24-Hour motor activity and autonomic cardiac functioning in major depressive disorder

The studies of this thesis concern the spontaneous pattern of motor activity and autonomic cardiac functioning in major depressive disorder. The main purpose of the studies was to obtain insight in the psychomotor and autonomic cardiac dysfunction in depression by investigating the 24-hour pattern of motor activity and the autonomic (sympathetic and parasympathetic) regulation of the cardiovascular system in healthy subjects and depressed inpatients. The data of the patients were assessed during a psychotropic drug free period drug and after double blind treatment during 4 weeks with imipramine or fluvoxamine. It was hypothesised that clinical state and antidepressant treatment affect the 24-uur pattern of motor activity and autonomic regulation in depressed patients. Furthermore, personality traits were theorised to contribute to variation in the 24-uur pattern of motor activity, and risk factors to variation in cardiovascular variability and baroreflex sensitivity. In addition, measurements of the spontaneous motor behavior and parasympathetic regulation in depressed patients were explored for their usefuloess to clarify the cholinergic dysfunction in major depressive disorder

Multiple usage of the CD PLUS/UNIX system: performance in practice

In August 1994, the CD PLUS/Ovid literature retrieval system based on UNIX was activated for the Faculty of Medicine and Health Sciences of Erasmus University in Rotterdam, the Netherlands. There were up to 1,200 potential users. Tests were carried out to determine the extent to which searching for literature was affected by other end users of the system. In the tests, search times and download times were measured in relation to a varying number of continuously active workstations. Results indicated a linear relationship between search times and the number of active workstations. In the "worst case" situation with sixteen active workstations, the time required for record retrieval increased by a factor of sixteen and downloading time by a factor of sixteen over the "best case" of no other active stations. However, because the worst case seldom, if ever, happens in real life, these results are considered acceptable

Adverse effects of extra-articular corticosteroid injections: A systematic review

Background. To estimate the occurrence and type of adverse effects after application of an extra-articular (soft tissue) corticosteroid injection. Methods. A systematic review of the literature was made based on a PubMed and Embase search covering the period 1956 to January 2010. Case reports were included, as were prospective and retrospective studies that reported adverse events of corticosteroid injection. All clinical trials which used extra-articular corticosteroid injections were examined. We divided the reported adverse events into major (defined as those needing intervention or not disappearing) and minor ones (transient, not requiring intervention). Results. The search yielded 87 relevant studies:44 case reports, 37 prospective studies and 6 retrospective studies. The major adverse events included osteomyelitis and protothecosis; one fatal necrotizing fasciitis; cellulitis and ecchymosis; tendon ruptures; atrophy of the plantar fat was described after injecting a neuroma; and local skin effects appeared as atrophy, hypopigmentation or as skin defect. The minor adverse events effects ranged from skin rash to flushing and disturbed menstrual pattern. Increased pain or steroid flare after injection was reported in 19 studies. After extra-articular injection, the incidence of major adverse events ranged from 0-5.8% and that of minor adverse events from 0-81%. It was not feasible to pool the risk for adverse effects due to heterogeneity of study populations and difference in interventions and variance in reporting. Conclusion. In this literature review it was difficult to accurately quantify the incidence of adverse effects after extra-articular corticosteroid injection. The reported adverse events were relatively mild, although one fatal reaction was reported

How occupational position and educational level modify each other's relationships with poor health status and morbidity.

Background: Socio-economic health disparities remained the same or even have grown despite economic growth and advanced medical technology and care. It seems relevant to know if health policies should focus on specific socio-economic groups in the future. The aim of this study was to explore individual and interaction effects of occupational position and educational level on selfperceived health status and morbidity.Methods: Data were obtained from the second Dutch National Survey of General Practice that was carried out in 2001 and included 104 general practices and 385 461 listed patients. GPs registered electronically at each patient contact the diagnosis (ICPC) for presented health problems, induced prescriptions for medication, and referrals to specialised care. Occupational position (ISEI) and educational level of patients were assessed by a socio-demographic census. Logistic regression analyses were used to study the individual and combined risk of the socio-economic (SES) indicators on different health indicators. Results: Patients with a lower occupational position and lower educational level had higher, independent risks of poor health status. An additional risk was found in patients belonging to both groups. Lower occupational position and educational level were also related to increased risks of depression, diabetes, myocardial infarction, osteoarthritis, dermatitis, muscle pain, and pain of neck/back. Risks of a low occupational position were only partly explained by a low educational level. Significant interaction effects between SES indicators were found in case of diabetes, myocardial infarction, and pain of neck/back. Conclusions: Lower occupational position and educational level have an increased risk on poor health status and occurrence of several diseases. Patients with both a lower occupational and educational level deserve the attention from health policies. It seems relevant to study combined effects of SES indicators in future studies. (aut.ref.

Policy of pharmacotherapy in elderly depressed patients in primary care: guidelines and sociodemographic and clinical determinants.

The researchers investigated the actual policy regarding antidepressant treatment by general practitioners (GPs) in elderly depressed patients. This policy was compared with the clinical guidelines and studied in relation to sociodemographic and clinical factors of the patients. (aut.ref.

Health disparities by occupation, modified by education: a cross-sectional population study.

BACKGROUND: Socio-economic disparities in health status are frequently reported in research. By comparison with education and income, occupational status has been less extensively studied in relation to health status or the occurrence of specific chronic diseases. The aim of this study was to investigate health disparities in the working population based on occupational position and how they were modified by education. METHODS: Our data were derived from the National Survey of General Practice that comprised 104 practices in the Netherlands. 136,189 working people aged 25-64 participated in the study. Occupational position was assessed by the International Socio-Economic Index of occupational position (ISEI). Health outcomes were self-perceived health status and physician-diagnosed diseases. Odds ratios were estimated using multivariate logistic regression analysis. RESULTS: The lowest occupational position was observed to be associated with poor health in men (OR = 1.6, 95% CI 1,5 to 1.7) and women (OR = 1.3, 95% CI 1.2 to 1.4). The risk of poor health gradually decreased in relation to higher occupational positions. People with the lowest occupational positions were more likely to suffer from depression, diabetes, ischaemic heart disease, arthritis, muscle pain, neck and back pain and tension headache, in comparison to people with the highest occupational position (OR 1.2 to 1.6). A lower educational level induced an additional risk of poor health and disease. We found that gender modified the effects on poor health when both occupational position and education were combined in the analysis. CONCLUSION: A low occupational position was consistently associated working people with poor health and physician-diagnosed morbidity. However a low educational level was not. Occupational position and education had a combined effect on self-perceived health, which supports the recent call to improve the conceptual framework of health disparities. (aut. ref.

Antidepressant prescriptions in first and second generation ethnic minorities in Dutch general practice.

Background: Ethnic minorities have poor access and different pathways to mental health care as compared to indigenous populations, but less is known about differences in antidepressant treatment in depressed patients among ethnic minorities. This papers studies antidepressant treatment in depressed patients among first and second generation ethnic minorities in general practice. Methods: We tested our hypothesis using data routine electronic medical records from 90 representative general practices in 2003. Ethnicity and generational status of ethnic minorities was determined by country of birth of subjects and their parents using information from the municipal population registration kept by Statistics Netherlands. Databases were linked on patient basis. Outcome measures were percentage of patients with antidepressant treatment and number of prescriptions in patients receiving antidepressants. The statistical analysis was conducted using multivariate regression models. A total of 2392 Dutch, Moroccan, Turkish, Surinamese and Antillean patients with depression aged 15–55 years among 322 369 matched patients < 55 years were included in the analysis. Results: Moroccan and Surinamese patients with a physician diagnosed depression had lower treatment rates with antidepressants (68.9% and 63.2%) than Dutch patients (72.9%) and all ethnic minorities had lower numbers of prescriptions. Differences in treatment rates were explained by variation in demographic and socioeconomic variables and co-morbidity with anxiety. The second generation was less likely than the indigenous population to receive antidepressant treatment (OR = 0.29) and both first and second generations received a reduced number of prescriptions (B =1.99 and B =2.43, respectively). These findings were independent of age and other background variables. Conclusions: The largest non-western minorities in the Netherlands received less antidepressant treatment for depression in general practice than the indigenous population. The largest difference was found in the second generation, which does not support the acculturation hypothesis. (aut. ref.

Antidepressant use and off-label prescribing in children and adolescents in Dutch general practice (2001-2005).

PURPOSE: To study the use of antidepressants in children and adolescents in Dutch general practice in 2001 and 2005 and to determine off-label prescribing. METHODS: Data were obtained from the Netherlands Information Network of General Practice (LINH) that comprised 97 practices in 2001 and 73 practices in 2005. General practitioners (GPs) recorded prescriptions with their indication in the medical records of the patients during one calendar year. We selected boys and girls aged 0-17 years (n = 83 442 in 2001; n = 62 969 in 2005) and identified those who got prescribed antidepressants (N06A). Prevalence of use, indications and percentage of off-label prescriptions were compared between 2001 and 2005. RESULTS: The prevalence of selective serotonin reuptake inhibitor (SSRI) use decreased from 1.2 to 1.1 per 1000 children and adolescents between 2001 and 2005. The use of tricyclic antidepressants (TCAs) and other antidepressants also decreased (0.8 to 0.7 and 0.3 to 0.2, respectively). TCAs were often prescribed for nocturnal enuresis, but in patients aged 12-17 years hyperactivity was the leading indication in both years. GPs continued to prescribe SSRIs for depression (about half of the prescriptions) after the safety warnings, while venlafaxine prescribed for depression decreased in favour of anxiety. Off-label prescribing of SSRIs increased from 16.7% to 34.4% and that of venlafaxine from 22.2% to 58.3%. All SSRI and venlafaxine prescriptions were unlicensed for age. CONCLUSIONS: The decreased use of SSRIs and venlafaxine suggests an impact of the safety warnings. A point of concern is the enlarged off-label prescribing and insight in the underlying reasons and its appropriateness is needed. (aut. ref.

The problem of diagnosing major depression in elderly primary care patients.

BACKGROUND: To clarify the problem of diagnosing major depression in elderly primary care patients, we studied the nuances of diagnostic classification by general practitioners (GPs) and the relationship between sociodemographic and clinical factors and an accurate diagnosis of depression. METHODS: As part of a national survey of general practice a standardised psychiatric interview (CIDI) was performed in 237 subjects > or =55 years screened for the presence of psychopathology. Fifty-five patients were found to suffer from a major depressive disorder in the last 12 months. In these patients, GPs registered during 1 year all contact diagnoses and prescriptions of medication. RESULTS: Nearly all depressed patients (96.4%) had one or more contacts with their GP during 1 year. GPs classified 20.8% of the patients as having a down/depressed feeling or depression, while 32.1% as having other psychological problems than depression. It was remarkable that an accurate diagnosis by GPs was significantly related to higher age in this age group. Regarding the clinical characteristics, there was a significantly higher number of prescriptions of antidepressants in the accurately diagnosed patients. We found no significant differences in respect to other clinical characteristics (e.g. severity and number of symptoms, comorbidity of anxiety and somatic disorders). CONCLUSIONS: GPs are aware of the psychological problems in half of the elderly patients with major depression, but do not explicitly distinguish depressive symptoms from other psychological problems or from social problems. Integrated programs may be more promising to improve the diagnostic rate than clinical education or guideline implementation alone. (aut.ref.