Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial

BACKGROUND

Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care.

METHODS

In a cluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) at baseline and after 3, 6, 9 and 12 months.

RESULTS

We recruited 180 patients with a DSM-IV diagnosis of PD or GAD, of whom 114 received CSC and 66 received usual primary care. On the BAI, CSC was superior to CAU [difference in gain scores from baseline to 3 months: -5.11, 95% confidence interval (CI) -8.28 to -1.94; 6 months: -4.65, 95% CI -7.93 to -1.38; 9 months: -5.67, 95% CI -8.97 to -2.36; 12 months: -6.84, 95% CI -10.13 to -3.55].

CONCLUSIONS

CSC, with guided self-help as a first step, was more effective than CAU for primary care patients with PD or GAD.

Cost utility analysis of a collaborative stepped care intervention for panic and generalized anxiety disorders in primary care

OBJECTIVE

Generalized anxiety and panic disorders are a burden on the society because they are costly and have a significant adverse effect on quality of life. The aim of this study was to evaluate the cost-utility of a collaborative stepped care intervention for panic disorder and generalized anxiety disorder in primary care compared to care as usual from a societal perspective.

METHODS

The design of the study was a two armed cluster randomized controlled trial. In total 43 primary care practices in the Netherlands participated in the study. Eventually, 180 patients were included (114 collaborative stepped care, 66 care as usual). Baseline measures and follow-up measures (3, 6, 9 and 12 months) were assessed using questionnaires. We applied the TiC-P, the SF-HQL and the EQ-5D respectively measuring health care utilization, production losses and health related quality of life.

RESULTS

The average annual direct medical costs in the collaborative stepped care group were 1854 Euro (95% C.I., 1726 to 1986) compared to €1503 (95% C.I., 1374 to 1664) in the care as usual group. The average quality of life years (QALYs) gained was 0.05 higher in the collaborative stepped care group, leading to an incremental cost effectiveness ratio (ICER) of 6965 Euro per QALY. Inclusion of the productivity costs, consequently reflecting the full societal costs, decreased the ratio even more.

CONCLUSION

The study showed that collaborative stepped care was a cost effective intervention for panic disorder and generalized anxiety disorder and was even dominant when a societal perspective was taken.

TRIAL REGISTRATION

trialregister.nl, Netherlands Trial Register NTR107.

Interpersonal psychotherapy for elderly patients in primary care

OBJECTIVE

Interpersonal psychotherapy (IPT) is recommended in most depression treatment guidelines, but little is known about its effectiveness in real-life practice. This study investigates whether IPT, delivered by mental health workers to elderly patients with major depressive disorder, is more effective than usual general practitioners' care (CAU).

METHODS

A pragmatic randomized, controlled trial was conducted in which 143 patients were allocated to IPT (10 sessions) or to CAU. PRIMary care Evaluation of Mental Disorders (PRIME-MD) and Montgomery Asberg Depression Rating Scale (MADRS) assessments were used as primary outcomes.

RESULTS

IPT was significantly more effective in reducing the percentage of patients with a diagnosis of depression (PRIME-MD), but not in inducing remission (MADRS <10). Among treatment completers, IPT was superior in improving social and overall mental functioning. A post hoc analysis revealed that IPT was superior to CAU in moderately to severely depressed patients, but not significantly so in mildly depressed patients.

CONCLUSIONS

IPT was more effective than CAU for elderly patients with moderate to severe major depressive disorder in general practice. Future research should focus on determinants of treatment outcome.

Secondary traumatization in partners and parents of Dutch peacekeeping soldiers

This study examines secondary traumatization among 708 partners and 332 parents of Dutch peacekeepers (i.e., personnel who participated in military actions implemented by international organizations such as the United Nations). Partners or parents of peacekeepers with 4 levels of posttraumatic stress symptoms were compared on posttraumatic stress, health problems, the quality of the marital relationship, and social support. In comparison with partners of peacekeepers without posttraumatic stress disorder (PTSD) symptoms, partners of peacekeepers with PTSD symptoms reported more sleeping and somatic problems, reported more negative social support, and judged the marital relationship as less favorable. No significant differences were found for parents. Thus, peacekeepers' stress reactions were related to various problems of their partners. A systemic approach to the treatment of persons with PTSD appears appropriate.

The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial

OBJECTIVES

To examine the effect of integrated emotion-oriented care on nursing home residents with dementia and nursing assistants.

DESIGN

A multi-site randomized clinical trial with matched groups, and measurements at baseline and after seven months.

SETTING

Sixteen psychogeriatric wards in fourteen nursing homes in the Netherlands.

PARTICIPANTS

One hundred and forty-six elderly residents with the diagnosis dementia of the Alzheimer (DAT) type, mixed DAT and vascular dementia, and dementia syndrome (NAO) and 99 nursing assistants.

INTERVENTIONS

Integrated emotion-oriented care and usual care. MESUREMENTS: Demented elderly: Behaviour and mood related to adaptation to the illness and the institutionalization. Nursing assistants: General health as measured by feelings of stress, stress reactions, feeling of competence and illness.

RESULTS

Positive effects in favour of the integrated emotion-oriented care were found in mild to moderately demented residents on two adaptive tasks: maintaining an emotional balance (less anxiety) and preserving a positive self-image (less dissatisfaction). In the trained group of nursing assistants fewer stress reactions were found only in those who perceived improvement in their emotion-oriented care skills after training.

CONCLUSION

Emotion-oriented care is more effective with regard to the emotional adaptation in nursing homes of persons with a mild to moderate dementia. For the severely demented elderly we did not find this surplus value. This outcome is of clinical importance for elderly persons with dementia who are cared for in nursing homes. With respect to the nursing assistants it is concluded that emotion-oriented care has a positive influence on stress reactions in some of them.

The confidence in diabetes self-care scale: psychometric properties of a new measure of diabetes-specific self-efficacy in Dutch and US patients with type 1 diabetes

OBJECTIVE

To examine psychometric properties of the Confidence in Diabetes Self-Care (CIDS) scale, a newly developed instrument assessing diabetes-specific self-efficacy in Dutch and U.S. patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Reliability and validity of the CIDS scale were evaluated in Dutch (n = 151) and U.S. (n = 190) outpatients with type 1 diabetes. In addition to the CIDS scale, assessment included HbA(1c), emotional distress, fear of hypoglycemia, self-esteem, anxiety, depression, and self-care behavior. The Dutch sample completed additional measures on perceived burden and importance of self-care. Test-retest reliability was established in a second Dutch sample (n = 62).

RESULTS

Internal consistency (Cronbach's alpha = 0.86 for Dutch patients and 0.90 U.S. patients) and test-retest reliability (Spearman's r = 0.85, P < 0.0001) of the CIDS scale were high. Exploratory factor analysis showed one strong general factor. Spearman's correlations between the CIDS scale and other measures were moderate and in the expected directions, and high HbA(1c) levels were associated with low CIDS scores in the U.S. sample only. Low CIDS scores were positively associated with self-care but not with glycemic control in the original samples. CIDS scores in the U.S. and Dutch samples did not show any statistically significant differences. U.S. men had higher CIDS scores than U.S. women.

CONCLUSIONS

The CIDS scale is a reliable and valid measure of diabetes-specific self-efficacy for use in patients with type 1 diabetes. High psychometric similarity allows for cross-cultural comparisons.

Visual rating of age-related white matter changes on magnetic resonance imaging: scale comparison, interrater agreement, and correlations with quantitative measurements

BACKGROUND AND PURPOSE

To provide further insight into the MRI assessment of age-related white matter changes (ARWMCs) with visual rating scales, 3 raters with different levels of experience tested the interrater agreement and comparability of 3 widely used rating scales in a cross-sectional and follow-up setting. Furthermore, the correlation between visual ratings and quantitative volumetric measurement was assessed.

METHODS

Three raters from different sites using 3 established rating scales (Manolio, Fazekas and Schmidt, Scheltens) evaluated 74 baseline and follow-up scans from 5 European centers. One investigator also rated baseline scans in a set of 255 participants of the Austrian Stroke Prevention Study (ASPS) and measured the volume of ARWMCs.

RESULTS

The interrater agreement for the baseline investigation was fair to good for all scales (kappa values, 0.59 to 0.78). On the follow-up scans, all 3 raters depicted significant ARWMC progression; however, the direct interrater agreement for this task was poor (kappa, 0.19 to 0.39). Comparison of the interrater reliability between the 3 scales revealed a statistical significant difference between the scale of Manolio and that of Fazekas and Schmidt for the baseline investigation (z value, -2.9676; P=0.003), demonstrating better interrater agreement for the Fazekas and Schmidt scale. The rating results obtained with all 3 scales were highly correlated with each other (Spearman rank correlation, 0.712 to 0.806; P< or =0.01), and there was significant agreement between all 3 visual rating scales and the quantitative volumetric measurement of ARWMC (Kendall W, 0.37, 0.48, and 0.57; P<0.001).

CONCLUSIONS

Our data demonstrate that the 3 rating scales studied reflect the actual volume of ARWMCs well. The 2 scales that provide more detailed information on ARWMCs seemed preferential compared with the 1 that yields more global information. The visual assessment of ARWMC progression remains problematic and may require modifications or extensions of existing rating scales.

Alendronate in the prevention of bone loss after a fracture of the lower leg

Fracture of a leg and the consequent absence from weight-bearing lead to local bone loss. A 1-year, single-center, prospective, randomized, double-blind study was conducted, to determine whether bone loss would occur in the proximal femur and the calcaneus after a fracture of the lower leg and whether this loss could be prevented by the antiresorptive drug bisphosphonate alendronate. Twenty-three men and 18 women with a recent unstable fracture of the lower leg were randomized to receive either 10 mg of alendronate daily or placebo. Bone mineral density (BMD) of both hips and the lumbar spine was measured at baseline and 6 weeks and 3, 6, and 12 months after start of the treatment. Quantitative ultrasound (QUS) measurements of the calcaneus were performed at baseline on the noninjured side and at 6 weeks and 3, 6, and 12 months after start of treatment on both sides. After 1 year, in the placebo group, there was a significant decrease from baseline in BMD of the hip on the side of the fracture. In the alendronate group, there was no significant change from baseline. The differences in BMD between the two treatment groups on the side of the fracture were significant in all sites of the hip: 4.4% (p = 0.016) in the trochanter, 4.6% (p = 0.016) in the femoral neck, and 3.9% (p = 0.009) in the total hip. In the hip on the contralateral side, there were no significant changes from baseline in either treatment group and there was no difference between the two treatment groups. BMD in the lumbar spine increased in the alendronate group, and after 1 year there was a significant difference between the active treatment and placebo group of 3.4% (p = 0.04). One year after fracture, ultrasound parameters of the calcaneus in the placebo group were significantly lower on the fractured side compared with the contralateral side (p < 0.01). In the alendronate group, no significant difference between the two sides was observed. In conclusion, BMD of the proximal femur was still decreased 1 year after a fracture of the lower leg. Alendronate prevented this bone loss.

Mean clinical challenge rate and level of recognition of depression remain unchanged after two years of vocational training

OBJECTIVES

Our aim was to evaluate whether trainees encounter more difficult clinical situations (clinical challenge rate) and more patients with signs of depression in the last year of their training (T(1)) than in the first year (T(0)), and whether depression is recognized by trainees more frequently at T(1) than at T(0).

METHODS

An evaluation was undertaken of videotapes made by a random sample of 48 vocational trainees in general practice. Experienced staff members (GPs) assessed the clinical challenge rate of consultations at the two time points with the reliable and valid Amsterdam Clinical Challenge Scale (ACCS). They also rated the presence of signs of depression in the consultations (yes/no) and whether these were recognized by the trainee (yes/no).

RESULTS

Baseline and follow-up measurements (T(0) and (T(1))) were available for 45 trainees, from the original cohort of 48 at T(0), and for 527 consultations. Both at T(0) and at T(1), the mean ACCS score was 2.3 (T(0) SD = 0.95; n = 269) (T(1) SD = 0.92; n = 258). For each trainee, the mean difference in ACCS score between T(0) and T(1) was 0.01 [95% confidence interval (CI) -0.15 to 0.17]. According to staff-assessments, 66 patients had signs of depression (34 at T(0) and 32 at T(1)). Trainees recognized depression in 12 consultations (12/34 = 35%) at T(0) and in 11 consultations (11/32 = 34%) at T(1) (relative risk 1.0; 95% CI 0.4-2.9).

CONCLUSION

A focus on the challenge level of consultations, an individualized, integrated approach and the introduction of a new final consultation skills examination may be the way forward.

Exploring differences between subgroups of multiple sclerosis patients in health-related quality of life

Health-related quality of life (HRQoL) questionnaires finding increasing use in medicine, but still only few publications have reported on HRQoL in patients with multiple sclerosis (MS). Because of its progressive and disabling nature, the disease has a considerable effect on HRQoL. To facilitate the interpretation of scores for the heterogeneous MS population, we explored differences between subgroups of MS out-patients (n = 90) on two HRQoL instruments: the Medical Outcome Study Short Form-36 and the Disability and Impact Profile. Three disease-related characteristics were studied: severity of MS, time since diagnosis, and MS progression in the past 6 months. The results show that each of these have an effect on one or more aspects of HRQoL. Thus, the longer the disease duration and the more severe and progressive the MS, the lower is the patient's experienced HRQoL.

Sagittal MR of multiple sclerosis in the spinal cord: fast versus conventional spin-echo imaging

PURPOSE

We compared conventional spin-echo (CSE) with fast spin-echo (FSE) dual-echo MR images to determine which of these sequences was better able to depict spinal cord abnormalities in patients with multiple sclerosis (MS).

METHODS

CSE and FSE dual-echo MR images were obtained in 37 patients with MS and in six healthy control subjects, all of whom were examined on a 1.0-T MR unit with a phased-array coil and cardiac triggering. Two blinded interpreters graded the MR studies, first separately and then by consensus. Images were scored for presence of artifacts, number of focal lesions, and presence of a diffuse increase in signal intensity.

RESULTS

No abnormalities were seen in the volunteers. The CSE sequences were significantly less hindered by MR imaging artifacts than were the FSE sequences. Interobserver agreement was slightly higher for the CSE than the FSE sequences. After reaching a consensus, the observers found that both CSE and FSE techniques enabled detection of approximately the same number of focal lesions; however, in three patients, small single lesions seen on the CSE images were missed on the FSE images. Also, depiction of a diffuse increase in signal intensity was better on the CSE images. As a result, more patients had abnormal findings on the CSE sequences than on the FSE sequences (35 versus 31).

CONCLUSION

Cardiac-triggered dual-echo FSE sequences are almost as good as CSE sequences for depicting spinal MS lesions. Therefore, in cases of established spinal MS, FSE techniques may be as effective as CSE techniques. Because sensitivity for subtle abnormalities is lower with FSE imaging, CSE remains the preferred technique for patients with suspected MS of the spinal cord.

MR of the spinal cord in multiple sclerosis: relation to clinical subtype and disability

PURPOSE

To determine whether the MR appearance of the spinal cord in patients with multiple sclerosis (MS) differs according to clinical subtype.

METHODS

The spinal cords of 20 healthy control subjects and 60 patients with MS (22 with relapsing-remitting disease, 22 with secondary-progressive disease, and 16 with primary-progressive disease) were examined with sagittal dual-echo spin-echo MR imaging and with axial T2*-weighted gradient-echo MR imaging. Two interpreters scored the images for focal lesions and for diffuse abnormalities. Cross-sectional areas of the cords were measured at the C-2 level.

RESULTS

No abnormalities were found in any of the control subjects nor in two of the patients. Fifty (83%) of 60 patients had focal lesions. Diffuse abnormality and focal lesions were found in 50% of patients with secondary-progressive MS, in 25% of patients with primary-progressive disease, and in 18% of patients with relapsing-remitting disease. Diffuse abnormality without focal lesions was found in seven patients with primary-progressive MS and in one patient with secondary-progressive MS. Patients with diffuse abnormalities had a smaller cross-sectional area of the spinal cord and they suffered from more disability than did patients without diffuse abnormalities.

CONCLUSION

The MR appearance of the spinal cord differs among clinical subgroups of MS. Diffuse abnormality of the spinal cord is associated with a progressive clinical course and greater disability.