Two-year course trajectories of anxiety disorders: do DSM classifications matter?

Objective: Anxiety disorders have been shown to differ in their course, but it is unknown whether DSM-categories represent clinically relevant course trajectories. We aim to identify anxiety course trajectories using a data-driven method and to examine whether these course trajectories correspond to DSM-categories or whether other clinical indicators better differentiate them. Method: 907 patients with panic disorder with agoraphobia, panic disorder without agoraphobia , agoraphobia, social phobia, or generalized anxiety disorder according to DSMIV criteria were derived from a prospective cohort study (Netherlands Study of Depression and Anxiety). Baseline data were collected between September 2004 and February 2007; follow-up data, between October 2006 and March 2009. Latent class growth analysis was conducted, based on symptoms of anxiety and avoidance assessed with the Life Chart Interview covering a 2-year time period. Identified course trajectories were compared with DSM-IV diagnoses and a wider set of predictors. Results: We identified a class with minimal symptoms over time (41.7%), a moderately severe chronic class (42.8%), and a severe chronic class (15.4%). Panic disorder with agoraphobia (OR = 2.14; 95% CI, 1.48-3.09) and social phobia (OR = 1.97; 95% CI, 1.46-2.68) predicted moderately severe chronicity; panic disorder with agoraphobia (OR = 2.70; 95% CI, 1.66-4.40), social phobia (OR = 2.46; 95% CI, 1.62-3.74), and generalized anxiety disorder (OR = 1.86; 95% CI, 1.23-2.82) predicted a severe chronic course. However, baseline severity, duration of anxiety, and disability better predicted severe chronic course trajectories than DSM-categories. Additionally, partner status, age at onset, childhood trauma, and comorbid depressive disorder predicted chronic courses. Conclusions: Course of anxiety was pleomorphic with over 40% having a favorable course, thereby questioning the common notion of chronicity of anxiety disorders. Severity, duration of anxiety, and disability were able to better identify severe chronic course trajectories as compared with DSM-IV categories. These findings facilitate the identification of chronic course trajectories of anxiety disorders in clinical care and support current debates on staging and profiling of mental disorders

Effectiveness and cost-effectiveness of a self-management training for patients with chronic and treatment resistant anxiety or depressive disorders: Design of a multicenter randomized controlled trial

Contains fulltext : 179427.pdf (publisher's version ) (Open Access)Background: Many patients with anxiety or depressive disorders achieve no remission of their symptoms after evidence-based treatment algorithms. They develop a chronic course of the disorder. Current care for these patients usually consists of long-term supportive contacts with a community psychiatric nurse and pharmacological management by a psychiatrist. Data on the effectiveness of these treatments is lacking. A psychosocial rehabilitation approach, where self-management is an increasingly important part, could be more suitable. It focuses on the restoration of functioning and enhancement of patients’ autonomy and responsibility. Treatment with this focus, followed by referral to primary care, may be more (cost-)effective. Methods: A multicenter randomized controlled trial is designed for twelve participating specialized outpatient mental health services in the Netherlands. Patients with chronic and treatment resistant anxiety or depressive disorders, currently receiving supportive care in specialized outpatient mental health care, are asked to participate. After inclusion, patients receive the baseline questionnaire and are randomized to the intervention group or the usual care control group. The intervention focuses on rehabilitation and self-management and is provided by a trained community psychiatric nurse, followed by referral to primary care. Measurements take place at 6, 12, and 18 months after baseline. This study evaluates both the effectiveness (on quality of life, symptom severity, and empowerment), and cost-effectiveness of the intervention compared to usual care. In addition, a questionnaire is designed to get insight in which self-management strategies patients use to manage their disorder, and in the experiences of patients with the change of care setting. Discussion: In this study we evaluate the effectiveness and cost-effectiveness of a self-management intervention for patients with chronic and treatment resistant anxiety or depressive disorders in specialized outpatient mental health care. The results of this study may provide a first ‘proof-of-concept’ in this under-researched but important field, and might be relevant for a large group of patients in the context of a transition of the Dutch health care system. Trial registration: Netherlands Trial Register: NTR3335, registered 7 March 2012.8 p

Effectiveness of the implementation of guidelines for anxiety disorders in specialized mental health care

Contains fulltext : 155141.pdf (publisher's version ) (Closed access)OBJECTIVE: To examine the effect of implementing anxiety disorders guidelines on guideline adherence and patient outcomes in specialized mental health care. METHOD: A treatment setting in which guidelines were implemented (intervention condition) was compared with one in which guidelines were only disseminated (control condition). RESULTS: Of 61.7% of 81 intervention-condition patients received treatment according to the guidelines vs. 40.6% of 69 control-condition patients (P = 0.01). At 1-year follow-up, intervention-condition patients showed a greater decrease in anxiety symptoms (d = 0.48, P < 0.05); higher percentages of response (52.6% vs. 33.8%; P = 0.025) and remission (33.3% vs.16.9%; P = 0.026); and a greater decrease in the rate of phobic avoidance (d = 0.34, P < 0.05). At 2-year follow-up, control-condition patients had experienced a longer period of treatment, which had eroded most of these differences, except for phobic avoidance. CONCLUSION: Systematic guideline implementation results in earlier gains and shorter treatment times