Crisis intervention and acute psychiatry in Amsterdam, 20 years of change: a historical comparison of consultations in 1983 and 2004-2005

AIM

There has been a striking increase in the number of compulsory admission proceedings in the Netherlands since 1992, to such an extent that treatment in Amsterdam's psychiatric clinics is in danger of being dominated by coercive treatment. Our aim was to establish a picture of the changes in emergency psychiatry that have contributed to the increase in the number of acute compulsory admissions.

METHODS

A cohort (N = 460) of psychiatric emergency consultations with the city crisis service in 1983 was compared with a similar cohort (N = 436) in 2004-2005. The study focused on the following variables: patient characteristics, crisis-service procedures and consultation outcomes.

RESULTS

Compared with 1983, there are now more services involved in crisis support in the public domain for psychiatric patients. The number of patients referred by the police has risen from 29% to 63%. In 1983, all consultations took place where the patients were located; at present, 60% take place at the crisis service premises. The number of psychotic patients in the cohort has increased from 52.0% and 63.3 %. There has been an increase in the proportion of compulsory admissions and a sharp decrease in the proportion of voluntary admissions from 61% to 28% of all admissions. Overall, the percentage of consultations leading to a psychiatric admission has fallen from 42% to 27%.

CONCLUSION

The front-line outreach service of 1983 has changed into a specialist psychiatric emergency department with a less pronounced outreach component. Voluntary admissions to psychiatric hospitals have almost disappeared as a feature of the crisis service.

[Alexithymia: important for understanding mood disorders with older adults?]

Alexithymia (cognitive and affective emotion regulation) may be important for understanding mood disorders in older adults. In the present study it is examined whether alexithymia (i) acts as a stable personality trait, (ii) is independent from the Big Five personality traits, and (iii) is associated with the course and outcome of depressive disorder. Alexithymia was assessed at intake and after three months in older adults with a (sub)clinical depressive disorder using the The Bermond Vorst Alexithymia Questionnaire (BVAQ). The results show that alexithymia acts as a stable and independent personality trait. Alexithymia was no predictor for the outcome of depression after three months. It was concluded that alexithymia should be considered when assessing and treating depression in older adults. However, further research is necessary.

Benefit-risk analysis for the clinician: 'primum non nocere' revisited--the case for antipsychotics in the treatment of behavioural disturbances in dementia

The results of clinical trials are often presented in a way that only highlights either the benefits or the risks of the treatment under study. Especially in older age, clinical psychiatric problems are often of complex nature, which requires integrating multiple sources of data to reach clinical decisions. An analytical, decision-making strategy can be of help in arranging the results of various studies in such a way as to aid decision-making. In this paper, we clarify this method using the case of the risks and benefits of using antipsychotics in older people with dementia and behavioural disturbances.

The 2-year prognosis of panic episodes in the general population

BACKGROUND

Panic disorder (PD) is generally considered to be a chronic or intermittent disorder. This view may be biased because of a lack of general population studies investigating panic from the onset of an episode onwards. Data regarding the course of subthreshold panic disorder (sub-PD) and predictors of its course are lacking.

METHOD

Using data from a large community-based survey, the Netherlands Mental Health and Incidence Study (NEMESIS), that retrospectively assessed the 2-year course of panic with a Life Chart Interview (LCI), this study investigated remission, chronicity and recurrence in subjects with new episodes of PD or sub-PD. Predictor variables of remission consisted of sociodemographics, psychobiological, environmental, psychiatric and panic-related factors.

RESULTS

In PD, remission of panic attacks occurred in 64.5% of subjects, mean time to remission was 5.7 months, and the remission rate was 5.8/100 person-months. In 43.3% of subjects panic was still present after 1 year. Recurrence of panic attacks occurred in 21.4% of those with PD who had achieved remission and for whom sufficient follow-up time was available. In general, the course of sub-PD was more favourable. Predictors of remission were female gender, the absence of ongoing difficulties, subthreshold panic and a low initial frequency of attacks.

CONCLUSIONS

These results suggest that the course of panic is diverse in the general population, thereby underlining the need for accurate predictors. This requires further research including biological data and additional psychological data. In addition, given the large proportion with a relapse, relapse prevention should be part of any treatment programme.

Psychometric properties of an interviewer-administered version of the Kessler Psychological Distress scale (K10) among Dutch, Moroccan and Turkish respondents

The Kessler Psychological Distress scale (K10) is an instrument that is widely used to screen for mental disorders, but information is lacking on its psychometric qualities in non-Western samples. This study used a population-based sample (N = 725) to assess the reliability and validity of the K10 across ethnic groups in an urban area. The results were generally supportive of the K10 as a reliable and valid instrument to screen for anxiety and depression in all three groups. Cronbach's alpha was high (0.93) and the results indicated the existence of a solid single factor structure. Item bias in relation to ethnic background was minor. In each group, there was good criterion validity with respect to one-month DSM-IV diagnosis for depressive and/or anxiety disorder. The results nevertheless highlight the importance of cross-cultural validation, as we found different cut-off values for ethnic subgroups to obtain optimal sensitivity and specificity for detecting depressive and/or anxiety disorders.

Outcome of depression in later life in primary care: longitudinal cohort study with three years' follow-up

OBJECTIVES

To study the duration of depression, recovery over time, and predictors of prognosis in an older cohort (>or=55 years) in primary care.

DESIGN

Longitudinal cohort study, with three years' follow-up.

SETTING

32 general practices in West Friesland, the Netherlands.

PARTICIPANTS

234 patients aged 55 years or more with a prevalent major depressive disorder.

MAIN OUTCOME MEASURES

Depression at baseline and every six months using structured diagnostic interviews (primary care evaluation of mental disorders according to diagnoses in Diagnostic and Statistical Manual of Mental Disorders, fourth edition) and a measure of severity of symptoms (Montgomery Asberg depression rating scale). The main outcome measures were time to recovery and the likelihood of recovery at different time points. Multivariable analyses were used to identify variables predicting prognosis.

RESULTS

The median duration of a major depressive episode was 18.0 months (95% confidence interval 12.8 to 23.1). 35% of depressed patients recovered within one year, 60% within two years, and 68% within three years. A poor outcome was associated with severity of depression at baseline, a family history of depression, and poorer physical functioning. During follow-up functional status remained limited in patients with chronic depression but not in those who had recovered.

CONCLUSION

Depression among patients aged 55 years or more in primary care has a poor prognosis. Using readily available prognostic factors (for example, severity of the index episode, a family history of depression, and functional decline) could help direct treatment to those at highest risk of a poor prognosis.

Depression and excess mortality: evidence for a dose response relation in community living elderly

CONTEXT

Depression is associated with an increased mortality risk. It is not known to what extent depression characteristics such as severity and length of exposure to depression contribute to the association with excess mortality.

OBJECTIVES

To investigate the association between depression severity and duration with mortality in community-living elderly.

DESIGN

Two-wave prospective cohort study with 10-year follow-up of vital status. Assessment of depression at baseline and at three year follow-up (GMS-AGECAT). Cox proportional hazards analyses of mortality with depression according to severity and length of exposure, adjusted for demographic variables, physical illnesses, cognitive decline and functional disabilities.

SETTING AND PARTICIPANTS

Randomly selected cohort of 3 746 non-demented older community-living persons in the city of Amsterdam.

MAIN OUTCOME MEASURES

Excess mortality of both the baseline cohort, and of non-demented subjects participating in both assessments (n = 1989).

RESULTS

Both moderate (MHR 1.29, 95% CI 1.03-1.61) and severe depression (MHR 1.34, 95% CI 1.07-1.68) predicted 10-year mortality after multivariate adjustment. Chronic depression was associated with a 41% higher mortality risk in 6-year follow-up compared to subjects without depression.

CONCLUSIONS

Severity and chronicity of depression are associated with a higher mortality risk. In combination with other findings this is suggestive of a causal relationship and may have implications for both preventive and treatment strategies of late-life depression.

[Treatment for chronic depression: cognitive behavioral analysis system of psychotherapy (CBASP)]

BACKGROUND

Chronic depression is a common disorder in secondary care. Treatment results for this group of depressed patients are often disappointing and the existing treatment protocols are insufficiently tailored to chronic MDD. For this reason, an effective psychotherapeutic treatment will constitute a welcome addition to the range of treatments currently available for chronically depressed patients.

AIM

To describe 'cognitive behavioral analysis system of psychotherapy' (CBASP), the first form of psychotherapy specifically designed for the treatment of chronic depression.

METHOD

This article describes the evidence, rational and the most important techniques of CBASP.

RESULTS

In the United States CBASP has proven to be effective in one trial. As a result of these findings, CBASP is recommended in the Dutch treatment guidelines as an evidence-based treatment option for chronic depression. However, the findings have not yet been replicated and little is known about possible ways of implementing CBASP in the Netherlands. For this reason a randomised controlled trial on the effectiveness of CBASP has started in three psychiatric hospitals in the Netherlands.

CONCLUSION

CBASP is recommended as a treatment option for chronic depression in the Dutch treatment guidelines, but evidence should be further supported by additional research.

[Changes in crisis intervention and emergency psychiatry, Amsterdam emergency consultations in 1983 and 2005]

BACKGROUND

Since 1992 The Netherlands has seen a striking increase in the number of compulsory admissions. There is a danger that coercion will become the dominant form of treatment in the Amsterdam clinics.

AIM

To build up a picture of the changes in emergency psychiatry which have contributed to the increase in the number of acute compulsory admissions.

METHOD

A cohort (n = 460) of consultations conducted by the city crisis service in 1983 was compared with a similar cohort (n = 436) of consultations conducted in 2004-2005 based on the following variables: crisis-service procedures, patient characteristics, diagnosis and consultation outcomes.

RESULTS

In 2003-2004 more services were involved with psychiatric patients in acute situations in the public domain than were involved in 1983. The number of patients referred by the police almost doubled, rising from 29.3 to 62.7%. In 1983 all consultations took place where the patients were located; in 2004-2005 60% took place at the premises of the crisis service. The number of psychotic patients in the cohort rose from 52 to 63.3%. There was a rise in the number of compulsory admissions (from 16.7 to 20%) and a sharp decline in voluntary admissions (from 25.7 to 7.6%). The total number of admissions following a consultation decreased from 42 to 28%.

CONCLUSIONS

The front-line outreach service of 1983 has been transformed into a specialist psychiatric emergency department with only a modest outreach component. Voluntary admissions via the consultation service have almost ceased. Further research is needed into the characteristics of the consultations and into the variables that play a role in the use of compulsion in emergency psychiatry.

[Screening for depression and anxiety in residential homes for the elderly]

Elderly persons in residential homes in the Netherlands are at high risk for developing major depressive and anxiety disorders. A stepped-care protocol being used in a study for vulnerable elderly in the community may also be feasible and effective for this group. A pilot study in a residential home in Amsterdam showed more problems than expected in screening and motivating the inhabitants for this intervention protocol. This article describes the problems in our screening procedure. A personal approach, performed by familiar persons, directed at the more independent inhabitants is most likely to succeed. The need for research on effectiveness and feasibility of evidence based methods in residential care remains evident. However, the more vulnerable inhabitants need something else. For this group of inhabitants we need to look more closely to the needs and possibilities by conducting research using a qualitative design.

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.

[Old age psychiatry in the Netherlands]

In recent years there have been significant developments in psychiatry for the elderly in the Netherlands. Epidemiological research has widened its scope, collaborating with other disciplines and thereby creating a range of new perspectives. Patient care is shifting gradually to the general hospital and psychiatry for the elderly has a definite place in the curriculum for trainee psychiatrists. Increasingly, integrated care arrangements are becoming available for elderly psychiatric patients with handicaps. Psychiatry for the elderly has obtained a firm foothold in the Netherlands and should be able to participate in and benefit from the developments that are expected in the years to come.

Work and family roles and the association with depressive and anxiety disorders: differences between men and women

BACKGROUND

This study examined the associations of (combinations of) social roles (employee, partner and parent) with the prevalence of anxiety and depressive disorders and whether social roles contribute to the explanation of the female preponderance in these disorders.

METHOD

This was a cross-sectional study using data from 3857 respondents aged 25-55 of NEMESIS (Netherlands Mental Health Survey and Incidence Study). Depression and anxiety disorders were measured using the CIDI 1.1.

RESULTS

The OR of depressive disorders and anxiety disorders among women compared to men was 1.71 (95% CI: 1.40-2.10). Among both genders, the partner role was associated with decreased risks of depression and anxiety and the parent role was not. The work role was a significant protective factor of depression and anxiety for men (OR=0.40; 95% CI: 0.24-0.69) but not for women (OR=0.86; 95% CI: 0.66-1.12). The effect of the work role was positive among women without children (OR=0.28; 95% CI: 0.14-0.54), but not among those with children (OR=1.01; 95% CI: 0.75-1.35). The gender risk for depression and anxiety decreased significantly by adding the work role variables into the model.

LIMITATIONS

This was a cross-sectional study. This study did not give insight into the quality of social roles.

CONCLUSION

The work role contributed to the explanation of the female preponderance in depression and anxiety disorders. Considering depression and anxiety among women, a focus upon quality and meaning of the work role, and barriers in combining the work role and parent role may be essential.

The effect of chronic benzodiazepine use on cognitive functioning in older persons: good, bad or indifferent?

OBJECTIVE

This study investigates the effects of benzodiazepine (BZ) use on cognitive performance in elderly persons in a longitudinal design.

STUDY DESIGN AND SETTING

Data were obtained from the Longitudinal Aging Study Amsterdam (LASA), in the Netherlands. 2,105 respondents (>/=62 years of age) were included and had repeated measurements over a period of 9 years. For all BZs the type, dosage, frequency and duration of use was measured. The equivalent of a dose of diazepam was determined with regard to type and dosage and a cumulative dosage was calculated. General cognitive functioning was measured with the Mini-Mental State Examination, information processing speed was measured with the coding task, fluid intelligence with Raven's Coloured Progressive Matrices and episodic memory with the Auditory Verbal Learning Test. Multilevel analyses were used to investigate the relationship between BZ use and cognitive decline.

RESULTS

A negative effect of BZ use on cognitive performance was found. However, the effect sizes were very small.

CONCLUSION

This study suggests that both duration and cumulative exposure to BZ has a small negative effect on the long-term cognitive functioning of elderly people in the community.

[The GDS-8; a short, client- and user-friendly shortened version of the Geriatric Depression Scale for nursing homes]

The objective of this study was to construct a patient- and user-friendly shortened version of the Geriatric Depression Scale (GDS) that is especially suitable for nursing home patients. The study was carried out on two different data bases including 23 Dutch nursing homes. Data on the GDS (n=410), the Mini Mental State Examination (n=410) and a diagnostic interview (SCAN; n=333), were collected by trained clinicians. Firstly, the items of the GDS-15 were judged on their clinical applicability by three clinical experts. Subsequently, seven items that were identified as unsuitable were removed using the GDS-data of the Assess-project (n=77), and internal consistency was calculated. Secondly, with respect to criterion validity (sensitivity, specificity, area under ROC and positive and negative predictive values), the newly constructed 8-item version of the GDS was validated in the AGED data set (n=333), using DSM-IV diagnosis for depression as measured by the SCAN as 'gold standard'. In the AGED dataset, the GDS-8 was internally consistent (alpha=.80) and high sensitivity rates of 96.3% for major depression and 83.0% for minor depression were found, with a specificity rate of 71.7% at a cut-off point of 2/3. The GDS-8 has good psychometric properties. Given that the GDS-8 is less burdening for the patient, more comfortable to use and less time consuming, it may be a more feasible screening test for the frail nursing home population.

Symptoms of anxiety and depression in the course of cognitive decline

BACKGROUND/AIMS

Anxiety and depression are common inpatients with cognitive decline and Alzheimer's disease (AD), and recognition and treatment of these symptoms can improve their quality of life. The present study investigates anxiety and depression in different phases of cognitive decline.

METHODS

The sample consisted of five groups of elderly people in different phases of cognitive decline; four from a community-based sample (Longitudinal Aging Study Amsterdam), and one group of elderly people diagnosed with AD. ANOVAs were performed to investigate group differences in the severity and prevalence of anxiety and depression, and comorbid anxiety and depressive symptoms.

RESULTS

The prevalence rates of anxiety, comorbid anxiety and depressive symptoms and depressive symptoms follow a pattern of an increasing prevalence as cognitive performance declines and a decrease in the prevalence when cognitive functioning is severely impaired. AD patients report fewest anxiety symptoms.

CONCLUSION

We found that the prevalence of anxiety symptoms, depressive symptoms and comorbid anxiety and depressive symptoms seems to increase in the early phase of cognitive decline, and decreases as cognitive functioning further declines. Elderly diagnosed with AD report less anxiety as expected, probably due to lack of insight caused by AD.

Construction and validation of a patient- and user-friendly nursing home version of the Geriatric Depression Scale

OBJECTIVE

To construct a patient- and user-friendly shortened version of the Geriatric Depression Scale (GDS) that is especially suitable for nursing home patients.

METHODS

The study was carried out on two different data bases including 23 Dutch nursing homes. Data on the GDS (n = 410), the Mini Mental State Examination (n = 410) and a diagnostic interview (SCAN; n = 333), were collected by trained clinicians. Firstly, the items of the GDS-15 were judged on their clinical applicability by three clinical experts. Subsequently, items that were identified as unsuitable were removed using the data of the Assess project (n = 77), and internal consistency was calculated. Secondly, with respect to criterion validity (sensitivity, specitivity, area under ROC and positive and negative predictive values), the newly constructed shortened GDS was validated in the AGED data set (n = 333), using DSM-IV diagnosis for depression as measured by the SCAN as 'gold standard'.

RESULTS

The eight-item GDS that resulted from stage 1 showed good internal consistency in both the Assess data set (alpha = 0.86) and the AGED dataset (alpha = 0.80). In the AGED dataset, high sensitivity rates of 96.3% for major depression and 83.0% for minor depression were found, with a specificity rate of 71.7% at a cut-off point of 2/3.

CONCLUSION

The GDS-8 has good psychometric properties. Given that the GDS-8 is less burdening for the patient, more comfortable to use and less time consuming, it may be a more feasible screening test for the frail nursing home population.

Cognitive functioning in elderly patients with early onset bipolar disorder

BACKGROUND

Very little is known about the long term cognitive sequelae of bipolar disorder.

AIM

To investigate neuropsychological functioning in older euthymic persons with early onset bipolar disorder.

METHOD

Fifteen older patients (age >60) with an early onset (<50 years) bipolar-I disorder in a euthymic mood were tested using a comprehensive neuropsychological test battery. Neuropsychological functioning was compared with that of a sex, age and education-matched group of 15 comparison subjects without mood disorders or memory complaints.

RESULTS

Bipolar subjects scored lower than comparison subjects on selective attention, verbal memory, verbal fluency and mental effort tests.

CONCLUSIONS

The findings suggest that euthymic bipolar patients are impaired across a range of cognitive domains. This could represent a trait-like cognitive disability related to the disease, as the impairments are comparable with those found in younger bipolar patients.

[Stability of personality in later life]

The relation of aging and the stability of personality in late life is evaluated by a literature review. The findings of six longitudinal studies reveal that rank-order consistency continues into old age. The mean-level stability reveals a concave curve for 'neuroticism' with an increase after age 80, a decrease for 'extraversion', and an increase for 'agreeableness'. The methodological and conceptual issues of personality assessment with old adults can be resolved by using a self report scale which corresponds to the capacities and the lifestyle of older adults and by involving age related variables into analyses.

Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis

AIMS/HYPOTHESIS

Evidence strongly suggests that depression and type 2 diabetes are associated, but the direction of the association is still unclear. Depression may occur as a consequence of having diabetes, but may also be a risk factor for the onset of type 2 diabetes. This study examined the latter association by reviewing the literature and conducting a meta-analysis of longitudinal studies on this topic.

METHODS

Medline and PsycInfo were searched for articles published up to January 2005. All studies that examined the relationship between depression and the onset of type 2 diabetes were included. Pooled relative risks were calculated using fixed and random effects models. To explore sources of heterogeneity between studies, subgroup analyses and meta-regression analyses were performed.

RESULTS

Nine studies met our inclusion criteria for this meta-analysis. The pooled relative risk was 1.26 (1.13-1.39) using the fixed effects model and 1.37 (1.14-1.63) using the random effects model. Heterogeneity between studies could not be explained by (1) whether studies controlled for undetected diabetes at baseline; (2) the method of diabetes assessment at follow-up; (3) the baseline overall risk of diabetes in the study population; and (4) follow-up duration.

CONCLUSIONS/INTERPRETATION

Depressed adults have a 37% increased risk of developing type 2 diabetes mellitus. The pathophysiological mechanisms underlying this relationship are still unclear and warrant further research. A randomised controlled study is needed to test whether effective prevention or treatment of depression can reduce the incidence of type 2 diabetes and its health consequences.

[The prevention of psychiatric disorders]

About 450 million people all over the world suffer from psychiatric disorders. Limitations and handicaps are caused especially by unipolar depression, excessive alcohol consumption, schizophrenia and manic-depressive disorder. It is expected that the importance of psychiatric disorders for public health will increase in the coming decades. Psychiatric disorders are often the cause of death, destroy the lives of both patients and their families, have far-reaching economic consequences and are often complicated by somatic diseases. The advances in the field of treatment are impressive but can have only a limited effect on the consequences of psychiatric disorders for public health. The incidence of psychiatric disorders can be reduced by more than 25%. The greatest effects have been seen with depressive disorders, indicated prevention and the use of cognitive therapy. Indicated prevention has also been found to be effective in psychotic disorders. Debriefing is ineffective in posttraumatic stress disorder. The efficacy of universal prevention has not been investigated. There are still insufficient data to develop evidence-based guidelines for the prevention of psychiatric disorders.

[Epidemiology of panic]

BACKGROUND

There is uncertainty about the clinical relevance of panic disorder and subsyndromal panic disorder.

AIM

To assess the clinical relevance ofpanic disorder and subsyndromal panic disorder.

METHOD

We searched Medline and PsycINFO for population studies performed as from 1980. We used as search terms: 'general population', 'psychiatr', 'prevalence' and 'panic'. On the basis of the studies found we compiled a review of the epidemiology of panic which enabled us to assess the clinical relevance.

RESULTS

The life time prevalence of panic disorder is 2.1%; subsyndromal panic disorder is more prevalent (limited symptom attacks 7.5%, infrequent panic attacks 5.1%). Lifetime psychiatric comorbidity is high. The risk and symptom profile for panic disorder and subsyndromal panic disorder is the same. The course of both disorders is unfavourable. There is an increased risk that someone with panic disorder will develop a depression; subsyndromal panic disorder is a non-specific precursor of psychopathology. Both panic disorder and subsyndromal panic disorder are associated with attempted suicide, deficiencies and the use of the health care services, even after comorbidity has been corrected for.

CONCLUSION

It is incorrect only to label panic symptoms 'pathological' if they satisfy the DSM criteriafor panic disorder; both panic disorder and subsyndromal panic disorder are clinically relevant.