Depression in older age:challenges for general practitioners

The aim of this thesis was to clarify the care delivered by general practitioners (GPs) to older adults with depression. Older adults represent a large cohort in general practice, and will eventually face (health) problems. If these problems interact with others, they are referred to as complex problems. Older patients with depression may be prone to face these complex problems because their mental health interacts with other problems. In this thesis, we report that feelings of loneliness were frequently present among older adults with depression, and that these contributed to a worse prognosis of their depression. Loneliness was also adversely related to having contact for a mental health problem with a care provider. Other factors associated with contact with a care provider were age, ethnicity, and household income. The presence of a psychiatric disorder was not associated with having contact. A meta-analysis demonstrated that cognitive behavioural therapy is an effective treatment for depression, while other non-pharmacological treatments were not sufficiently studied. Furthermore, adherence to antidepressant therapy was at stake: more than one third discontinued antidepressant use prematurely and about a quarter discontinued within the first four weeks of treatment. Finally, older adults with depression have more chronic somatic diseases, use more drugs chronically (independent of the use of antidepressants), and were more often nonadherent to cardiovascular drugs as compared to mentally healthy controls. These findings confirm that older adults with depression often have complex problems. The findings contribute to our knowledge of care requirements for older adults with depression by identifying key difficulties in the provision of care by GPs

Investigating the current knowledge and needs concerning a follow-up for long-term cardiovascular risks in Dutch women with a preeclampsia history:a qualitative study

Background There is increasing evidence that a history of preeclampsia is an important risk factor for future cardiovascular events. Awareness of this risk could provide opportunities for identification of women at risk, with opportunities for prevention and / or early intervention. A standardized follow-up has not yet been implemented in the north of the Netherlands. The objective of this qualitative study was to explore the opinions and wishes among women and physicians about the follow-up for women with a history of preeclampsia. Methods Semi-structured interviews with 15 women and 14 physicians (5 obstetricians, 4 general practitioners, 3 vascular medicine specialists and 2 cardiologists) were performed and addressed topics about knowledge on CVR, current - and future follow-up. Women were approached through the HELLP foundation and their physicians. Physicians were approached by email. The interviews were recorded, typed and coded using ATLAS.ti software. A theoretical-driven thematic analysis was performed. Results Women had some knowledge about the association between preeclampsia and the increased CVR, but missed information from their health care providers. Specialists were aware of the association, but the information and advice they provided to their patients was minimal and inconsistent according to themselves. Whereas some general practitioners regarded their own knowledge as limited. There was a clear desire among women for a more extensive follow-up with specific attention to both emotional and physical consequences of preeclampsia. Physicians indicated that they preferred to see a follow up program concerning the CVR at the general practitioner as part of the already existent cardiovascular risk management (CVRM) program. Conclusion Women and medical specialists consider it important to improve aftercare for women after a pregnancy complicated by preeclampsia. Introducing these women into the CVRM program at the general practitioner is regarded as a preferred first step. Further research is warranted to establish an evidence-based guideline for the follow-up of these women

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care:A systematic review and meta-analysis

Purpose: Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care. Methods: We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool. Results: Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = −0.19, 95%CI −0.31 to −0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = −0.22, 95%CI −0.35 to −0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness. Limitations: The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety. Conclusions: E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety

Risk of bias assessment for the included randomized controlled trials.

<p>Based on the Cochrane Collaboration’s tool for assessing risk of bias, + indicates low risk of bias,—indicates high risk of bias, and? indicates unclear risk of bias.</p

Characteristics of included studies conducted in community settings.

<p>Characteristics of included studies conducted in community settings.</p