Publications by authors named "Rob H S van den Brink"

25 Publications

  • Page 1 of 1

A prospective study into change of vitamin D levels, depression and frailty among depressed older persons.

Int J Geriatr Psychiatry 2021 07 25;36(7):1029-1036. Epub 2021 Feb 25.

Department of Psychiatry, University Centre of Psychiatry, University Medical Centre Groningen, Groningen, The Netherlands.

Objectives: While vitamin D is involved in frailty as well as depression, hardly any study has examined the course of vitamin D levels prospectively. The objective of this study is to examine whether a change of vitamin D in depressed older adults is associated with either depression course, course of frailty, or both.

Methods: The study population consisted of 232 of 378 older adults (60-93 years) with a DSM-IV defined depressive disorder participating in the Netherlands Study of Depression in Older persons, a prospective clinical cohort study. Baseline and 2-year follow-up data on depressive disorder (DSM-IV diagnosis), symptom severity (inventory of depressive symptoms), frailty phenotype (and its individual components) and vitamin D levels were obtained. Linear mixed models were used to study the association of change in vitamin D levels with depression course, course of frailty, and the combination.

Results: Vitamin D levels decreased from baseline to follow-up, independent from depression course. An increase in frailty was associated with a significantly sharper decrease of vitamin D levels over time. Post hoc analyses showed that this association with frailty might be driven by an increase of exhaustion over time and counteracted by an increase in walking speed.

Conclusions: Our findings generate the hypothesis that vitamin D supplementation in late-life depression may improve frailty, which may partly explain inconsistent findings of randomised controlled trials evaluating the effect of vitamin D for depression. We advocate to consider frailty (components) as an outcome in future supplementation trials in late-life depression.
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http://dx.doi.org/10.1002/gps.5507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248246PMC
July 2021

Clinical characteristics of late-life depression predicting mortality.

Aging Ment Health 2021 03 13;25(3):476-483. Epub 2019 Dec 13.

Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.

Objective: Depression has been associated with increased mortality rates, and modifying mechanisms have not yet been elucidated. We examined whether specific subtypes or characteristics of late-life depression predict mortality.

Methods: A cohort study including 378 depressed older patients according to DSM-IV criteria and 132 never depressed comparisons. The predictive value of depression subtypes and characteristics on the six-year mortality rate, as well as their interaction with somatic disease burden and antidepressant drug use, were studied by Cox proportional hazard analysis adjusted for demographic and lifestyle characteristics.

Results: Depressed persons had a higher mortality risk than non-depressed comparisons (HR = 2.95 [95% CI: 1.41-6.16], = .004), which lost significance after adjustment for age, sex, education, smoking, alcohol, physical activity, number of prescribed medications and somatic comorbidity. Regarding depression subtypes and characteristics, only minor depression was associated with a higher mortality risk when adjusted for confounders (HR = 6.59 [95% CI: 1.79-24.2], = .005).

Conclusions: Increased mortality rates of depressed older persons seem best explained by unhealthy lifestyle characteristics and multiple drug prescriptions. The high mortality rate in minor depression, independent of these factors, might point to another, yet unknown, pathway towards mortality for this depression subtype. An explanation might be that minor depression in later life reflects depressive symptoms due to underlying aging-related processes, such as inflammation-based sickness behavior, frailty, and mild cognitive impairment, which have all been associated with increased mortality.
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http://dx.doi.org/10.1080/13607863.2019.1699900DOI Listing
March 2021

Measuring social support in psychiatric patients and controls: Validation and reliability of the shortened Close Persons Questionnaire.

J Psychiatr Res 2019 09 12;116:118-125. Epub 2019 Jun 12.

University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, the Netherlands.

Although previous studies have underlined the protective role of social support for physical and psychological health, no self-report questionnaires are validated for measuring social support in large-scale psychiatric epidemiological studies. In the current study, we aim to validate the shortened version of the Close Persons Questionnaire (CPQ), a self-report questionnaire that is administered twice to measure social support received from the partner (CPQ-p) as well as from a close friend/family member (CPQ-f). Data of psychiatric patients (n = 1891) and controls (n = 1872) from three Dutch epidemiological studies that assessed determinants of psychopathology were used to validate the shortened CPQ. This included determining factor structure and reliability for the different scales. Using multigroup confirmatory factor analyses, a four-factor model proved to be the best fitting model for both the CPQ-p and CPQ-f. The resulting subscales -emotional support, practical support, negative support experiences, inadequacy of support-showed moderate to good reliability for both the CPQ-p and the CPQ-f, and were all correlated with other social measures in the expected directions. The shortened version of the CPQ proves to be a valid and reliable measure of social support for both psychiatric patients and controls. Further research is needed to assess usability of the shortened version of the CPQ for clinical practice.
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http://dx.doi.org/10.1016/j.jpsychires.2019.06.006DOI Listing
September 2019

Study design of the Routine Outcome Monitoring for Geriatric Psychiatry & Science (ROM-GPS) project; a cohort study of older patients with affective disorders referred for specialised geriatric mental health care.

BMC Psychiatry 2019 06 17;19(1):182. Epub 2019 Jun 17.

University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

Background: Affective disorders, encompassing depressive-, anxiety-, and somatic symptom disorders, are the most prevalent mental disorders in later life. Treatment protocols and guidelines largely rely on evidence from RCTs conducted in younger age samples and ignore comorbidity between these disorders. Moreover, studies in geriatric psychiatry are often limited to the "younger old" and rarely include the most frail. Therefore, the effectiveness of treatment in routine clinical care for older patients and impact of ageing characteristics is largely unknown.

Objective: The primary aim of the Routine Outcome Monitoring for Geriatric Psychiatry & Science (ROM-GPS) - project is to examine the impact of ageing characteristics on the effectiveness of treatment for affective disorders in specialised geriatric mental health care.

Methods: ROM-GPS is a two-stage, multicentre project. In stage one, all patients aged ≥60 years referred to participating outpatient clinics for specialised geriatric mental health care will be routinely screened with a semi-structured psychiatric interview, the Mini International Neuropsychiatric Interview and self-report symptom severity scales assessing depression, generalized anxiety, hypochondria, and alcohol use. Patients with a unipolar depressive, anxiety or somatic symptom disorder will be asked informed consent to participate in a second (research) stage to be extensively phenotyped at baseline and closely monitored during their first year of treatment with remission at one-year follow-up as the primary outcome parameter. In addition to a large test battery of potential confounders, specific attention is paid to cognitive functioning (including computerized tests with the Cogstate test battery as well as paper and pencil tests) and physical functioning (including multimorbidity, polypharmacy, and different frailty indicators). The study is designed as an ongoing project, enabling minor adaptations once a year (change of instruments).

Discussion: Although effectiveness studies using observational data can easily be biased, potential selection bias can be quantified and potentially corrected (e.g. by propensity scoring). Knowledge of age-related determinants of treatment effectiveness, may stimulate the development of new interventions. Moreover, studying late-life depressive, anxiety and somatic symptom disorders jointly enables data-driven studies for more optimal classification of these disorders in later life.

Trial Registration: Dutch Trial Register: NL6704 ( www.trialregister.nl ). Retrospectively registered on 2017-12-05.
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http://dx.doi.org/10.1186/s12888-019-2176-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580500PMC
June 2019

A Cross-National Analysis of the Psychometric Properties of the Geriatric Anxiety Inventory.

J Gerontol B Psychol Sci Soc Sci 2020 08;75(7):1475-1483

Mental Health Center GGZ Drenthe, Assen, The Netherlands.

Objectives: Assessing late-life anxiety using an instrument with sound psychometric properties including cross-cultural invariance is essential for cross-national aging research and clinical assessment. To date, no cross-national research studies have examined the psychometric properties of the frequently used Geriatric Anxiety Inventory (GAI) in depth.

Method: Using data from 3,731 older adults from 10 national samples (Australia, Brazil, Canada, The Netherlands, Norway, Portugal, Spain, Singapore, Thailand, and United States), this study used bifactor modeling to analyze the dimensionality of the GAI. We evaluated the "fitness" of individual items based on the explained common variance for each item across all nations. In addition, a multigroup confirmatory factor analysis was applied, testing for measurement invariance across the samples.

Results: Across samples, the presence of a strong G factor provides support that a general factor is of primary importance, rather than subfactors. That is, the data support a primarily unidimensional representation of the GAI, still acknowledging the presence of multidimensional factors. A GAI score in one of the countries would be directly comparable to a GAI score in any of the other countries tested, perhaps with the exception of Singapore.

Discussion: Although several items demonstrated relatively weak common variance with the general factor, the unidimensional structure remained strong even with these items retained. Thus, it is recommended that the GAI be administered using all items.
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http://dx.doi.org/10.1093/geronb/gbz002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424278PMC
August 2020

Vitamin D deficiency and course of frailty in a depressed older population.

Aging Ment Health 2020 01 15;24(1):49-55. Epub 2018 Nov 15.

University Centre of Psychiatry, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.

To study the association between vitamin D levels and frailty, its components and course in a depressed sample. Baseline and two-year follow-up data from the depressed sample of the Netherlands Study of Depression in Older persons (NESDO), a prospective observational cohort study, were analyzed. The 378 participants (aged 60-93) had a diagnosis of depression according to DSM-IV criteria. Frailty was defined according to Fried's physical phenotype. 25-OH vitamin D measurement was performed by liquid chromatography - tandem mass spectrometry. Linear and logistic regression analyses were performed, adjusted for covariates. Higher vitamin D levels were cross-sectionally associated with lower prevalence of frailty (OR 0.64 [95%-CI 0.45 - 0.90], = .010), predicted a lower incidence of frailty among non-frail depressed patients (OR 0.51 [95%-CI 0.26 - 1.00], =.050), and, surprisingly, the persistence of frailty among frail depressed patients (OR 2.82 [95%-CI 1.23 - 6.49], =.015). In a depressed population, higher vitamin D levels were associated with lower prevalence and incidence of frailty. Future studies should examine whether the favorable effect of low vitamin D levels on the course of frailty can be explained by confounding or whether unknown pathophysiological mechanisms may exert protective effects.
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http://dx.doi.org/10.1080/13607863.2018.1515885DOI Listing
January 2020

Vitamin D deficiency, depression course and mortality: Longitudinal results from the Netherlands Study on Depression in Older persons (NESDO).

J Psychosom Res 2016 Apr 10;83:50-6. Epub 2016 Mar 10.

University Medical Center Groningen, University Center of Psychiatry, University of Groningen, Groningen, The Netherlands.

Objective: To study the effect of vitamin D levels on depression course and remission status after two years, as well as attrition and mortality, in an older cohort.

Methods: This study was part of the Netherlands Study on Depression in Older persons (NESDO), a prospective cohort study. 367 depressed older persons (≥ 60 years) were included. Baseline vitamin D status, reasons for loss to follow up, clinical depression diagnosis at two-year follow up, and six-monthly symptom scores were obtained. Data were analyzed by logistic regression and random coefficient models and adjusted for confounders of vitamin D status.

Results: Vitamin D had no effect on the course of depression or remission, except for a trend towards lower remission rates in the severely deficient subgroup (25-(OH) vitamin D<25 nmol/l). Patients who died during follow up had significantly lower 25-(OH) vitamin D and 1,25-(OH)2 vitamin D levels than patients with continued participation.

Conclusions: For the total sample we found no effect of vitamin D levels on the course of depression or remission rates. However, we did find an effect of lower vitamin D levels on mortality. This strengthens the interpretation of vitamin D deficiency being a marker for poor somatic health status. The trend towards lower remission rates in the severely deficient subgroup raises the question whether this group could benefit from supplementation. Randomized controlled trials are necessary to study this.
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http://dx.doi.org/10.1016/j.jpsychores.2016.03.004DOI Listing
April 2016

Risk assessment by client and case manager for shared decision making in outpatient forensic psychiatry.

BMC Psychiatry 2015 May 27;15:120. Epub 2015 May 27.

Department of Psychiatry, University of Groningen, University Medical Center Groningen, CC73, PO Box 30.001, 9700 RB, Groningen, The Netherlands.

Background: In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client's appreciation of his own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning.

Methods: In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied.

Results: Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring -0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager's structured professional risk estimate for violence in combination with the client's self-appraisal on key risk and protective factors (AUC = 0.70; 95%CI: 0.60-0.80).

Conclusions: In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry.
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http://dx.doi.org/10.1186/s12888-015-0500-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443540PMC
May 2015

Predictive validity of the Short-Term Assessment of Risk and Treatability for violent behavior in outpatient forensic psychiatric patients.

Psychol Assess 2015 Jun 15;27(2):377-91. Epub 2014 Dec 15.

University Center for Psychiatry.

It remains unclear whether prediction of violence based on historical factors can be improved by adding dynamic risks, protective strengths, selection of person-specific key strengths or critical vulnerabilities, and structured professional judgment (SPJ). We examine this in outpatient forensic psychiatry with the Short-Term Assessment of Risk and Treatability (START) at 3 and 6 months follow-up. An incident occurred during 33 (13%) out of 252 3-month and 44 (21%) out of 211 6-month follow-up periods (n = 188 unique clients). Pearson correlations for all predictor variables were in the expected directions. Prediction of recidivism based on historical factor ratings (odds ratio [OR] = 1.10) could not be improved through the addition of dynamic risk, protective strength, or key or critical factor scores (all ORs ns). The addition of the SPJ improved the model to modest accuracy (area under the curve [AUC] = .64) but made no independent significant contribution (OR = 1.55, p = .21) for the 3-month follow-up. For the 6-month follow-up, SPJ scores also increased predictive accuracy to modest (AUC = .67) and made a significant independent contribution to the prediction of the outcome (OR = 1.98, p = .04). Multicollinearity limits were unviolated. Limitations apply, however, results are similar to those from clinical, researcher rated samples and are discussed in the light of setting specific characteristics. Although it is too early to advocate implementing risk assessment instruments in clinical practice, we can conclude that clinicians in a heterogeneous outpatient forensic psychiatric setting can achieve similar results with the START as clinicians and research staff in more homogeneous inpatient settings.
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http://dx.doi.org/10.1037/a0038270DOI Listing
June 2015

Association between metabolic syndrome and depressive symptom profiles--sex-specific?

J Affect Disord 2013 Dec 23;151(3):1138-42. Epub 2013 Aug 23.

Pro Persona, Department of Old Age Psychiatry, Wolfheze/Arnhem, The Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. Electronic address:

Background: The association between depression and metabolic syndrome is becoming more obvious. Waist circumference (WC) might be the most important metabolic syndrome (MetS) feature in relation to late-life depression, with a possible mediating role for adiponectin.

Methods: Cross-sectional population based survey of 1277 participants (50-70 years). We measured all components of MetS, plasma adiponectin levels and depressive symptoms using Beck Depression Inventory (BDI). Principal components analysis on the BDI items revealed two factors, representing a cognitive-affective and a somatic-affective symptom-cluster. Multiple linear regression models with the BDI sum score and both depression symptom-clusters as dependent variables, respectively, were used to examine the association with each component of metabolic syndrome adjusted for confounders. We explored sex-differences as well as a hypothesised mediating effect of adiponectin.

Results: The presence of MetS as well as number of metabolic risk factors were significantly associated with BDI sum score. In men WC, triglycerides and HDL cholesterol explained variance in depressive symptoms, whereas in women this effect was confined to WC. Moreover, irrespective of sex, all associations were primarily driven by the somatic-affective symptom-cluster. Adiponectin neither mediated nor moderated any of the associations found.

Limitations: Cross-sectional design limits causal interpretation. Being a population-based survey, some selection bias might have occurred toward healthier part of population.

Conclusions: Although pathophysiological mechanisms underlying the association between metabolic disturbances and depression remains to be elucidated, our study points to sex-differences as well as a specific phenotype of depression that is associated with metabolic disturbances.
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http://dx.doi.org/10.1016/j.jad.2013.07.029DOI Listing
December 2013

Role of the police in linking individuals experiencing mental health crises with mental health services.

BMC Psychiatry 2012 Oct 17;12:171. Epub 2012 Oct 17.

Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Background: The police are considered frontline professionals in managing individuals experiencing mental health crises. This study examines the extent to which these individuals are disconnected from mental health services, and whether the police response has an influence on re-establishing contact.

Methods: Police records were searched for calls regarding individuals with acute mental health needs and police handling of these calls. Mental healthcare contact data were retrieved from a Psychiatric Case Register.

Results: The police were called upon for mental health crisis situations 492 times within the study year, involving 336 individuals (i.e. 1.7 per 1000 inhabitants per year). Half of these individuals (N=162) were disengaged from mental health services, lacking regular care contact in the year prior to the crisis (apart from contact for crisis intervention). In the month following the crisis, 21% of those who were previously disengaged from services had regular care contact, and this was more frequent (49%) if the police had contacted the mental health services during the crisis. The influence of police referral to the services was still present the following year. However, for the majority (58%) of disengaged individuals police did not contact the mental health services at the time of crisis.

Conclusions: The police deal with a substantial number of individuals experiencing a mental health crisis, half of whom are out of contact with mental health services, and police play an important role in linking these individuals to services. Training police officers to recognise and handle mental health crises, and implementing practical models of cooperation between the police and mental health services in dealing with such crises may further improve police referral of individuals disengaged from mental health services.
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http://dx.doi.org/10.1186/1471-244X-12-171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511214PMC
October 2012

Routine violence risk assessment in community forensic mental healthcare.

Behav Sci Law 2010 May-Jun;28(3):396-410

Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands.

We developed a method for periodic monitoring of violence risk, as part of routine community forensic mental healthcare. The feasibility of the method was tested, as well as its predictive validity for violent and risk enhancing behavior in the subsequent months. Participants were 83 clients who received forensic psychiatric home treatment, and six case managers. The method proved feasible and informative. Violent and risk enhancing behavior could be predicted to a reasonable extent (AUC = .77, 95% CI = .70-.85; respectively .76, .70-.82). Dynamic risk factors had an incremental predictive value over static factors in the prediction of violent behavior (OR = 4.30, 1.72-10.73). The professional judgment of the case managers added further predictive power (OR = 2.16, 1.40-3.33), corroborating the structured professional judgment approach. Finally, unmet needs for care of the client were associated with a reduced risk for violent and risk enhancing behavior (OR = .80, 0.69-0.93, and 0.84, 0.72-0.97). This latter finding suggests that in cases with unmet needs the case manager saw opportunities to do something about the risk. Currently we are testing whether using the method actually prevents violence.
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http://dx.doi.org/10.1002/bsl.904DOI Listing
September 2010

Only incident depressive episodes after myocardial infarction are associated with new cardiovascular events.

J Am Coll Cardiol 2006 Dec 9;48(11):2204-8. Epub 2006 Nov 9.

Department of Psychiatry, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.

Objectives: The purpose of this research was to study whether incident and non-incident depression after myocardial infarction (MI) are differentially associated with prospective fatal and non-fatal cardiovascular events.

Background: Post-MI depression is defined as the presence of depression after MI. However, only about one-half of post-MI depressions represent an incident episode, whereas the other half are ongoing or recurrent depressions. We investigated whether these subtypes differ in cardiovascular prognosis.

Methods: A total of 468 MI patients were assessed for the presence of an International Classification of Diseases-10 depressive disorder during the year after index MI. A comparison was made on new cardiovascular events (mean follow up: 2.5 years) between patients with no, incident, and non-incident post-MI depression by survival analysis.

Results: Compared with non-depressed patients, those with an incident depression had an increased risk of cardiovascular events (hazard ratio [HR] 1.65; 95% confidence interval [CI] 1.02 to 2.65), but not those with a non-incident depression (HR 1.12; 95% CI 0.61 to 2.06), which remained after controlling for confounders (HR 1.76; 95% CI 1.06 to 2.93 and HR 1.39; 95% CI 0.74 to 2.61, respectively).

Conclusions: Only patients with incident post-MI depression have an impaired cardiovascular prognosis. A more detailed subtyping of post-MI depression is needed, based on an integration of recent findings on the differential impact of depression symptom profiles and personality on cardiac outcomes.
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http://dx.doi.org/10.1016/j.jacc.2006.06.077DOI Listing
December 2006

Decreased impact of post-myocardial infarction depression on cardiac prognosis?

J Psychosom Res 2006 Oct;61(4):493-9

Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Objective: A recent meta-analysis suggests that the impact of post-myocardial infarction (MI) depression on cardiac prognosis has decreased over the last decade. We tested whether depression still significantly affects prognosis in the present health care situation.

Methods: Four hundred ninety-four MI patients were screened for depression. Patients with depression were compared with patients without on cardiovascular events (fatal or nonfatal) during an average follow-up of 2.5 years. Demographic characteristics and cardiac risk factors were controlled for.

Results: We found that depression was associated with the occurrence of cardiovascular events in both univariate [hazard ratio (HR), 1.84; 95% confidence interval, 1.24-2.72] and multivariate analysis (HR, 1.56; 1.02-2.38).

Conclusions: Depression still has an independent impact on cardiac prognosis after MI, but this influence is smaller than found in early studies. Improvements in general care for MI and better recognition and treatment of post-MI depression may have decreased the impact of depression on prognosis.
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http://dx.doi.org/10.1016/j.jpsychores.2006.02.016DOI Listing
October 2006

Course of depressive symptoms after myocardial infarction and cardiac prognosis: a latent class analysis.

Psychosom Med 2006 Sep-Oct;68(5):662-8. Epub 2006 Sep 20.

Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands.

Objective: The presence of depressive symptoms after myocardial infarction (MI) is a risk factor for new cardiovascular events. The importance of the course of post-MI depressive symptoms for cardiac prognosis is not clear. We therefore set out to investigate whether different courses of post-MI depressive symptoms can be identified and determine their associations with cardiac events.

Methods: Data were derived from the Depression after Myocardial Infarction (DepreMI) study, a naturalistic follow-up study of patients admitted for an MI in four hospitals in The Netherlands (N = 475). Scores on the Beck Depression Inventory (BDI) during hospitalization and at 3, 6, and 12 months post-MI were analyzed. Using latent class analysis (LCA), we identified classes characterized by distinctive courses of depressive symptoms and then examined their link to cardiac prognosis.

Results: The prevalence of significant depressive symptoms ranged from 22.7% to 25.5% throughout the post-MI year. Five distinct courses were found: no depressive symptoms (56.4%), mild depressive symptoms (25.7%), moderate and increasing depressive symptoms (9.3%), significant but decreasing depressive symptoms (4.6%), and significant and increasing depressive symptoms (4.0%). Subjects in this last class had, statistically, a significantly higher risk for a new cardiovascular event compared with subjects without depressive symptoms (hazard ratio (HR) = 2.73; p = .01). Controlling for baseline cardiac status and sociodemographic data did not alter the association (HR = 2.46; p = .03).

Conclusions: Post-MI depressed subjects with significant and increasing depressive symptoms are at particular risk of new cardiac events. This subgroup may be most suited for evaluation of the effects of antidepressant treatment on cardiac prognosis.
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http://dx.doi.org/10.1097/01.psy.0000233237.79085.57DOI Listing
November 2006

Symptom dimensions of depression following myocardial infarction and their relationship with somatic health status and cardiovascular prognosis.

Am J Psychiatry 2006 Jan;163(1):138-44

University of Groningen Department of Psychiatry, the Netherlands.

Objective: The reporting of depressive symptoms following myocardial infarction may be confounded by complaints originating from the myocardial infarction. Therefore, it is difficult to estimate the effects of post-myocardial infarction depression and its treatment on cardiovascular prognosis. The authors' goal was to study the relationship between depressive symptom dimensions following myocardial infarction and both somatic health status and prospective cardiovascular prognosis.

Method: In two studies of myocardial infarction patients (N=494 and 1,972), the Beck Depression Inventory was used to determine the dimensional structure of depressive symptoms following myocardial infarction. Three symptom dimensions-somatic/affective, cognitive/affective, and appetitive-were compared with baseline left ventricular ejection fraction, Charlson comorbidity index, Killip class, and previous myocardial infarction. The relationship between depressive symptom dimensions and prospective cardiovascular mortality and cardiac-related readmissions was also examined (mean follow-up duration=2.5 years).

Results: Somatic/affective symptoms were associated with poor health status (left ventricular ejection fraction, Charlson comorbidity index, Killip class, and previous myocardial infarction) and predicted cardiovascular mortality and cardiac events. Cognitive/affective symptoms were only marginally associated with somatic health status and not with cardiovascular death and cardiac events. Appetitive symptoms were related to somatic health status but did not predict cardiovascular death or cardiac events.

Conclusions: Somatic/affective depressive symptoms following myocardial infarction were confounded by somatic health status yet were prospectively associated with cardiac prognosis even after somatic health status was controlled. Cognitive/affective depressive symptoms were only marginally related to health status and not to cardiac prognosis. These findings suggest that treatment of depression following myocardial infarction might improve cardiovascular prognosis when it reduces somatic/affective symptoms.
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http://dx.doi.org/10.1176/appi.ajp.163.1.138DOI Listing
January 2006

Depression following myocardial infarction: first-ever versus ongoing and recurrent episodes.

Gen Hosp Psychiatry 2005 Nov-Dec;27(6):411-7

Department of Psychiatry, University Hospital Groningen, The Netherlands.

Background: Depression following myocardial infarction (MI) can be a first-ever episode for some, whereas for others, it may represent a recurrent episode or one that was present at the onset of the infarction. We investigated if there are differences in pre- and post-MI characteristics between these subtypes.

Methods: Four hundred sixty-eight patients admitted for an MI were assessed for the presence of an ICD-10 depressive disorder following MI. A comparison was made between first-ever and ongoing or recurrent depression on demographic and cardiac data, personality, and depression characteristics.

Results: Depressive disorder during the first post-MI year was present in 25.4% of the MI patients (n = 119), and almost half were ongoing or recurrent (n = 53, 44.5%). Recurrent and ongoing depression was related to high neuroticism (Z = 2.77, P < .01), whereas first-ever depression was associated with MI severity (poor left ventricular ejection fraction: Z = 1.64, P = .05; PTCA or CABG during hospitalization: Z = 1.88, P = .03; arrhythmic events: Z = 1.49, P = .06).

Conclusions: Our results suggest that in the first-ever post-MI depression cases, depression may be triggered by the severity of the MI, whereas ongoing and recurrent depression is more related to personality. Future research should address the question whether these subtypes of depression differ in cardiovascular prognosis and response to psychiatric treatment.
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http://dx.doi.org/10.1016/j.genhosppsych.2005.05.007DOI Listing
February 2006

The care provided by general practitioners for persistent depression.

Eur Psychiatry 2006 Mar 31;21(2):87-92. Epub 2005 Aug 31.

Mental Health Care Friesland, Leenwarden The Netherlands.

Purpose: To examine the care provided by general practitioners (GPs) for persistent depressive illness and its relationship to patient, illness and consultation characteristics.

Subjects And Method: Using the Composite International Diagnostic Interview-Primary Health Care Version (CIDI-PHC) a sample of 264 patients with ICD-10 depression was identified among consecutive primary care patients in the Netherlands. At 1-year follow-up 78 of these patients (30%) still fulfilled the criteria of an ICD-10 depression and were considered persistent cases. At baseline and follow-up the GPs specified their diagnosis and treatment. The extent of recognition as a mental health problem, accuracy of diagnosis as a depression and treatment in accordance with clinical guidelines for depression was examined. In addition it was examined whether these steps in adequate GP care for persistent depression were related to patient, illness and consultation characteristics.

Results: Twenty percent of the persistent depression cases were not recognized at baseline or during follow-up, 28% was recognized but not accurately diagnosed, 17% was accurately diagnosed, but did not receive adequate treatment and 35% was treated adequately. Recognition was associated with psychological reason for encounter; accurate diagnosis with absence of activity limitation days; and adequate treatment with severity of depression and higher educational level.

Conclusion: Non-recognition, misdiagnosis and inadequate treatment are not limited to patients with a relatively mild and brief depression but are also prominent in patients with a persistent depression, who consulted their GP 8.2 times on average during the year their depression persisted.
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http://dx.doi.org/10.1016/j.eurpsy.2005.05.002DOI Listing
March 2006

Who is at risk of post-MI depressive symptoms?

J Psychosom Res 2005 May;58(5):425-32; discussion 433-4

Department of Psychiatry, University Hospital Groningen, Graduate School of Behavioral and Cognitive Neurosciences, University of Groningen, The Netherlands.

Objective: The aim of this study was to identify cardiologic, psychologic, and demographic risk factors in two groups of patients with post-myocardial infarction (MI) depressive symptoms (in-hospital and during the postdischarge year).

Methods: Patients admitted for MI were assessed for depressive symptoms with the Beck Depression Inventory (BDI) during hospitalization and 3, 6, and 12 months post-MI. We contrasted both groups with nondepressed patients.

Results: Pre-MI vital exhaustion, living alone, history of depressive disorder, history of MI, poor performance on exercise tolerance testing, and female gender were significantly and independently associated with in-hospital depressive symptoms. Pre-MI vital exhaustion, history of depressive disorder, female gender, poor ejection fraction, and longer hospital stay were independent predictors of the development of postdischarge depressive symptoms.

Conclusions: Post-MI depressive symptoms seem largely driven by the psychological and social consequences of the MI in patients vulnerable to depression, as indexed by a history of depression and vital exhaustion.
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http://dx.doi.org/10.1016/j.jpsychores.2005.02.005DOI Listing
May 2005

Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment.

J Affect Disord 2005 Jan;84(1):43-51

Department of Psychiatry and Graduate School of Behavioral and Cognitive Neuroscience's, University of Groningen, The Netherlands.

Background: Although good physician communication is associated with positive patient outcomes, it does not figure in current depression treatment guidelines. We examined the effect of depression treatment, communicative skills and their interaction on patient outcomes for depression in primary care.

Methods: In a cohort of 348 patients with ICD-10 depression in primary care, patient outcomes were studied over 3- and 12-month follow-ups. The association of these outcomes with both depression-specific process of care variables and a nonspecific variable-communicative skillfulness of GP-was examined. Patient outcomes consisted of change from baseline in symptomatology, disability, activity limitation days, and duration of the depressive episode.

Results: In accordance with treatment guidelines, some main effects of depression treatment were found, in particular on symptomatology, but these remained small (effect size<0.50). A moderate effect was found for treatment with a sedative, which proved to be related to worse patient outcomes at 12 months. An accurate GP diagnosis of depression and adequate antidepressant treatment were associated with better patient outcomes, but only when provided by GPs with good communicative skills. In contrast to the main effects, these interactions were seen on disability and activity limitation days, not on symptomatology.

Limitations: The study is observational and does not permit firm conclusions about causal relationships. Communicative skillfulness of the GP was assessed by patient report only.

Conclusion: Neither depression-specific interventions nor good GP communication skills seem to be sufficient for optimal patient improvement. Only the combination of treatments according to guidelines and good communication skills results in an effective antidepressive treatment.
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http://dx.doi.org/10.1016/j.jad.2004.09.005DOI Listing
January 2005

Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis.

Psychosom Med 2004 Nov-Dec;66(6):814-22

Department of Cardiology, Thoraxcenter, University Hospital Groningen, P.O. Box 30.001, 9700 RB, The Netherlands.

Objective: To assess the association of depression following myocardial infarction (MI) and cardiovascular prognosis.

Methods: The authors performed a meta-analysis of references derived from MEDLINE, EMBASE, and PSYCINFO (1975-2003) combined with crossreferencing without language restrictions. The authors selected prospective studies that determined the association of depression with the cardiovascular outcome of MI patients, defined as mortality and cardiovascular events within 2 years from index MI. Depression had to be assessed within 3 months after MI using established psychiatric instruments. A quality assessment was performed.

Results: Twenty-two papers met the selection criteria. These studies described follow up (on average, 13.7 months) of 6367 MI patients (16 cohorts). Post-MI depression was significantly associated with all-cause mortality (odds ratio [OR], fixed 2.38; 95% confidence interval [CI], 1.76-3.22; p <.00001) and cardiac mortality (OR fixed, 2.59; 95% CI, 1.77-3.77; p <.00001). Depressive MI patients were also at risk for new cardiovascular events (OR random, 1.95; 95% CI, 1.33-2.85; p = .0006). Secondary analyses showed no significant effects of follow-up duration (0-6 months or longer) or assessment of depression (self-report questionnaire vs. interview). However, the year of data collection (before or after 1992) tended to influence the effect of depression on mortality (p = .08), with stronger associations found in the earlier studies (OR, 3.22; 95% CI, 2.14-4.86) compared with the later studies (OR, 2.01; 95% CI, 1.45-2.78).

Conclusions: Post-MI depression is associated with a 2- to 2.5-fold increased risk of impaired cardiovascular outcome. The association of depression with cardiac mortality or all-cause mortality was more pronounced in the older studies (OR, 3.22 before 1992) than in the more recent studies (OR, 2.01 after 1992).
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http://dx.doi.org/10.1097/01.psy.0000146294.82810.9cDOI Listing
August 2005

Are effects of depression management training for General Practitioners on patient outcomes mediated by improvements in the process of care?

J Affect Disord 2004 Jun;80(2-3):173-9

Department of Psychiatry and Graduate School of Behavioural and Cognitive Neurosciences, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.

Background: Depression treatment by General Practitioners (GPs) and patient outcomes improved significantly after a comprehensive 20-h training program of GPs. This study examines whether the effects on patient outcomes are caused by the improvements in the process of care.

Methods: Seventeen GPs participated in the training program. A pre-test-post-test design was used. A total of 174 patients (85 pre-test, 89 post-test) aged 18-65 met ICD-10 criteria for recent onset major depression. The main indicator of mediation was a drop in training effect size (eta2) on patient outcome after adjustment for individual and combined process of care variables. We evaluated depression-specific (recognition, accurate diagnosis, prescription of antidepressant, adequate antidepressant treatment) and a non-specific process of care variable (communicative skillfulness of the GP) as well as the combination of adequate antidepressant treatment and communicative skillfulness. Patient outcomes were assessed at 3 months and consisted of change in severity of symptomatology, level of daily functioning and activity limitation days from baseline.

Results: Depression-specific interventions mediated up to one third of the observed improvement in patient outcome. 'Adequate dosage and duration of an antidepressant' explained 36% of the training effect on patient outcome (eta2 from 0.044 to 0.028). 'Communicative skillfulness of the GP' only was a weak mediator (18% explained; eta2 from 0.044 to 0.036). However, the combination of both, that is adequate antidepressant treatment by a communicative skillful GP, proved to be the strongest mediator of the observed training effect on patient outcomes (59% explained; eta2 from 0.044 to 0.018).

Limitations: The training effects on patient outcomes in this sample were small. Hence, the scope for mediation was limited.

Conclusion: GP communication skills are important to enhance depression-specific interventions in bringing about improvements in patient outcomes and should be addressed in GP training programs for the treatment of depression.
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http://dx.doi.org/10.1016/S0165-0327(03)00074-0DOI Listing
June 2004

Treatment of depression after myocardial infarction and the effects on cardiac prognosis and quality of life: rationale and outline of the Myocardial INfarction and Depression-Intervention Trial (MIND-IT).

Am Heart J 2002 Aug;144(2):219-25

Department of Psychiatry, Graduate School of Behavioral and Cognitive Neurosciences, University Hospital Groningen, Groningen, The Netherlands.

Background: Patients with a depressive disorder after myocardial infarction (MI) have a significantly increased risk of major cardiac events. The Myocardial INfarction and Depression-Intervention Trial (MIND-IT) investigates whether antidepressive treatment can improve the cardiac prognosis for these patients. The rationale and outline of the study are described.

Methods: In this multicenter randomized clinical trial, 2140 patients admitted for MI are screened for depressive symptoms with a questionnaire 0, 3, 6, 9, and 12 months after MI. Patients with symptoms undergo a standardized psychiatric interview. Those with a post-MI depressive episode are randomized to intervention (ie, antidepressive treatment; n = 190) or care-as-usual (CAU; n = 130). In the intervention arm, the research diagnosis is to be confirmed by a psychiatrist. First-choice treatment consists of placebo-controlled treatment with mirtazapine. In case of refusal or nonresponse, alternative open treatment with citalopram is offered. In the CAU arm, the patient is not informed about the research diagnosis. Psychiatric treatment outside the study is recorded, but no treatment is offered. Both arms are followed for end points (cardiac death or hospital admission for MI, unstable angina, heart failure, or ventricular tachyarrhythmia) during an average period of 27 months. Analysis is on an intention-to-treat basis.

Conclusion: The MIND-IT study will show whether treatment of post-MI depression can improve cardiac prognosis.
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August 2002

Predictability of the one-year course of depression and generalized anxiety in primary care.

Gen Hosp Psychiatry 2002 May-Jun;24(3):156-63

Department of Psychiatry, Graduate School of Behavioral and Cognitive Neurosciences and Graduate School of Experimental Psychopathology, University of Groningen, The, Groningen, Netherlands.

Several predictors of the course of depression and generalized anxiety have been identified. Whether these predictors provide a solid basis for primary care physicians (PCPs) to give an accurate prognosis remains unclear. A parallel study showed modest agreement between PCP prognosis and observed course (kappa< or = 0.21). It is the aim of the present study to establish the extent to which the one-year course of depression and generalized anxiety in primary care is in fact predictable. Predictability is operationalized as the combined predictive power of major prognostic factors identified in the literature. We identified 269 cases of ICD-10 depression and 134 of generalized anxiety among consecutive PCP attenders. For these patients a statistical model was built that provided optimal predictions of the one-year course of the disorder, based on the prognostic factors discerned. The predictions were compared with the actual course observed. Reasonable agreement (kappa = 0.37 for depression, kappa = 0.35 for anxiety) and good association (gamma = 0.66 for depression, gamma=0.67 for anxiety) were found between predicted and observed course. Nevertheless, the combined predictive power of the prognostic factors remains limited. A realistic evaluation of the accuracy of the PCP prognosis should take this limited predictability into account.
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http://dx.doi.org/10.1016/s0163-8343(02)00183-4DOI Listing
August 2002
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