detection of symptoms and diagnosis in at-risk individuals. There is a lack of illness awareness among patients, families, and the public; scarcity of information, training and education among primary care providers; stigmatizing beliefs. Early symptom recognition and timely intervention result in better outcome and prognosis; effective management leads to a functional recovery. In the current model of care, there is insufficient cooperation between health and social care providers, patients and families, inadequate utilization of pharmacological and psychosocial interventions, lacking patient monitoring, and low implementation of integrated community care.
Early detection and early intervention programs, timely intervention, and relapse prevention are essential for effective management of schizophrenia. It requires a paradigm shift from symptom control, achieving and maintaining remission, to the emphasis on recovery. Since the current services are not able to accomplish this goal, changes in mental health policies are needed.
El objetivo de este análisis era evaluar la eficacia a corto (8 semanas) y largo plazo (24 semanas) de tres dosis fijas de venlafaxina de liberación prolongada (LP) y placebo en la adaptación social de los pacientes contrastorno de ansiedad generalizada (TAG). Analizamos los datos de 544 pacientes ambulatorios que participant en un estudio multicéntrico doble ciego de grupos paralelos controlado con placebo de 24 semanas realizado en 55 centros en cinco países. Todos los pacientes cumplían los criterios del DSM-IV para TAG y se asignaron aleatoriamente para recibir 37,5, 75 y 150 mg de venlafaxina LP o placebo emparejado administrado oralmente una vez al día. La adaptación social se midió utilizando la Escala de Adaptación Social-Autoinforme, que explora la adaptación social en las áreas laboral, social y de ocio, familia extensa, relación primaria (matrimonial), parental y unidad familiar. En la línea de base, los pacientes con TAG tenían un nivel alto de disfunción social. La venlafaxina LP mostró una mejoría relacionada con la dosis en el deterioro social durante el tratamiento a corto plazo y en el mantenimiento de esta mejoria a largo plazo. En el subgrupo con deterioro social mas importante, las tasas de remisión con el placebo en la HAM-A fueron bajas, y la magnitud de la diferencia venlafaxina-placebo en la puntuación total media de la HAM-A fue alta, alcanzando más de 7 puntos. Los beneficios del tratamiento de venlafaxina LP del TAG se extienden más alia de la mejoría de los síntomas de ansiedad, a una mejoría significativa en el deterioro del funcionamiento que se asocia con la enfer medad.
Los investigadores intentaron explicar el solapamiento entre la ansiedad y la depresión proponiendo que algunos elementos de los cuestionarios autoadministrados estaban mal seleccionados y que ambos constructos se deben considerar más bien como muldimensionales. Así, planteamos la hipótesis de que el Inventario de Ansiedad como Rasgo (TAI) de Spielberger incluye elementos relacionados con la depresión.
Una muestra no clínica de 193 sujetos rellenó el TAI y la Escala Hospitalaria de Ansiedad y Depresión. Se postularon factores a partir del contenido de los elementos y se sometieron a análisis factorial confirmatorio (AFC).
Encontramos cinco factores: un factor de ansiedad de 10 elementos que contenía tres factores; un factor de falta de éxi-to que contenía cuatro elementos correlacionado con el factor de anhedonia de la HADS, y un factor de felicidad de seis elementos.
El TAI incluye medidas de ansiedad, depresión y bienestar. Por consiguiente, el solapamiento con otras medidas de depresión puede derivar de la selección de los elementos. Este trabajo aguarda replicación en muestras normales y patológicas independientes.
Background The paper describes the rationale, sensitivity and specificity of the Anxiety Screening Questionnaire (ASQ), a disorder-specific screening instrument for use in primary care.
Method Two hundred and fifty subjects sampled from psychiatric, primary care settings and the community, participated in a test-retest reliability as well as a procedural validity study, using the M–CIDI with DSM–IV algorithms as a diagnostic yardstick.
Results The ASQ was found to be easy to administer and acceptable and efficient in terms of sensitivity and specificity for generalised anxiety syndromes. The test– retest item reliability was good to excellent with kappa values of 0.6 or above. As compared with the validity standard, the DSM – IV/CIDI diagnoses caseness sensitivity was generally high (above 82%) for all diagnostic domains covered, whereas the specificity was only high for DSM – IV threshold and subthreshold generalised anxiety disorder.
Conclusions These preliminary findings demonstrate the usefulness of this anxiety screening questionnaire, constructed closely following the guidelines of specific diagnostic criteria.
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