The Depression Initiative. Description of a collaborative care model for depression and of the factors influencing its implementation in the primary care setting in the Netherlands

BACKGROUND: In the Depression Initiative, a promising collaborative care model for depression that was developed in the US was adapted for implementation in the Netherlands. AIM: Description of a collaborative care model for major depressive disorder (MDD) and of the factors influencing its implementation in the primary care setting in the Netherlands. DATA SOURCES: Data collected during the preparation phase of the CC:DIP trial of the Depression Initiative, literature, policy documents, information sheets from professional associations. RESULTS: Factors facilitating the implementation of the collaborative care model are continuous supervision of the care managers by the consultant psychiatrist and the trainers, a supportive web-based tracking system and the new reimbursement system that allows for introduction of a mental health care-practice nurse (MHC-PN) in the general practices and coverage of the treatment costs. Impeding factors might be the relatively high percentage of solo-primary care practices, the small percentage of professionals that are located in the same building, unfamiliarity with the concept of collaboration as required for collaborative care, the reimbursement system that demands regular negotiations between each health care provider and the insurance companies and the reluctance general practitioners might feel to expand their responsibility for their depressed patients. CONCLUSION: Implementation of the collaborative care model in the Netherlands requires extensive training and supervision on micro level, facilitation of reimbursement on meso- and macro level and structural effort to change the treatment culture for chronic mental disorders in the primary care settin

Long-term antidepressant use: a qualitative study on perspectives of patients and GPs in primary care

Background Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission. Aim To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use. Design and setting Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands. Method Patients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20). Results The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation. Conclusion Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan

The Geochemistry of Rocks from Asama Volcano, Japan. New Approaches in the Quantitative Interpretation of the Chemical Composition of Volcanic Rocks

In dealing with the geochemistry of volcanic rocks, it appears imperative, first, to refine the procedure of rock analysis with respect to both major and minor components, and second, to improve present methods of interpreting analytical data on common rock suites such as basalts, andesites and dacites. In regard to the first problem, the rapid method of silicate analysis as described by Shapiro and Brannock (1956) and by Riley (1958) deserves special attention. With such a method it is possible to estimate the accuracy and precision of data with far greater ease than is possible with a classical one, yet without any loss of quality. For the determination of some components, however, it is felt that the procedures recommended previously lack precision and/or simplicity. In Part I of this paper, new methods are suggested for these components. The sum of Mg, Ca and Mn is titrated with EDTA in the presence of Al, Fe and other metals, using thymolphthalein complexone as indicator at pH 10-10.5. The sum of Al and Fe is determined by the back-titration of excess EDTA with the standard Cu solution. PAN is used as indicator at pH about 4, and tartrate is added as the masking agent of Ti. Na and K are determined by flame photometry using very dilute solutions (1-5ppm Na or K), without the separation of other metals and without the use of the internal standard. Sr is included in the scheme of analysis, and is determined by flame photometry according to the standard addition technique. These procedures are tested for their accuracy using the standard samples G-1 and W-1 (Tables 3, 5, 9, 12 and 15). Procedures for other components are also described in the text in full detail. The system of analytical procedures recommended is shown in Table 16. To investigate the problem of the interpretation of compositional variation, typical rocks from Asama volcano and the surrounding area were selected, namely, andesites and dacites of calc-alkaline type. Twenty-one samples, described in Tables 18 and 19, are analyzed according to the above procedures. Results are shown in Table 20. Variation diagrams are presented in Figs. 3 to 5. Since it may be questioned whether the "trend" seen in the diagrams implies a genetic relationship, a least squares approximation technique has been introduced in order to determine whether the composition of the main components of a rock (F) can be expressed by the linear combination of a selected set of compositions of a magma and the phenocrysts crystallized from it : F(o)=F(1)x(1)+F(2)x(2)+······+F(m)x(m) ······(1) where F(1), F(2), ... denote the compositions of a magma and minerals, and F(o) is the calculated composition of F. These calculations lead to the conclusion that there are at least two series of rocks in Asama (Tables 25 to 30 and Fig. 9), distinguished from each other mainly by their K(2)O content. Those rocks showing features of assimilation (Aramaki, 1963) all belong to the K(2)O-rich series. Contents of minor components such as TiO(2), MnO, P(2)O(5) and SrO are analyzed by the linear regression technique in two ways, for example : TiO(2)(o)=C(1)x(1)+C(2)x(2)+ ······(2) and TiO(2)(o)=aMgO+bFe(o) +cK(2)O ······(3) These methods are found useful in discriminating rocks of different ongm and in distinguishing the characteristic behavior of each component. Results of calculations (Tables 31 to 34) support the conclusion reached by calculations based on the contents of major components

Cost-effectiveness of collaborative care including PST and an antidepressant treatment algorithm for the treatment of major depressive disorder in primary care; a randomised clinical trial

BACKGROUND: Depressive disorder is currently one of the most burdensome disorders worldwide. Evidence-based treatments for depressive disorder are already available, but these are used insufficiently, and with less positive results than possible. Earlier research in the USA has shown good results in the treatment of depressive disorder based on a collaborative care approach with Problem Solving Treatment and an antidepressant treatment algorithm, and research in the UK has also shown good results with Problem Solving Treatment. These treatment strategies may also work very well in the Netherlands too, even though health care systems differ between countries. METHODS/DESIGN: This study is a two-armed randomised clinical trial, with randomization on patient-level. The aim of the trial is to evaluate the treatment of depressive disorder in primary care in the Netherlands by means of an adapted collaborative care framework, including contracting and adherence-improving strategies, combined with Problem Solving Treatment and antidepressant medication according to a treatment algorithm. Forty general practices will be randomised to either the intervention group or the control group. Included will be patients who are diagnosed with moderate to severe depression, based on DSM-IV criteria, and stratified according to comorbid chronic physical illness. Patients in the intervention group will receive treatment based on the collaborative care approach, and patients in the control group will receive care as usual. Baseline measurements and follow up measures (3, 6, 9 and 12 months) are assessed using questionnaires and an interview. The primary outcome measure is severity of depressive symptoms, according to the PHQ9. Secondary outcome measures are remission as measured with the PHQ9 and the IDS-SR, and cost-effectiveness measured with the TiC-P, the EQ-5D and the SF-36. DISCUSSION: In this study, an American model to enhance care for patients with a depressive disorder, the collaborative care model, will be evaluated for effectiveness in the primary care setting. If effective across the Atlantic and across different health care systems, it is also likely to be an effective strategy to implement in the treatment of major depressive disorder in the Netherlands

Long-Term and Short-Term Antidepressant Use in General Practice: Data from a Large Cohort in the Netherlands

Background: Antidepressant use is highly prevalent. Research has mainly focused on efficacy during short periods of use for depression and anxiety. There is a relative paucity of data regarding the frequency of long-term use. Methods: To determine the prevalence and possible increase of long-term use of antidepressants over recent years, we analyzed routine general practice care data in a large cohort of patients (n = 156,620) in and around Amsterdam, The Netherlands. Additionally, predictors of long-term use were studied. Results: Prevalence of long-term use of antidepressants is substantial, and such use appears to be increasing: 30.3% of use was long-term over the period 1995-2005 compared to 43.7% for the period 2005-2015. Higher age, a registered diagnosis of anxiety or depression, and the use of SSRIs or SNRIs were associated with long-term use in multivariate analysis. In addition, specific antidepressants were differentially associated with long-term use. Conclusions: Long-term antidepressant use is substantial and appears to be on the rise. Awareness of this phenomenon should be increased, such use should be prevented when possible, and reasons for long-term use need to be examined

Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials

Objectives To examine the risk of relapse and time to relapse after discontinuation of antidepressants in patients with anxiety disorder who responded to antidepressants, and to explore whether relapse risk is related to type of anxiety disorder, type of antidepressant, mode of discontinuation, duration of treatment and follow-up, comorbidity, and allowance of psychotherapy.Design Systematic review and meta-analyses of relapse prevention trials.Data sources PubMed, Cochrane, Embase, and clinical trial registers (from inception to July 2016).Study selection Eligible studies included patients with anxiety disorder who responded to antidepressants, randomised patients double blind to either continuing antidepressants or switching to placebo, and compared relapse rates or time to relapse.Data extraction Two independent raters selected studies and extracted data. Random effect models were used to estimate odds ratios for relapse, hazard ratios for time to relapse, and relapse prevalence per group. The effect of various categorical and continuous variables was explored with subgroup analyses and meta-regression analyses respectively. Bias was assessed using the Cochrane tool.Results The meta-analysis included 28 studies (n=5233) examining relapse with a maximum follow-up of one year. Across studies, risk of bias was considered low. Discontinuation increased the odds of relapse compared with continuing antidepressants (summary odds ratio 3.11, 95% confidence interval 2.48 to 3.89). Subgroup analyses and meta-regression analyses showed no statistical significance. Time to relapse (n=3002) was shorter when antidepressants were discontinued (summary hazard ratio 3.63, 2.58 to 5.10; n=11 studies). Summary relapse prevalences were 36.4% (30.8% to 42.1%; n=28 studies) for the placebo group and 16.4% (12.6% to 20.1%; n=28 studies) for the antidepressant group, but prevalence varied considerably across studies, most likely owing to differences in the length of follow-up. Dropout was higher in the placebo group (summary odds ratio 1.31, 1.06 to 1.63; n=27 studies).Conclusions Up to one year of follow-up, discontinuation of antidepressant treatment results in higher relapse rates among responders compared with treatment continuation. The lack of evidence after a one year period should not be interpreted as explicit advice to discontinue antidepressants after one year. Given the chronicity of anxiety disorders, treatment should be directed by long term considerations, including relapse prevalence, side effects, and patients' preferences

Cost-utility of collaborative care for major depressive disorder in primary care in the Netherlands.

Objective Major depression is a great burden on society, as it is associated with high disability/costs. The aim of this study was to evaluate the cost-utility of Collaborative Care (CC) for major depressive disorder compared to Care As Usual (CAU) in a primary health care setting from a societal perspective. Methods A cluster randomized controlled trial was conducted, including 93 patients that were identified by screening (45-CC, 48-CAU). Another 57 patients were identified by the GP (56-CC, 1-CAU). The outcome measures were TiC-P, SF-HQL and EQ-5D, respectively measuring health care utilization, production losses and general health related quality of life at baseline three, six, nine and twelve months. A cost-utility analysis was performed for patients included by screening and a sensitivity analysis was done by also including patients identified by the GP. Results The average annual total costs was €1131 (95% C.I., €− 3158 to €750) lower for CC compared to CAU. The average quality of life years (QALYs) gained was 0.02 (95% C.I., − 0.004 to 0.04) higher for CC, so CC was dominant from a societal perspective. Taking a health care perspective, CC was less cost-effective due to higher costs, €1173 (95% C.I., €− 216 to €2726), of CC compared to CAU which led to an ICER of 53,717 Euro/QALY. The sensitivity analysis showed dominance of CC. Conclusion The cost-utility analysis from a societal perspective showed that CC was dominant to CAU. CC may be a promising treatment for depression in the primary care setting. Further research should explore the cost-effectiveness of long-term CC. Keywords: Cost utility, Primary health care, Depressive disorder, Collaborative care, Randomized controlled tria