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Prediction of prolonged treatment course for depressive and anxiety disorders in an outpatient setting: The Leiden routine outcome monitoring study
Abstract
Objective
The aim of this study was to improve clinical identification of patients with a prolonged treatment course for depressive and anxiety disorders early in treatment.
Method
We conducted a cohort study in 1.225 adult patients with a depressive or anxiety disorders in psychiatric specialty care setting between 2007 and 2011, with at least two Brief Symptom Inventory (BSI) assessments within 6 months. With logistic regression, we modelled baseline age, gender, ethnicity, education, marital status, housing situation, employment status, psychiatric comorbidity and both baseline and 1st follow-up BSI scores to predict prolonged treatment course (>2 years). Based on the regression coefficients, we present an easy to use risk prediction score.
Results
BSI at 1st follow-up proved to be a strong predictor for both depressive and anxiety disorders (OR = 2.17 (CI95% 1.73–2.74); OR = 2.52 (CI95% 1.86–3.23)). The final risk prediction score included BSI 1st follow-up and comorbid axis II disorder for depressive disorder, for anxiety disorders BSI 1st follow-up and age were included. For depressive disorders, for 28% of the patients with the highest scores, the positive predictive value for a prolonged treatment course was60% (sensitivity 0.38, specificity 0.81). For anxiety disorders, for 35% of the patients with the highest scores, the positive predictive value for a prolonged treatment course was 52% (sensitivity 0.55, specificity 0.75).
Conclusions
A high level of symptoms at 2–6 months of follow-up is a strong predictor for prolonged treatment course. This facilitates early identification of patients at risk of a prolonged course of treatment; in a relatively easy way by a self-assessed symptom severity.
... Comorbidity of depression and anxiety is substantial (Merikangas et al., 2003) and often associated with a more chronic course of illness, and people with comorbid anxiety-depression often experience a higher degree of work disability compared to people without comorbidity (Hendriks et al., 2015). General predictors of prolonged RTW following depression or anxiety are older age (Lammerts et al., 2015;Vemer et al., 2013;Dewa et al., 2003), female gender (Vemer et al., 2013;Koopmans et al., 2008), low level of education (Ervasti et al., 2014), being married or cohabitant (Vemer et al., 2013;Tolman et al., 2009), as well as severity of depression and anxiety symptoms (Dewa et al., 2003;Banerjee et al., 2014;Druss et al., 2001;Nielsen et al., 2012;Bultmann et al., 2006). In contrast, a recent study found a high RTW among patients in moderate or high anxiety trajectories, high depressive symptom trajcetory, and moderate to low workfunctioning trajectory (Arends et al., 2019). ...
... indicate that practitioners should be careful to predict the outcome of the anxiety disorder based on initial symptom severity. Contrary to other studies (Penninx et al., 2011;Boer et al., 2019), we found older age to be associated with being in a more favorable trajectory class (mild-vs moderate-decreasing), maybe because people benefit more from treatment and gain more beneficial coping strategies with age. ...
Background
Depression and anxiety are heterogenous disorders often combined into one entity in studies. Few studies have compared trajectories of depression and anxiety among clinically ill. We aimed to identify specific trajectories of depression, and anxiety and predictors of trajectory membership.
Methods
Latent growth mixture modelling was carried out on data from the IPS-MA trial (n=261), a supported employment intervention for people with mood or anxiety, to identify trajectories of depression and anxiety. Logistic regression was used to estimate predictors for trajectory membership. Associations between trajectory class and remission of comorbid depression or anxiety and return to work were also tested.
Results
We identified three trajectories of depression and anxiety symptoms respectively; moderate-decreasing (60%), moderate-stable (26%), and low-stable (14%) depression and mild-decreasing (59%), moderate-decreasing (33%), and moderate-stable (8%) anxiety. The depression model showed low precision in class separation (entropy 0.66), hence, predictors of class membership were not estimated. For anxiety, lower age and higher levels of depressive symptoms were associated with a less desirable trajectory. Remission of comorbid depressive symptoms after two years differed significantly between classes (p<0.000). Fewer had returned to work in the two moderate classes compared to the mild-decreasing anxiety class.
Limitations
Depression model not reliable. Only 80 % of participants from original study included. Not able to distinguish between anxiety disorders.
Conclusion
Trajectories of anxiety confirm that, even after two years, a rather large proportion in the moderate-stable class had symptoms of moderate anxiety, moderate comorbid depressive symptoms, and less probability of having returned to work.
Trial Registration
ClinicalTrials.govNCT01721824
... Compared to non-chronic/episodic depression, patients with PDD have a poor prognosis due to the persistence of depressive symptoms, reflected in poorer response to psychotherapy and antidepressants in specialized mental healthcare [5][6][7][8][9][10][11]; increased mental healthcare utilization [12]; and more frequent psychiatric hospitalizations [13][14][15]. More intensive prolonged care (i.e., higher number of attempted psychotherapeutic or pharmacotherapeutic treatments) does not always mean better outcomes for patients with PDD: often they remain symptomatic for a longer time or experience more frequent recurrence of chronic episodes [6,12,[16][17][18][19][20][21][22][23][24][25]. Even when depressive symptoms improve, patients with PDD may continue to experience residual social and occupational functional impairments and have difficulty finding meaning and enjoyment in life [26][27][28]. ...
Background: Persistent depressive disorder (PDD) is prevalent and debilitating. For patients with PDD, psychiatric rehabilitation using self-management interventions is advised as the next therapeutic step after multiple unsuccessful treatment attempts. The “Patient and Partner Education Program for All Chronic Diseases” (PPEP4All) is a brief, structured selfmanagement program that focuses on functional recovery for patients and their partners/caregivers. In chronic somatic disorder populations, PPEP4All has already been shown to be clinically effective. We examined whether PPEP4All adapted for PDD (PPEP4All-PDD, 9 weekly group or individual sessions) is also clinically effective for adults/elderly with PDD and their partners/caregivers compared to care-as-usual (CAU) in specialized mental healthcare.
Methods: In this mixed-method multicenter pragmatic randomized controlled trial, 70 patients with PDD and 14 partners/caregivers were allocated to either PPEP4All-PDD (patients, n = 37; partners/caregivers, n = 14) or CAU (patients, n = 33; partners/caregivers, not included) and completed questionnaires at 0, 3, 6, and 12 months regarding depressive symptoms, psychopathology, psychosocial burden, mental resilience, and happiness/wellbeing. Qualitative data were collected regarding treatment satisfaction. Data were analyzed using mixed model analyses and an intention-to-treat (ITT) approach.
Results: There was no statistically significant difference in any outcome regarding clinical effectiveness between PPEP4All-PDD and CAU. Subgroup analysis for depressive symptoms did not show any interaction effect for any subgroup. Although 78% of participants recommended PPEP4All-PDD, there was no difference in treatment satisfaction between PPEP4All-PDD (score = 6.6; SD = 1.7) and CAU (score = 7.6; SD = 1.2), p = 0.06.
Conclusion: Although depressive symptoms did not improve relative to CAU, this only confirmed that treatment for patients with treatment-resistant PDD should move from symptom reduction to functional recovery. Also, functional recovery may be reflected in other outcomes than psychosocial burden, such as self-empowerment, in patients with treatment-resistant PDD. Future research on PPEP4All-PDD could focus on a longer-term program and/or online program that may also be offered earlier in the treatment process as an empowerment intervention.
Trial Registration: Netherlands Trial Register Identifier NL5818. Registered on 20 July 2016, https://clinicaltrialregister.nl/nl/trial/20302
... Moreover, recent studies support the presence of a general psychopathology factor within various psychiatric disorders rather than viewing mental disorders as distinct and categorical conditions (Caspi et al., 2014). Such a measure would be of added value to MBC, especially considering that MBC has been proven to be effective for multiple disorders including depressive disorder (Guo et al., 2015;Kendrick et al., 2009;Lewis et al., 2015;Newnham et al., 2010), anxiety (Boer et al., 2019;Gual-Montolio et al., 2020), bipolar disorder (Cerimele et al., 2019), substance use (Simon et al., 2020), and schizophrenia (Dinakaran et al., 2020). ...
The Brief Adjustment Scale–6 (BASE-6) was recently developed for measuring general psychological functioning within measurement-based care (MBC). The present study further evaluated psychometric properties, generalizability to race/ethnic populations, and clinical utility of the BASE-6. Three adult samples, Sample 1: online community participants ( n = 394); Sample 2: college students ( n = 249); Sample 3: outpatient clinic clients ( n = 80), were included. The results demonstrated a high level of internal consistency, good test–retest reliability, and convergent validity in all samples. The unidimensional structure of BASE-6 was confirmed and factorial invariance was established across groups. Finally, the BASE-6 captured change over time by demonstrating a large effect size of pre–post treatment changes and significant linear change in multilevel growth modeling. These results support the BASE-6 as a reliable and valid measure regardless of race/ethnicity and can sensitively detect clinical change over the course of the treatment. Thus, the BASE-6 appears to accurately monitor overall psychological adjustment.
... An additional treatment aimed at PPT may be appropriate only for patients who remain symptomatic in spite of treatment. Moreover, it is likely that patients with higher levels of PPT simply need to be treated longer to achieve full remission in symptoms (Boer et al., 2019). However, one could also argue that patients with high PPT should be treated differently or more intensely, to achieve the same symptom level after 6 to 8 months of treatment as their lower PPT counterparts (Angstman et al., 2011). ...
Previous studies have failed to take baseline severity into account when assessing the effects of pathological personality traits (PPT) on treatment outcome. This study assessed the prognostic value of PPT (Dimensional Assessment of Personality Pathology-Short Form) on treatment outcome (Brief Symptom Inventory [BSI-posttreatment]) among patients with depressive and/or anxiety disorders (N = 5689). Baseline symptom level (BSI-pretreatment) was taken into account as a mediator or moderator variable. Results showed significant effects of PPT on outcome, of which Emotional Dysregulation demonstrated the largest association (β = 0.43, p < 0.001). When including baseline BSI score as a mediator variable, a direct effect (β = 0.11, p < 0.001) remained approximately one-third of the total effect. The effects of Emotional Dysregulation (interaction effect β = 0.061, p < 0.001) and Inhibition (interaction effect β = 0.062, p < 0.001), but not Compulsivity or Dissocial Behavior, were moderated by the baseline symptom level. PPT predicts higher symptom levels, both before and after treatment, but yields relatively small direct effects on symptom decline when the effect of pretreatment severity is taken into account.
... Clinicians are resigned to providing long-term supportive nonspecific treatment (i.e., care as usual), due to the considerable suffering of patients and the absence of alternative treatment options [13]. More intensive prolonged care, however, often fails to improve therapeutic response; previous research has shown that patients with increasing depression symptom levels have a poor treatment prognosis despite receiving more intensive care [14][15][16]. The ongoing unsuccessful treatment leaves both patients and clinicians feeling powerless and frustrated [13]. ...
Background
After regular treatment, patients with persistent depressive disorder (PDD) may remain in specialized psychiatric outpatient care without achieving remission. Lacking other options, these patients often receive long-term, non-protocolized care as usual (CAU) that does not involve the partner/caregiver of the patient. Although the revised depression treatment guidelines suggest focusing on psychiatric rehabilitation and self-management as the next treatment step for PDD, an evidence-based cost-effective self-management protocol for PDD is lacking. This study investigates the “Patient and Partner Education Program for All Chronic Illnesses” (PPEP4All) as a brief self-management protocol that could lead to lower costs, higher quality of life, and less disease burden in PDD patients and their partners/caregivers.
Methods
Presented is the rationale and methods of a multicenter pragmatic randomized controlled trial to evaluate the clinical efficacy and cost-effectiveness of PPEP4All for patients with PDD and their partners/caregivers. In accordance with current recommendations, a mixed methods research approach is used with both quantitative and qualitative data. A total of 178 eligible outpatients with PDD and their partners/caregivers are recruited and randomized to either PPEP4All or CAU. Those assigned to PPEP4All receive nine weekly self-management sessions with a trained PPEP4All therapist. Primary and secondary outcome measurements are at 0, 3, 6, and 12 months.
Discussion
This project will result in the implementation of a self-management intervention for patients with PDD, meeting an urgent need in mental healthcare. Using PPEP4All can optimize the quality and efficiency of care for both patients with PDD and their partners/caregivers.
Trial registration
Netherlands Trial Register Identifier NTR5973. Registered on 20 July 2016.
... 10,11 Throughout the decades of its existence, the BSI was translated into several languages. [12][13][14][15][16][17][18] ...
The existence of a general factor related to psychiatric symptoms is supported by studies using a variety of methods and in both clinical and non-clinical samples. This study aims to evaluate the replicability of internal structure of the Brief Symptom Inventory in a large Brazilian sample. Participants were 6,427 Brazilian subjects (81% female). The mean age was 42.1 years old (SD = 13.6, Min = 13, Max = 80). All participants fulfilled the online version of the Brief Symptom Inventory. This scale presents a general score (GSI), and nine specific clusters of symptoms (depression, anxiety, phobic anxiety, interpersonal sensibility, psychoticism, paranoid ideation, obsessive-compulsive, hostility, and somatization symptoms). Confirmatory factorial analysis was performed to assess the factorial BSI structure. Results support that the bifactorial solution was the best-fitting model and the general factor arise as the main dimension explaining most of the reliable variability in the data. Findings suggest that BSI internal structure was replicated in a non-clinical sample and the general factor is the most reliable score. However, it is necessary a better understanding about the meaning of the general factor scores in a non-clinical to increase the interpretability of its scores.
Anxiety-related disorders constitute the leading prevalent mental disorders, with major burden on patients, their relatives, and society. Moreover, there is considerable treatment nonadherence/nonresponse. We used routine outcome monitoring (ROM) data from outpatients covering four anxiety-related disorders (DSM-IV-R, N = 470) to examine their 6-month treatment course and its predictors: generalized anxiety disorder, panic disorder with agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Measures included Mini-International Neuropsychiatric Interview Plus, Brief Symptom Inventory (BSI), Montgomery-Åsberg Depression Rating Scale (MADRS), Brief Anxiety Scale (BAS), and Short Form Health Survey 36 (SF-36). On the clinician-rated instruments (MADRS/BAS), all anxiety-related disorder groups showed a significant albeit modest improvement after treatment. On the BSI self-rating, only generalized anxiety disorder and posttraumatic stress disorder showed a significant modest improvement. No anxiety-related disorder groups improved significantly regarding SF-36 physical functioning. For BSI symptom course, significant predictors were comorbid somatoform/total disorders, SF-36 physical functioning/general health, and MADRS score. Clinical implications and future research recommendations are discussed.
Background: After regular treatment, patients with persistent depressive disorder (PDD) may remain in specialized psychiatric outpatient care without achieving remission. Lacking other options, these patients often receive long-term, non-protocolized care as usual (CAU) that does not involve the partner/caregiver of the patient. Although the revised depression treatment guidelines suggest focusing on psychiatric rehabilitation and self-management as the next treatment step for PDD, an evidence-based cost-effective self-management protocol for PDD is lacking. This study investigates the “Patient and Partner Education Program for All Chronic Illnesses” (PPEP4All) as a brief self-management protocol that could lead to lower costs, higher quality of life, and less disease burden in PDD patients and their partners/caregivers.
Methods: Presented is the rationale and methods of a multicenter pragmatic randomized controlled trial to evaluate the clinical efficacy and cost-effectiveness of PPEP4All for patients with PDD and their partners/caregivers. In accordance with current recommendations, a mixed-methods approach is used with both quantitative and qualitative data. A total of 178 eligible outpatients with PDD and their partners/caregivers are recruited and randomized to either PPEP4All or CAU. Those assigned to PPEP4All receive nine weekly self-management sessions with a trained PPEP4All-therapist. Primary and secondary outcome measurements are at 3, 6, 12 months.
Discussion: This project will result in the implementation of a self-management intervention for patients with PDD, meeting an urgent need in mental healthcare. Using PPEP4All can optimize the quality and efficiency of care for both patients with PDD and their partners/caregivers.
Trial registration: Netherlands Trial Register Identifier: NTR5973. Registered on 20 July 2016.
To determine the economic impact of sustained non-remission of depression on the total annual all-cause healthcare costs of patients with a history of depression.
Adults with ≥2 claims with depression diagnosis codes from the HealthCore Integrated Research Database(SM) were invited to participate in this retrospective/prospective fixed-cohort repeated-measures study. Patients with scores >5 at initial survey and 6-month assessment on the Quick Inventory of Depressive Symptomatology (QIDS-SR) were considered to be in "sustained non-remission", while those with scores ≤5 at both assessments were considered to be in "sustained remission". Patients also completed self-report instruments to assess pain, fatigue, anxiety, sleep difficulty, and other health and wellness domains. Survey data were linked to patient claims (12-month pre- and post-initial survey periods). After adjusting for demographic and clinical characteristics using propensity scores, post-survey costs and resource utilization were compared between remission and non-remission groups using non-parametric bootstrapping methods.
Of the 640 patients who met inclusion criteria, 140 (21.9%) were in sustained remission and 348 (54.5%) never achieved remission. Using propensity-score adjusted costs, sustained non-remission of depression was associated with higher annual healthcare expenditures of >$2,300 per patient ($14,627 vs. $12,313, p=.0010) compared to remitted patients. Higher costs were associated with greater resource utilization and increased medication use. Non-remitters were prescribed more medications than remitters, including antidepressants and second-generation antipsychotics. Although length of antidepressant exposure over 12 months was similar, remitters were more likely to be adherent to antidepressants. Non-remission was associated with anxiety, pain, fatigue, sleep disruption, diabetes, anemia, obesity, and heavy drinking.
Failing to achieve remission of depression was associated with increased costs and greater resource utilization. Clinicians should strive to achieve sustained remission in patients with depression. Study limitations included reliance on claims data for initial identification of cohort and high rate of attrition in the analytic sample.