Background Patients who consult their GP about psychological complaints, such as feeling anxious or depressed, are often initially given a psychological symptom diagnosis. However, it remains unclear whether these symptoms will develop into psychiatric conditions, which is crucial for informing patients about their prognosis and guiding GPs in their management. Aims To explore the course of psychological symptom diagnoses and compare GPs' management strategies for (a) psychological symptom diagnoses that persisted for more than a year and (b) those that changed into psychiatric conditions during the first year of care. Methods We performed a retrospective cohort study using the Family-Medicine Network database. We included all episodes of care (EoC) that started with a psychological symptom diagnosis between 2008 and 2021. We performed negative binomial analyses and logistic regression analyses to compare management strategies and number of contacts between EoC that changed into psychiatric conditions and persistent psychological symptoms (>1 year) during the first year of care. Results Out of the 14 633 EoC that started with a psychological symptom diagnosis, 79.4% resolved within 1 year, 12.8% persisted as psychological symptoms and 7.8% changed into psychiatric conditions. In EoC that changed into psychiatric conditions, as compared with EoC that persisted as psychological symptoms, we observed a significantly higher number of contacts with the GP (RR=1.76, 95% CI 1.63 to 1.91) as well as an increased total number of interventions (RR=1.71, 95% CI 1.58 to 1.84). Conclusion Most psychological symptoms remain for only a short period of time and only a few persist or change into psychiatric conditions. Future research should investigate the factors that influence patients' decisions to seek further help from their GPs as well as those that contribute to the transition from psychological symptom diagnoses to a psychiatric condition.

BACKGROUND:Behavioural activation reduces depressive symptoms in older adults but its working mechanisms remain unknown. Physical activity may play a role by decreasing depressive symptoms in older adults. We investigated whether an increase in physical activity explains the effects of behavioural activation on depressive symptoms in older adults. METHODS:Participants were 44 adults aged 65-88 years, who participated in a cluster randomised trial evaluating the effectiveness of an eight-week behavioural activation treatment (n = 25) compared with eight weeks of treatment as usual (TAU; n = 19) in primary care. Mediation analysis was used to evaluate whether the effects of behavioural activation on depression were mediated by physical activity as assessed by trunk accelerometer. RESULTS:Physical activity did not mediate the effect of behavioural activation on depression because physical activity was not related to type of treatment (p = 0.336). An increase in physical activity was associated (R2adj = 0.075) with a decrease in depressive symptoms, regardless of type of treatment (p < 0.05). CONCLUSION:In this sample, physical activity did not explain the difference in effectiveness between behavioural activation and treatment as usual. In line with the literature, our results showed an association of a small increase in physical activity with a decrease in depressive symptoms, regardless of treatment modality. Larger studies are needed to replicate these findings. TRIAL REGISTRATION:Netherlands Trial Register, NL5436.

BACKGROUND:Persistent physical symptoms are among the most common and challenging presentations in general practice, whether investigations are normal or reveal pathology insufficient to explain their severity. Patients and clinicians alike often experience these presentations as a dead end. Traditional biomedical models assume that symptoms passively reflect structural pathology, and that normal test results imply the absence of illness. OBJECTIVES:To introduce predictive processing as a theoretical framework for understanding persistent physical symptoms in general practice, and to outline its implications for clinical explanation and management. METHODS:This opinion paper draws on the predictive processing and active inference literature to develop a clinically applicable account of symptom perception, illustrated with clinical scenarios from general practice. RESULTS:Predictive processing proposes that symptoms are active perceptual constructions, generated by the brain as it infers the state of the body from incoming signals and prior beliefs. When prior beliefs of danger or irreversibility are strong, and peripheral signals are weak or ambiguous, these prior beliefs can dominate perception, producing substantial suffering in the absence of clear pathology. This framework explains symptom-test discordance and reframes normal results: they do not end clinical responsibility, but shift it towards modifying symptom-sustaining priors towards expectations of safety and recovery. CONCLUSION:For the general practitioner, this framework provides a coherent scientific rationale for explanation, continuity of care, expectation management, cognitive approaches and graded activity. These interventions emerge as core clinical tools, not consolation, when "nothing is found".

Feeling down is notalways a symptom of depressive disorder. Mostly the feeling is understandable in the light of the circumstances. The first approach should be a good conversation about what is happening, about the patient's aims and possibilities: the person-centered approach. However, when the patient has recurrent depressive episodes, has severe limitations in functioning or periods of mania, then the disease-centered approach is necessary, resulting in diagnosing depressive disorder (or bipolar disorder) and treating the patient according to the guidelines. In primary care, systematic screening of suicidality in depressed patients is not effective; case-finding is the preferred strategy.

Background: Many antidepressant users experience the process of stopping as challenging because of withdrawal symptoms. Support factors, such as patients experiencing empathy from their healthcare providers, potentially contribute to successful discontinuation. Objectives: To examine the relation between experienced empathy and successful antidepressant discontinuation. Design: Part of a larger prospective cohort study in major depressive disorder patients using sertraline or citalopram recruited through university medical centres and connected general practitioners, pharmacies and mental health institutions. The larger study aimed to identify factors associated with remission and patients’ experiences with discontinuing antidepressants. Method: Patients were followed for 24 months. We measured objective and subjective discontinuation success. Subjective discontinuation was measured with the Discontinuation Success Scale, a scale with three subscales (subjective feeling of success, positive and negative effects of discontinuation). Empathy was measured with the Consultation and Relational Empathy (CARE) measure. To analyse the association between perceived empathy and discontinuation success, we used regression analyses. Results: Of 918 participants in the larger study, 235 attempted discontinuation and 153 could be included in the analysis. About two-thirds of the participants were successful in discontinuing antidepressant medication. We did not find an association between perceived empathy and objective discontinuation success. Perceived empathy was positively associated with subjective success and negatively associated with the negative effects of discontinuation. Conclusion: Although we could not demonstrate an association of perceived empathy and objective discontinuation, we consider the finding of a relation between subjective success as relevant because a successful experience regarding antidepressant discontinuation may positively influence the initiation of future attempts.

This qualitative study aims to explore patient perspectives and experiences with functional recovery in late-life depression. Purposive sampling was used to include patients (60 years and older) with a depression diagnosis in the past year (in full or partial remission at inclusion). This led to the inclusion of 12 participants. Participants were recruited from an outpatient psychiatric clinic in the Netherlands. Semi-structured interviews were conducted, transcribed and analysed using both inductive and deductive thematic analysis. The Social Production Function (SPF) theory was utilised as a framework to deductively categorise themes under the subjective well-being instrumental goals. This study highlights the critical role of stimulation/activation, comfort, affection and aging in functional recovery in late-life depression. Under the theme of stimulation/activation, we found that motivation, participation, balance and structure were considered highly relevant. Affection, in the form of support, maintaining contact with people and cultivating meaningful connections, made a valuable contribution to the functional recovery process. Within the theme of comfort, participants described how comorbidities affected their recovery, requiring adjustment and acceptance. While themes arose that corresponded to status and behavioural confirmation, they were considered less significant to the recovery process. The inductively found theme 'the role of aging' was added to the themes of the SPF framework. It showed that functional recovery from late-life depression could not be understood without the effects of aging. These results show how the SPF theory aligns with older adults' goal of well-being. The findings underscore the need for personalised care focusing on functional recovery and offer a foundation for the evaluation of future interventions.

Feeling down is notalways a symptom of depressive disorder. Mostly the feeling is understandable in the light of the circumstances. The first approach should be a good conversation about what is happening, about the patient's aims and possibilities: the person-centered approach. However, when the patient has recurrent depressive episodes, has severe limitations in functioning or periods of mania, then the disease-centered approach is necessary, resulting in diagnosing depressive disorder (or bipolar disorder) and treating the patient according to the guidelines. In primary care, systematic screening of suicidality in depressed patients is not effective; case-finding is the preferred strategy.

PURPOSE Person-centered care is foundational to good quality primary care and has positive effects on health outcomes and patient satisfaction. The Person-Centered Primary Care Measure (PCPCM) is a recently developed, patient-reported survey able to assess personcenteredness and has demonstrated strong validity and reliability. Little is known, however, about the feasibility of the PCPCM in non-English-speaking settings. We aimed to translate the questionnaire into Dutch, psychometrically evaluate the translated version, and ensure its feasibility for patients in Dutch primary care. METHODS We translated the PCPCM into Dutch using forward-backward translations. We conducted psychometric evaluations to ensure its feasibility among Dutch-speaking primary care patients, with special attention to low literacy populations. Next, we assessed structural validity, convergent validity using the Quality of Care Through the Patient's Eyes (QUOTE) questionnaire, and internal consistency in a cross-sectional study in primary care. RESULTS Translation and adaptation for low literacy populations required 4 iterations. In 4 general practices, 205 patients completed the survey. Confirmatory factor analyses could not confirm the 1-factor solution. The 3-factor solution was found to be a more optimal fit: comprehensiveness of care, personal relation, and contextual care. Internal reliability was high (Cronbach's a were 0.82, 0.73, and 0.86, respectively). We found a strong correlation between the total PCPCM and QUOTE scores (Spearman's r = 0.65, P <.001), indicating good convergent validity. CONCLUSION The Dutch version of the PCPCM has acceptable validity and reliability for measuring person-centeredness in primary care among Dutch-speaking populations including those with low literacy.

Introduction: Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the costeffectiveness compared to treatment as usual (TAU) is unknown. Methods: An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (>= 65 years) with moderate to severe depressive symptoms (PHQ-9 >= 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios. Results: Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -euro485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs. Discussion: Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.

Many patients with fatigue do not visit a physician. In patients who do consult the general practitioner, the cause of their fatigue is explained in about a quarter: 8 percent has a somatic cause while psychosocial causes explain 16 percent. In about three quarters the cause of fatigue remains unexplained. Because of the low prevalence of somatic causes the general practitioner will be reluctant to perform additional examinations but a thorough physical examination is essential. In patients with a longer duration of fatigue (> 6 months) it is indicated to expand inquiries. This starts with extending history taking in the direction of consanguinity and hereditary diseases. More comprehensive blood tests and investigation of sleep are important further steps. Referral to a specialist is essential as specialists are more familiar with scripts of rare diseases. The prognosis of longer lasting fatigue is bad, especially in the case of fatigue meeting criteria for ME/CFS. Treatment of longer lasting fatigue could compromise of psycho-education, exercise and specific therapies for sleeping disorders.

BackgroundLate-life depression is a serious mental health problem. Behavioral Activation (BA) is an effective, accessible psychotherapeutic treatment for older adults. However, little is known about which symptoms decrease and how associations between depressive symptoms change during BA treatment.MethodsUsing data from a cluster-randomized trial for older adults with late-life depression, we estimated a partial correlation network and a relative importance network of depressive symptoms before and after 8 weeks of BA treatment in primary care (n = 96). Networks were examined with measures of network structure, connectivity, centrality as well as stability.ResultsThe most central symptoms at baseline and post-treatment were anhedonia, fatigue, and feeling depressed. In contrast, sleeping problems had the lowest centrality. The post-treatment network was significantly more interconnected than at baseline. Moreover, all symptoms were significantly more central at post-treatment.ConclusionOur findings highlight the utility of the network approach to better understand symptom networks of depressed older adults before and after BA treatment. Results show that network connectivity and centrality of all symptoms increased after treatment. Future studies should investigate longitudinal idiographic networks to explore symptom dynamics within individuals over time.

OBJECTIVE:Persistent somatic symptoms (PSS) describe recurrent or continuously occurring symptoms such as fatigue, dizziness, or pain that have persisted for at least several months. These include single symptoms such as chronic pain, combinations of symptoms, or functional disorders such as fibromyalgia or irritable bowel syndrome. While stigmatisation by healthcare professionals is regularly reported, there are limited measurement instruments demonstrating content validity. This study develops a new instrument to measure stigmatisation by healthcare professionals, the Persistent Somatic Symptom Stigma scale for Healthcare Professionals (PSSS-HCP). METHODS:Development was an iterative process consisting of research team review, item generation and cognitive interviewing. We generated a longlist of 60 items from previous reviews and qualitative research. We conducted 18 cognitive interviews with healthcare professionals in the United Kingdom (UK). We analysed the relevance, comprehensibility and comprehensiveness of items, including the potential for social desirability bias. RESULTS:After research team consensus and initial feedback, we retained 40 items for cognitive interviewing. After our first round of interviews (n = 11), we removed 20 items, added three items and amended five items. After our second round of interviews (n = 7), we removed four items and amended three items. No major problems with relevance, comprehensibility, comprehensiveness or social desirability were found in remaining items. CONCLUSIONS:The provisional version of the PSSS-HCP contains 19 items across three domains (stereotypes, prejudice, discrimination), demonstrating sufficient content validity. Our next step will be to perform a validation study to finalise item selection and explore the structure of the PSSS-HCP.

Er zijn grofweg 2 manieren van consultvoering bij mensen met psychische klachten: de technisch-wetenschappelijke en de narratieve. Bij de eerste gaat het erom een diagnose te stellen volgens de DSM, bij de tweede is het de bedoeling het verhaal van de patiënt op tafel te krijgen. Deze methoden vullen elkaar aan. Wij stellen een consultvoering voor – stepped diagnosis – waarbij je begint met de minst ingrijpende benadering (de narratieve) en zo nodig stapsgewijs intensievere benaderingen kiest. De laatste stap is de technisch-wetenschappelijke benadering, waarmee je meteen begint bij ernstige of acute problematiek.

Iedere patiënt is uniek binnen een grote diversiteit in leeftijd, etniciteit, gender, sociaaleconomische status, religie en lichamelijke en verstandelijke mogelijkheden. Aandacht voor die uniciteit begint bij persoonsgerichte en inclusieve communicatie in de spreekkamer. Taal en communicatie hebben namelijk veel invloed op de arts-patiëntrelatie en belangrijke patiëntuitkomsten. Daarnaast kunnen de juiste woorden een veilige, inclusieve plek creëren voor iedere patiënt. Het is dus relevant om stil te staan bij de woorden die we dagelijks in onze spreekkamer gebruiken, in het bijzonder met betrekking tot genderdiversiteit.

OBJECTIVE:Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.METHODS:A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.RESULTS:We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.CONCLUSION:No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

De visie ‘Huisartsenzorg voor patiënten met psychische problematiek’ is een belangrijk begin voor het omschrijven van huisartsenzorg voor mensen met psychische problemen, maar voorziet de huisarts in de spreekkamer nog niet van een echte leidraad. Wat vinden huisartsen en POH’s-ggz van het document? Wij geven een voorzet.

Background Persistent fatigue after COVID-19 is common; however, the exact incidence and prognostic factors differ between studies. Evidence suggests that age, female sex, high body mass index, and comorbidities are risk factors for long COVID. Aim To investigate the prevalence of persistent fatigue after COVID-19 in patients with a mild infection (managed in primary care) during the first wave of the pandemic and to determine prognostic factors for persistent fatigue. Design and setting This was a prospective cohort study in Dutch general practice, combining online questionnaires with data from electronic health records. Method Patients who contacted their GP between March and May 2020 and were diagnosed with COVID-19 during the first wave of the pandemic were included. Patients were matched to controls without COVID-19 based on age, sex, and GP practice. Fatigue was measured at 3, 6, and 15 months, using the Checklist of Individual Strength. Results All the participants were GP attendees and included 179 with suspected COVID-19, but who had mild COVID and who had not been admitted to hospital with COVID, and 122 without suspected COVID-19. Persistent fatigue was present in 35% (49/142) of the suspected COVID-19 group and 13% (14/109) of the non-COVID-19 group (odds ratio 3.65; 95% confidence interval = 1.82 to 7.32). Prognostic factors for persistent fatigue included low education level, absence of a partner, high neuroticism (using the Eysenck Personality Questionnaire Revised-Short Form), low resilience, high frequency of GP contact, medication use, and threatening experiences in the past. The latter three factors appeared to be prognostic factors for persistent fatigue specifically after COVID-19 infection. Conclusion GP patients with COVID-19 (who were not admitted to hospital with COVID) have a fourfold higher chance of developing persistent fatigue than GP patients who had not had COVID-19. This risk is even higher in psychosocially vulnerable patients who had COVID-19.

Discontinuing antidepressant medication (ADM) can be challenging for patients and clinicians. In the current study we investigated if Mindfulness-Based Cognitive Therapy (MBCT) added to supported protocolized discontinuation (SPD) is more effective than SPD alone to help patients discontinue ADM. This study describes a prospective, cluster-randomized controlled trial (completed). From 151 invited primary care practices in the Netherlands, 36 (24%) were willing to participate and randomly allocated to SPD+MBCT (k = 20) or SPD (k = 16). Adults using ADM > 9 months were invited by GPs to discuss tapering, followed by either MBCT+SPD, or SPD alone. Exclusion criteria included current psychiatric treatment; substance use disorder; non-psychiatric indication for ADM; attended MBCT within past 5 years; cognitive barriers. From the approximately 3000 invited patients, 276 responded, 119 participated in the interventions and 92 completed all assessments. All patients were offered a decision aid and a personalized tapering schedule (with GP). MBCT consisted of eight group sessions of 2.5 hours and one full day of practice. SPD was optional and consisted of consultations with a mental health assistant. Patients were assessed at baseline and 6, 9 and 12 months follow-up, non-blinded. In line with our protocol, primary outcome was full discontinuation of ADM within 6 months. Secondary outcomes were depression, anxiety, withdrawal symptoms, rumination, well-being, mindfulness skills, and self-compassion. Patients allocated to SPD + MBCT (n = 73) were not significantly more successful in discontinuing (44%) than those allocated to SPD (n = 46; 33%), OR 1.60, 95% CI 0.73 to 3.49, p = .24, number needed to treat = 9. Only 20/73 allocated to MBCT (27%) completed MBCT. No serious adverse events were reported. In conclusion, we were unable to demonstrate a significant benefit of adding MBCT to SPD to support discontinuation in general practice. Actual participation in patient-tailored interventions was low, both for practices and for patients. (Trial registration: ClinicalTrials.gov PRS ID: NCT03361514 registered December 2017).

Introduction: Effective non-pharmacological treatment options for depression in older adults are lacking. Objective: The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated. Methods: In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up. Results: Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = −2.77, 95% CI = −4.19 to −1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42–1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = −1.53, 95% CI = −2.81 to −0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07–0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = −0.89 (−2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = −0.82 to 0.24). Conclusions: BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.

Documentaire: Even afwachten, een kijkje in het hoofd van de huisarts | regisseur/producent/distributie: Dick Walstock | 2022 | Te zien via https://vimeo.com/796231559 , wachtwoord WachtMaarAf23 (beschikbaar van 7 maart tot 18 april 2023).