Subtypes of depression and their overlap in a naturalistic inpatient sample of major depressive disorder

Subtyping depression is important in order to further delineate biological causes of depressive syndromes. The aim of this study was to evaluate clinical and outcome characteristics of distinct subtypes of depression and to assess proportion and features of patients fulfilling criteria for more than one subtype. Melancholic, atypical and anxious subtypes of depression were assessed in a naturalistic sample of 833 inpatients using DSM-IV specifiers based on operationalized criteria. Baseline characteristics and outcome criteria at discharge were compared between distinct subtypes and their overlap. A substantial proportion of patients (16%) were classified with more than one subtype of depression, 28% were of the distinct anxious, 7% of the distinct atypical and 5% of the distinct melancholic subtype. Distinct melancholic patients had shortest duration of episode, highest baseline depression severity, but were more often early improvers; distinct anxious patients had higher NEO-Five Factor Inventory (NEO-FFI) neuroticism scores compared with patients with unspecific subtype. Melancholic patients with overlap of anxious features had worse treatment outcome compared to distinct melancholic and distinct anxious subtype. Distinct subtypes differed in only few variables and patients with overlap of depression subtypes may have independent clinical and outcome characteristics. Studies investigating biological causes of subtypes of depression should take influence of features of other subtypes into account.

How Effective Is Algorithm-Guided Treatment for Depressed Inpatients? Results from the Randomized Controlled Multicenter German Algorithm Project 3 Trial

BACKGROUND

Treatment algorithms are considered as key to improve outcomes by enhancing the quality of care. This is the first randomized controlled study to evaluate the clinical effect of algorithm-guided treatment in inpatients with major depressive disorder.

METHODS

Inpatients, aged 18 to 70 years with major depressive disorder from 10 German psychiatric departments were randomized to 5 different treatment arms (from 2000 to 2005), 3 of which were standardized stepwise drug treatment algorithms (ALGO). The fourth arm proposed medications and provided less specific recommendations based on a computerized documentation and expert system (CDES), the fifth arm received treatment as usual (TAU). ALGO included 3 different second-step strategies: lithium augmentation (ALGO LA), antidepressant dose-escalation (ALGO DE), and switch to a different antidepressant (ALGO SW). Time to remission (21-item Hamilton Depression Rating Scale ≤9) was the primary outcome.

RESULTS

Time to remission was significantly shorter for ALGO DE (n=91) compared with both TAU (n=84) (HR=1.67; P=.014) and CDES (n=79) (HR=1.59; P=.031) and ALGO SW (n=89) compared with both TAU (HR=1.64; P=.018) and CDES (HR=1.56; P=.038). For both ALGO LA (n=86) and ALGO DE, fewer antidepressant medications were needed to achieve remission than for CDES or TAU (P<.001). Remission rates at discharge differed across groups; ALGO DE had the highest (89.2%) and TAU the lowest rates (66.2%).

CONCLUSIONS

A highly structured algorithm-guided treatment is associated with shorter times and fewer medication changes to achieve remission with depressed inpatients than treatment as usual or computerized medication choice guidance.

Stability of remission rates in a 3-year follow-up of naturalistic treated depressed inpatients

BACKGROUND

Remission is a common outcome of short-term trials and the main goal of acute and longterm treatment. The longitudinal stability of remission has rarely been investigated under naturalistic treatment conditions.

METHODS

Naturalistic multisite follow-up study. Three-year symptomatic long-term outcome of initially hospitalized tertiary care patients (N = 784) with major depressive episodes. Remission rates as well as the switch rates between remission and non-remission were reported.

RESULTS

After one, two and three years 62 %, 59 % and 69 % of the observed patients met criteria for remission. During the follow-up 88 % of all patients achieved remission. 36 % of maintained remission from discharge to 3-years, 12 % of all patients never reached remission and 52 % percent showed a fluctuating course switching from remission to non-remission and vice versa. There was considerable transition between remission and non-remission. For example, from discharge to 1 year, from 1 to 2, and from 2 to 3 years 25 %, 21 % and 11 % lost remission.

CONCLUSION

Cumulative outcome rates are encouraging. Absolute rates at predefined endpoints as well as the fluctuations between these outcomes reflect the variable and chronic nature of major depression.

Characteristics and differences in treatment outcome of inpatients with chronic vs. episodic major depressive disorders

BACKGROUND

Approximately 20-30% of patients with Major depressive disorder (MDD) develop a chronic course of their disease. Chronic depression is associated with increased health care utilisation, hospitalisation and a higher disease burden. We identified clinical correlates and differences in treatment response of chronic MDD (cMDD) patients compared with non-chronic episodic depression in a huge sample of depressive inpatients.

METHODS

Data were collected from 412 inpatients who had been diagnosed with a major depressive episode (MDE; according to ICD-10) and scored 15 or higher on the 21-item Hamilton Depression Rating Scale (HRSD-21). All subjects were participants in the German Algorithm Project, phase 3 (GAP3). Patients who were diagnosed with a MDE within the last two years or longer (herein referred to as CD) were compared with non-chronic depressive patients (herein referred to as non-CD). CD and non-CD patients were assessed for the following: psychosocial characteristics, symptom reduction from hospital admission to discharge, symptom severity at discharge, remission and response rates, and pharmacological treatment during inpatient treatment. The primary outcome measure was the HRSD-21.

RESULTS

13.6% (n=56) of patients met the criteria for chronic depression. Compared with non-CD patients, patients with CD showed increased axis I comorbidities (74% vs. 52%, χ(2) (1)=7.31, p=.02), a higher level of depressive symptoms at baseline and discharge, increased duration of inpatient treatment (64.8 vs. 53.3 days; t=2.86, p=.03) and lower response (HRSD: 60.0% vs. 72.0%; χ(2) (1)=3.61, p<.04; BDI: 40.5% vs. 54.2%; χ(2) (1)=3.56, p=.04) and remission rates (BDI 17.9.% vs. 29.7%; χ(2) (1)=3.42, p=.05. However, both groups achieved a comparable symptom reduction during inpatient treatment. The prescribed pharmacological strategy had no significant influence on treatment outcome in patients with CD.

CONCLUSION

Inpatients with CD show higher symptom severity, lower response and remission rates and a longer duration of inpatient treatment, although they achieve comparable symptom reduction during treatment. These findings support the need to recognise CD and its defining characteristics as a distinct subclass of depression.

[Predictors of success of long-term treatment in alcohol dependency]

OBJECTIVE

There is a lack of positive predictors for long-term treatment of subjects with alcohol addiction. We analyzed the relation between motivation and other external variables of access to treatment as well as treatment outcome.

METHOD

434 persons with alcohol addiction, treated in 2004 in the Diakonie-Krankenhaus Harz (DHK), Elbingerode, as part of a long-term therapy, were followed-up one year after treatment. Access variables were defined and examined in relation to outcome variables with multiple linear and logistic regressions.

RESULT

Ways of accessing treatment had no effect on later treatment outcome, while motiva­tion at the start of therapy was relevant: Patients with ambivalent motivation had the most negative outcome.

CONCLUSION

Therapy motivation was the main predictor for the outcome of a long-term anti-addiction treatment. To improve the quality of the treatment system, interventions to strengthen motivation should be promoted.

[Involuntary psychiatric hospital admissions: a comparison between five hospitals in three German federal states]

BACKGROUND

There is considerable variance in involuntary psychiatric hospital admission rates both in Europe and Germany. In a prospective comparison between five hospitals in three German federal states we assessed and analyzed involuntary psychiatric hospital admissions, including the patient's perspective.

MATERIAL AND METHOD

All involuntarily admitted patients were assessed by an independent researcher. Clinical data, patient and psychiatrist views were documented with different instruments including the McArthur admission experience survey.

RESULTS

In this study 104 out of 244 involuntarily admitted patients gave informed consent. We found considerable differences between study centres concerning involuntary admission quotas (3.2-25.8% of all hospital admissions) and involuntary admission rates (16.6-97.6 per year per 100,000 inhabitants). Hospitals in the state of Baden-Württemberg had the lowest involuntary admission rates while they were highest in Bavaria. In Baden-Württemberg involuntarily admitted patients were more likely to suffer from chronic schizophrenia, they were more severely ill and experienced the involuntary hospital admission as more strenuous. There were no differences between centres concerning frequency of dangerous behavior or self-harm.

CONCLUSION

We found a high variance across regions concerning the reasons for, frequencies and legal basis of involuntary hospital admissions. Regional differences of legal frameworks and service organization can explain this only to a limited amount. Transparency, legal certainty and reflection of stakeholder roles are a future necessity. Furthermore, there is a need for stringent compliance with legal regulations and coherent documentation.

[S3 guidelines on diagnostics and therapy of bipolar disorders: development process and essential recommendations]

Bipolar disorders are severe psychiatric disorders with extensive individual and health economic consequences. Starting in 2007 the first German evidence and consensus based guideline for diagnostics and treatment of bipolar disorders was developed which holds the potential of increasing confidence of therapists, patients and relatives in the decision-making process and improving healthcare service experiences of patients and relatives. Apart from recommendations for diagnostics and treatment the guidelines provide those for trialogue action, knowledge transfer and self-help and for strategies for healthcare provision of this complex disorder. In the present article the methodology and essential recommendations are outlined and complemented in specific topics by corresponding articles in this special issue. Due to restrictions of the length of this presentation there is the need to refer to the comprehensive version of the guidelines at several points also regarding a detailed discussion of the limitations.

[Implementation of joint-crisis plans--a study of health care users and professionals]

OBJECTIVE

To study effects of the implementation of joint-crisis plans (JCP) on health-care users and professionals.

METHODS

The first 3 years of the implementation of JCP were followed with structured interviews with health-care users and professionals. Legal and administrative complications were documented.

RESULTS

36 of 44 subjects with JCP were assessed. Most of them had learned of JCP through other users or self-help. 55 % had prior experience with compulsory treatment. Better communication and self-determination were main goals of JCP. A relevant change in hospital treatment through JCP was not observed. Only few professionals had made direct experience with JCP. They valued JCP mildly positive. No legal and administrative complications were documented.

CONCLUSIONS

Only a small minority of users signed JCP. JCP were easily employed and improved communication and self-determination.

Clinical predictors of response and remission in inpatients with depressive syndromes

BACKGROUND

Most predictor analyses search for single predictors or rely on data from randomized controlled trials. We aimed at detecting a set of clinical baseline variables for prediction of response and remission in 1014 naturalistically treated inpatients with major depressive episode treated for 53.62 ± 47.5 days.

METHODS

A three-staged procedure was implemented. First, univariate tests were used for finding associations with baseline variables. Second, logistic regression and third-CART analyses were used to determine predictors of response to inpatient treatment.

RESULTS

Presence of suicidality, a higher initial HAMD-21 total score, an episode length <24 months, fewer previous hospitalizations, and absence of any ICD-10F4 comorbidity predicted response in 2 different statistical models. Remission was predicted by lower HAMD-21 baseline score, episode length <24 months and fewer previous hospitalizations in both models.

LIMITATION

Results were assessed by a post-hoc analysis, based on prospectively collected data. No controlled study design.

CONCLUSION

Contrary to current beliefs, baseline suicidality might be associated with higher chances for response. In addition, baseline severity might impact outcome depending on which criterion (remission or response) used.

Response and remission criteria in major depression--a validation of current practice

Remission and response were suggested as the most relevant outcome criteria for the treatment of depression. There is still marked uncertainty as to what cut-offs should be used on current depression rating scales. The goal of the present study was to compare the validity of different HAMD, MADRS and BDI cut-offs for response and remission. The naturalistic prospective study was performed in 12 psychiatric hospitals in Germany. All evaluable patients (n=846) were hospitalized and had to meet DSM-IV criteria for major depressive disorder. Biweekly ratings were assessed using HAMD-21, MADRS and BDI. A CGI-S score of 1 and a CGI-I score of at least 2 was used as the primary comparative measure of remission and response, respectively. A HAMD-21 cut-off ≤7 (AUC: 0.92), HAMD-17 cut-of ≤6 (AUC: 0.90), MADRS cut-off ≤7 (AUC: 0.94) and BDI cut-off ≤12 (AUC: 0.83) were associated with a maximum of specificity and sensitivity for defining remission. A minimum decrease of 47% of the HAMD-21 (AUC: 0.90), ≤57% for HAMD-17 (AUC: 0.89), ≤ 46% for MADRS (0.91) and a decrease of 47% for the BDI baseline score (AUC: 0.78) best corresponded CGI response criteria. Our data largely confirmed currently used remission and response criteria in naturalistically treated patients.

Do efficacy and effectiveness samples differ in antidepressant treatment outcome? An analysis of eligibility criteria in randomized controlled trials

BACKGROUND

Because of strict inclusion and exclusion criteria, results drawn from placebo-controlled randomized antidepressant efficacy trials may not be transferable to real-world patients.

METHOD

This study was performed from March 2000 to September 2005 as a prospective, multicenter follow-up. Patients were recruited from February 2000 to June 2005. All patients were hospitalized (N = 1,014) and met DSM-IV criteria for major depressive episode. Assessments with the 21-item Hamilton Depression Rating Scale were conducted biweekly until discharge. According to the most commonly applied exclusion criteria in randomized controlled antidepressant efficacy trials, patients were retrospectively divided into 2 groups: (1) patients not fulfilling exclusion criteria and therefore eligible for a randomized placebo-controlled trial, referred to as "efficacy sample," and (2) patients fulfilling at least 1 exclusion criterion, not being eligible for inclusion in an efficacy trial ("nonefficacy sample"). The efficacy sample was compared with the nonefficacy sample in terms of sociodemographic and clinical baseline variables and outcome measures, such as remission and response rates, 17-item Hamilton Depression Rating Scale mean scores, time to remission, and time to response.

RESULTS

Significant differences were found, with the efficacy sample being older (P = .03) and being more often treated at a university hospital (P = .02). The efficacy sample demonstrated superior outcome only in significantly higher mean Global Assessment of Functioning scores at discharge (P = .03). There were no differences regarding remission (P = .68) and response (P = .06) rates, length of hospital stay (P = .49), 17-item Hamilton Depression Rating Scale total score at discharge (P = .13), or time to response (P = .39) or remission (P = .16).

CONCLUSIONS

Both groups differed significantly in several baseline measures and final Global Assessment of Functioning scores but not in any other outcome measure. Challenging current beliefs, our findings show that results from efficacy antidepressant trials might be more generalizable than previously thought.

Relationship between baseline severity of depression and antidepressant treatment outcome

INTRODUCTION

Assessment of depression severity is of key importance, since several clinical guidelines recommend choice of treatment dependent on the depression severity grade. Using different tools to assess baseline severity may result in different outcomes.

METHODS

This paper describes the results of a multicentre, naturalistic study investigating the relationship between depression symptom severity (using 4 different measures of symptom severity) and clinical outcome among patients hospitalised for depression (N=1 014). Moreover, the impact of differences between methods of measuring depression severity has been investigated. Statistical analyses (univariate measurements, logistic regression models) were conducted to detect coherences and differences between the various methods of severity categorisation.

RESULTS

Results revealed different associations between outcome and classification methods. Response or remission rates varied if baseline severity was assessed by different instruments. Moreover, the number of responders increased with higher baseline severity grades of depression, whereas the number of remitters decreased. Additional analyses dependent on outcome criteria using continuous instead of categorical data revealed similar results.

DISCUSSION

Baseline severity may be only one of many other important clinical variables that mediate clinical outcome, but it is surely an important one deserving further research and consideration.

Prevalence and treatment outcome in anxious versus nonanxious depression: results from the German Algorithm Project

OBJECTIVE

The objective of this study was to explore the prevalence of anxious depression in an inpatient population, to describe its clinical and sociodemographic correlates, and to compare treatment outcomes between patients with anxious and nonanxious depression. Furthermore, the efficacy of algorithm-guided treatment versus treatment as usual in patients with anxious versus nonanxious depression was evaluated.

METHOD

Data were collected on 429 inpatients with the diagnosis of a depressive episode (according to ICD-10) and a score of ≥ or = 15 on the 21-item Hamilton Depression Rating Scale (HDRS-21). The German Algorithm Project, phase 3 (GAP3), was conducted between 2000 and 2005 in 10 psychiatric departments throughout Germany. A baseline HDRS-21 anxiety/somatization factor score of ≥ or = 7 was considered indicative of anxious depression. Remission was defined as an HDRS-21 score or ≤ = 9. To evaluate the efficacy of algorithm-guided treatment, patients were randomly assigned into 3 groups: 2 different treatment algorithms or treatment as usual.

RESULTS

The prevalence of anxious depression was 49%. Patients with anxious depression were more likely than those with nonanxious depression to be older (mean ± SD = 45.3 ± 12.8 vs 42.9 ± 12.0 years, odds ratio [OR] = 1.02 [95% CI, 1.00-1.03], P = .046), retired (70% vs 30%, OR = 3.09 [95% CI, 1.70-5.62], P = .000), without school qualification (74% vs 26%, OR = 3.11 [95% CI, 1.09-8.83], P = .035), more severely depressed (mean ± SD HDRS-21 score = 20.1 ± 5.0 vs 18.5 ± 4.4, OR = 1.08 [95% CI, 1.03-1.12], P = .001), and more likely to have a longer duration of the current episode (mean ± SD = 20.9 ± 26.2 vs 13.7 ± 14.3 weeks, OR = 1.02 [95% CI, 1.01-1.03], P = .011). Patients with anxious depression were more likely to display a variety of melancholic features. In patients with anxious depression compared to those with nonanxious depression, remission was less likely to be achieved (48.6% vs 61.5%, OR = 0.63 [95% CI, 0.42-0.92], P = .018) and took longer to occur (mean ± SD = 44 ± 3.4 vs 30 ± 2.8 days, HR = 0.65 [95% CI, 0.50-0.85], P = .001). There was no significant interaction with the treatment mode with regard to remission (Wald = 0.20, P = .890).

CONCLUSIONS

Anxious depression is common in patients diagnosed with depression. The poorer treatment outcome in patients with anxious depression demonstrates the need to address the issue of specific treatment strategies for this subgroup. However, anxious depression has no moderating effect on the efficacy of algorithm-guided treatment.

TRIAL REGISTRATION

http://www.germanctr.de/ Identifier: DRKS00000161.

Outcomes of 1014 naturalistically treated inpatients with major depressive episode

Due to strict exclusion criteria the generalizability of randomized controlled trials appears to be limited. Therefore, outcomes of naturalistically treated depressive inpatients with respect to depression mean scores, response and remission rates were evaluated. This was a multicenter trial, conducted in 12 psychiatric hospitals in Germany with a follow-up period of 4years. Patients were assessed biweekly from admission to discharge with diverse psychopathological rating scales. All patients (n=1014) met DSM-IV criteria for major depressive episode. Results are presented only for the acute inpatient treatment period. Mean inpatient treatment duration was 53.6+/-47.5days. Reduction on depression scales was evident as soon as week 2 and remained significant. Mean HAMD-17 total score decreased from 22.3 to 8.8. A total of 68.9% were classified as responders (> or =50% reduction of the initial HAMD-17 score), whereas 51.9% achieved remission (HAMD-17 total score < or =7). Of those who ultimately achieved response more than 40% did so within the first 2weeks. An individualized naturalistic inpatient treatment approach appears to be beneficial in terms of effectiveness.

Vocational rehabilitation for subjects with severe mental illnesses in Germany. A controlled study

OBJECTIVE

To assess the longitudinal effectiveness of a comprehensive vocational rehabilitation program in Germany.

METHODS

In a non-randomized open study, 106 participants of two comprehensive rehabilitation programs were prospectively and multidimensionally compared to a control group (n = 75) at program termination and at a 9 months follow-up. Primary outcome was employment status at 9 months follow-up, secondary outcome parameters were changes in symptoms (Positive and Negative Syndrome Scale), subjective well-being (WHOQOL-Bref), and level of functioning (Level of Functioning Scale) during the study.

RESULTS

Regarding the primary outcome measure, there was significant more day structuring employment (mainly sheltered) in the rehabilitation group than in the comparison group (39.7 vs. 18.7%) at 9 months follow-up. Regarding secondary outcomes, rehabilitation participants showed a better course in general symptoms, subjective well-being and level of functioning.

CONCLUSION

Vocational services proved to be effective to find day structuring employment for subjects with severe mental illness. Furthermore it had positive effects on functioning and psychological well-being during a 9-months follow-up period.

Bipolar I disorder with mood-incongruent psychotic symptoms: a comparative longitudinal study

OBJECTIVES

The purpose of this paper is to demonstrate similarities and differences between bipolar I patients with and without mood-incongruent symptoms (MIS) over a long period of time, independently of longitudinal syndromatic constellations.

METHODS

The Halle bipolarity longitudinal study (HABILOS) prospectively investigates 182 patients meeting the DSM-IV criteria for bipolar I disorders over a long period of time (x;- = 16.84 years). One thousand five hundred thirty-nine (1,539) episodes have been evaluated with standardized instruments. Patients and episodes were divided into two groups (with and without MIS) and were compared on various levels.

RESULTS

It was found: (1) The majority of the episodes of bipolar I patients during long-term course did not have MIS, but the majority of patients did. (2) Bipolar I patients with MIS differ from patients without MIS in the following features: (a) Bipolar I patients with MIS are more frequently males. (b) Bipolar I patients with MIS need treatment at a significantly younger age than those without MIS. (c) First manifestation of bipolar I disorder with MIS after the age of 50 is extremely seldom. (d) Bipolar I patients with MIS more frequently have relatives with schizophrenia. (e) Bipolar I patients with MIS more frequently become disabled and retire at a significantly younger age than patients without MIS and (f) Significantly fewer patients with MIS than those without MIS live in a stable partnership.

CONCLUSIONS

It can be concluded that bipolar I disorders with MIS are more severe disorders than bipolar I disorders without MIS. This finding in combination with the above results, however, can give rise to the conclusion that bipolar I disorders with MIS are the epiphenomenon of the overlap, possibly genetic, of a "schizophrenic spectrum" and a "bipolar spectrum" and their antagonistic influence creating a "schizo-affective" area between them as a kind of psychotic continuum between prototypes.

Prediction of Vocational Rehabilitation Outcome in Schizophrenia: Incremental Prognostic Validity of Learning Potential Beyond Basic Cognitive Performance

This article examines learning potential as a predictor of the success of a vocational rehabilitation program for patients with severe mental illness in Germany. Forty-one schizophrenia patients completed a pretest–training–posttest version of the Wisconsin Card Sorting Test as a measure of learning potential. Pretest scores indicated basic cognitive performance, and posttest scores indicated individual learning potential. Rehabilitation outcome was assessed using measures for work capability during the rehabilitation program and the level of vocational integration at 3-month follow-up. Individual learning potential was a better predictor of work capability and the level of vocational reintegration than basic cognitive performance. Our study demonstrates that learning potential is an informative predictor for rehabilitation outcome and adds information beyond basic cognitive performance.

The longitudinal polymorphism of bipolar I disorders and its theoretical implications

BACKGROUND

The longitudinal course of bipolar I disorders is often characterized by a polymorphism, which means that different kinds of episodes develop during the illness. This study investigated the characteristics, similarities and differences of the long-term course of bipolar I patients regarding the dominance of various kinds of episodes.

METHODS

One hundred eighty-two (182) patients with DSM-IV bipolar I disorder were longitudinally investigated (approximately 17 years duration of the illness) with standardized instruments. The dominance of mood, schizo-affective and schizophreniform episodes was estimated by means of a mathematic formula. According to that dominance, the patients were divided into three groups (mood-dominated, schizo-affective-dominated, schizophreniform-dominated), and these groups were compared to each other at various levels.

RESULTS

The long-term course of bipolar I patients is usually polymorphic showing not only mood episodes, but also schizo-affective and schizophreniform episodes. Nevertheless it is mainly mood-dominated. There are significant differences between patients with mood-dominated and patients with schizo-dominated course, especially in regard to age at first treatment, family history, global functioning, frequency of disability and age at retirement due to the mental illness. Patients with schizo-affective-dominated course occupy a position in-between, but showing stronger similarities with mood-dominated patients.

LIMITATIONS

The investigation is not blind; therefore, bias cannot be excluded. Retirement due to the mental illness is strongly connected with specific national features.

CONCLUSIONS

The polymorphic long-term course of bipolar disorders and the differences and similarities between mood-dominated, schizo-affective-dominated and schizo-dominated types of course could support the argument that a distinction between the prototypes "mood disorder" and "schizophreniform disorder" is not always possible, but that there is an overlap of affective and schizophreniform spectra and an "antagonistic influence" between them. Clinicians need to consider the polymorphism of the bipolar disorder in order to provide adequate treatment and prophylaxis. Researchers have to consider that the boundaries of diagnostic categories are very elastic and permeable, making a psychotic continuum possible.

A longitudinal study of learning potential and rehabilitation outcome in schizophrenia

OBJECTIVE

The study examined whether a measure of learning potential is prospectively related to the success of a vocational rehabilitation program for patients with severe mental illness in Germany.

METHODS

At rehabilitation intake (November 2002 to January 2004), 41 persons with schizophrenia or schizoaffective disorders completed a test-train-test version of the Wisconsin Card Sorting Test as a measure of learning potential. Research participants were classified as high scorers, learners, or nonlearners. Rehabilitation outcome was assessed with measures of work capability during the rehabilitation program, level of functioning during rehabilitation and at three-month follow-up, and level of vocational integration at three-month follow-up.

RESULTS

Individual learning potential was associated with the improvement of work-related learning ability during rehabilitation and with the level of functioning and the level of vocational integration at three-month follow-up (about 15 months after the initial testing). Generally, high scorers had better rehabilitation outcome at all assessment points regarding all outcome measures. Even though learners and nonlearners started at comparable levels at the beginning of the rehabilitation, learners benefited more from the program, whereas nonlearners showed a rather unfavorable rehabilitation outcome.

CONCLUSIONS

Findings supported the assumption that learning potential is an informative predictor of rehabilitation outcome and may add information beyond static cognitive measures. Learning potential should be considered in the further development of vocational rehabilitation programs.

A longitudinal study of learning potential and rehabilitation outcome in schizophrenia

OBJECTIVE

The study examined whether a measure of learning potential is prospectively related to the success of a vocational rehabilitation program for patients with severe mental illness in Germany.

METHODS

At rehabilitation intake (November 2002 to January 2004), 41 persons with schizophrenia or schizoaffective disorders completed a test-train-test version of the Wisconsin Card Sorting Test as a measure of learning potential. Research participants were classified as high scorers, learners, or nonlearners. Rehabilitation outcome was assessed with measures of work capability during the rehabilitation program, level of functioning during rehabilitation and at three-month follow-up, and level of vocational integration at three-month follow-up.

RESULTS

Individual learning potential was associated with the improvement of work-related learning ability during rehabilitation and with the level of functioning and the level of vocational integration at three-month follow-up (about 15 months after the initial testing). Generally, high scorers had better rehabilitation outcome at all assessment points regarding all outcome measures. Even though learners and nonlearners started at comparable levels at the beginning of the rehabilitation, learners benefited more from the program, whereas nonlearners showed a rather unfavorable rehabilitation outcome.

CONCLUSIONS

Findings supported the assumption that learning potential is an informative predictor of rehabilitation outcome and may add information beyond static cognitive measures. Learning potential should be considered in the further development of vocational rehabilitation programs.

Temperament and personality in bipolar I patients with and without mixed episodes

BACKGROUND

Personality and temperament are supposed to have an impact on the clinical expression and course of an affective disorder. There is some indication, that mixed episodes result from an admixture of inverse temperamental factors to a manic syndrome. In a preliminary report [Brieger, P., Roettig, S., Ehrt, U., Wenzel, A., Bloink, R., Marneros, A., 2003. TEMPS-a scale in 'mixed' and 'pure' manic episodes: new data and methodological considerations on the relevance of joint anxious-depressive temperament traits. J. Affect. Disord. 73, 99-104] we reported support for this assumption. The present study completes the preliminary results and compares patients with and without mixed episodes with respect to personality and personality disorders in addition.

METHODS

Patients who had been hospitalized for bipolar I disorder were reassessed after 4.8 years. We examined temperament (TEMPS-A), personality (NEO-FFI) and frequency of personality disorders (SCID-II). Furthermore, illness-related parameters like age at first treatment, depressive and manic symptomatology, frequency and type of episodes and level of functioning were obtained and patients with and without mixed episodes were compared.

RESULTS

Patients with (n=49) and without mixed episodes (n=86) did not differ significantly with regard to the illness-related parameters and personality dimensions. The frequency of personality disorders was significantly higher in patients with prior mixed episodes. With respect to temperament, scores of the depressive, cyclothymic, irritable and anxious temperament were significantly higher in patients with mixed episodes.

LIMITATIONS

We were not able to assess premorbid temperament and premorbid personality.

CONCLUSIONS

The findings of the present study support the assumption of Akiskal [Akiskal, H.S., 1992b. The distinctive mixed states of bipolar I, II, and III. Clin. Neuropharmacol. 15 Suppl 1 Pt A, 632-633.] that mixed episodes are more frequent in subjects with inverse temperament.

Dimensions underlying outcome criteria in bipolar I disorder

OBJECTIVE

Various subjective and objective criteria are used to assess outcome in bipolar disorder. In this study, we explored to what extent they reflect distinct categories and whether underlying dimensions can be identified.

PATIENTS AND METHODS

One-hundred and twenty-one subjects with at least three episodes of bipolar I disorder (DSM-IV) were assessed on average 4.8 years after hospitalization. We assessed 14 variables reflecting different outcome criteria including subjective quality of life (SQOL), self-rated and observer-rated psychopathology, and functioning and disability. A principal component analysis was computed across all outcome variables. Identified dimensions were correlated with sociodemographic characteristics, illness history, premorbid adjustment and personality traits.

RESULTS

Three outcome dimensions were identified, i.e. a 'general subjective', a 'functioning/disability' and a 'manic/psychotic symptoms' dimension. Together they explain 69% of the total variance. The 'general subjective' dimension consists of SQOL scales and self-rated depressive symptoms. It is associated with comorbid anxiety disorders and personality disorders, high neuroticism and not having been in hospital in the last year. The 'functioning/disability' dimension comprises of criteria reflecting negative symptoms, disability and low functioning. It is associated with more prior illness episodes and low premorbid adjustment. The 'manic/psychotic symptoms' dimension consists of observer-rated manic and positive psychotic symptoms. It is correlated with not currently taking a specific medication.

LIMITATIONS

Cross-sectional design with a limited sample size.

CONCLUSION

The findings indicate that outcome criteria in bipolar I disorder can be grouped into three distinct dimensions reflecting (1) subjective appraisals, (2) functioning/disability and (3) manic/psychotic symptoms. While measurement of psychotic/manic symptoms has become a matter of course, until now few studies have assessed disability or subjective appraisal in bipolar illness. Therefore important aspects of bipolar illness might be overseen. For a better understanding, we suggest that longitudinal studies of bipolar I disorders should consider all three dimensions of outcome and measure them separately.

[Validating the efficacy of a group intervention program on the quality of life of depressed patient's spouses]

A new group intervention program has been assessed, rating its ability to increase the quality of life in partners of patients suffering under depression. Over a period of six months 66 subjects participated in an intervention group for a total of twelve sessions. The control group consisted of 50 persons, and quality of life was assessed with the WHOQOL-BREF. The five WHOLQOL domains were used as independent variables in random-effects regression models measuring the time effect. Although the quality of life of the subjects was below that of the general population at the beginning of the intervention, the study resulted in no significant improvement in quality of life. In contrast, satisfaction of participants with the intervention was high.

Change in work performance in vocational rehabilitation for people with severe mental illness: distinct responder groups

BACKGROUND

Vocational rehabilitation aims to improve work performance. Few studies have examined the course of work performance during vocational rehabilitation. It remains unclear whether all subjects profit equally from rehabilitation programs regarding improvement of work performance.

AIMS

The purpose of this study is to examine the course of work performance in order to differentiate between responder groups and to distinguish between those groups regarding sociodemographic status, psychiatric diagnosis, level of individual satisfaction and vocational rehabilitation success.

METHODS

Work performance of N = 125 subjects with severe mental disorders was rated on intake to the rehabilitation program and six months later with the German version of the Work Personality Profile (WPP). A cluster analysis was conducted to identify different responder groups.

RESULTS

Groups with poor, moderate, improving and superior work performance were identified. These groups differed in educational level, psychiatric diagnosis, individual satisfaction and rehabilitation outcome.

CONCLUSION

Not all subjects profit equally from vocational rehabilitation in terms of improvement of work performance. Unfavorable courses of work skills were shown for participants with schizophrenia and low education. Low individual satisfaction with performance is related to consistently low or moderate performance. Group differences predicted reintegration success. Future research should focus on different responder groups and their identification in early stages of the rehabilitation process to ensure appropriate assistance, particularly for subjects with poorer performance.

Maßnahmenabbrecher in der beruflichen Rehabilitation psychisch kranker Menschen

OBJECTIVE

To determine the conditional factors underlying a premature termination of vocational rehabilitation programs.

METHODS

123 rehabilitation participants were assessed prospectively regarding sociodemographic and psychopathological variables, level of functioning, subjective health, intellectual and work capacity.

RESULTS

23 persons terminated rehabilitation prematurely. Drop-outs differed regarding sociodemographic and illness-related variables, in subjective physical health, level of functioning, intelligence and work capacity. Three types of "drop-outs" could be identified: Termination due to exacerbation (of a functional psychosis), due to reluctance to show-up (mainly men with antisocial personality disorders) and a non-specific group.

CONCLUSION

Vocational rehabilitation of subjects with severe mental illness should take account of each rehabilitant's individual capacities and abilities as well as individual concepts of the disorder. Moreover, integrated concepts of medical treatment and vocational rehabilitation are needed to ensure rehabilitation success.

[Capability to work in vocational rehabilitation of the severe mentally ill: initial predictors and change after six months]

OBJECTIVE

Persons with severe mental illnesses often need additional vocational rehabilitation in order to gain or regain an adequate capability to work. The objective of this paper is the assessment of work capability and its development throughout the rehabilitation process, as well as clarification of its correlating variables, and predictors.

METHOD

We present data obtained at two different points in time (at rehabilitation program intake and at the six month mark of being in the program) from a sample of 117 rehabilitants. Capability to work was assessed by using the adapted German version of the Work Personality Profile (WPP), called the Arbeitsfähigkeitenprofil (AFP). Additionally, sociodemographic, intellectual, psychopathological, and subjective quality of life measures were examined.

RESULTS

The AFP sum score revealed a significant change after six months' participation in the rehabilitation program. More precisely, for the subscales "capability to learn" and "communication skills", a significant increase was obtained, whereas "social adaptation" showed a non-significant improvement.

CONCLUSION

Our results show that the rehabilitants' "capability to work" had improved at the six month mark of the rehabilitation program. It appears that baseline variables of the AFP subscales at program intake were largely related to psychopathology and subjective quality of life measures. Sociodemographic parameters, educational level, and attention measures were associated with work capability improvement after six months.

[Predicting improvement in work status of patients with chronic mental illness after vocational and integrative rehabilitation measurements]

PURPOSE

Chronically mentally ill patients often need special rehabilitation to be able to re-enter competitive employment. We know only very little about predicting favourable or unfavourable rehabilitation courses. The present study seeks to examine the relationship between successful rehabilitation -- as defined by a progress in professional ability -- and individual parameters obtained at initiation off-take.

METHOD

Data of 101 subjects who had completed a rehabilitation programme serve as the basis. At the beginning of rehabilitation, sociodemographic, intellectual, psychopathological and quality of life measures were obtained. Each participant was assigned to one of two rehabilitation outcome groups: progress vs. stagnation, determined by the vocational status after programme termination. Both groups were then compared regarding the aforementioned parameters at programme onset to identify substantial predictors for rehabilitation success via regression analysis.

RESULTS

High level of functioning, fewer periods of unemployment, a high level of work-related adaptation, and young age at programme onset were found to be predictive of progress in vocational status.

CONCLUSIONS

Objective parameters have a higher predictive potential regarding vocational reintegration of psychologically ill people compared to subjective criteria. Psychiatric diagnoses as defined by DSM-IV do not reveal relevant connections with subsequent vocational successful reintegration, whereas the initial level of functioning has a definite predictive value.

[Bipolar affective and schizoaffective disorders of older age -- classification, symptoms and course]

Bipolar affective and schizoaffective disorders of older age are underdiagnosed, although they are of growing importance for psychiatric services. In this review article, we present and discuss results concerning classification, psychopathology, epidemiology, course, prognosis, neuroimaging, family studies and therapy. Bipolar (schizo)affective disorders of older age are a diagnostic heterogeneous group, especially as secondary manias must be separated from "endogenous" bipolar disorders nosologically. Bipolar (schizo)affective disorders of older age show some peculiarities: Gender ratio, age at onset, mortality and comorbidity with neurological disease are amongst them. Nevertheless, in many other aspects bipolar (schizo)affective disorders of older age do not differ from bipolar disorders of younger patients. For the acute and maintenance treatment there is a dearth of controlled studies. Lithium is of great importance. Other substances, as well as psychoeducation and ECT may be used analogously as in younger patients, if age specific factors are taken into account (as for example the danger of falls).

Eine Studie über Personen mit Verwahrlosung, Vermüllung oder Horten

PURPOSE

Who develops neglect, lives in filth and squalor or tends to hoard? What happens to people with such tendencies, after heaving been discovered by community mental health services?

MATERIALS AND METHODS

During a two-year observation period it was attempted to study all such persons in the city of Halle/Saale. Life history as well as medical, social and psychiatric variables were assessed. After a mean period of 11 months these persons were re-assessed.

RESULTS

35 persons who lived in squalor and filth or in a neglected condition or who were known to hoard were assessed (60 % male, mean age: 63 years). 17 persons (49 %) suffered from an organic brain disease, 14 (40 %) fulfilled criteria of psychotic illness (mainly schizophrenia). In 9 cases a comorbid physical disorder contributed to the prevailing living conditions. After 11 months, for 21 persons (60 %) no amelioration of neglect, squalor or hoarding was observed, which was especially true for persons suffering from a psychotic illness. The results yielded some evidence that interventions, which aimed at living conditions (such as moving to sheltered accommodation), had positive effects, while this was not true for standard mental health care within community services and hospital treatment.

CONCLUSION

Neglect, living in squalor and hoarding are frequently symptoms of an underlying psychiatric or somatic illness. In this respect the results suggest that "standard care" proved to be of limited effect -- especially for subjects with a psychotic illness.

[Anxiety disorders comorbid with unipolar depression. Clinical diagnoses versus standardized diagnostic interview]

Anxiety disorders frequently co-occur with affective disorders. It is well-known that such comorbid anxiety disorders are more frequently diagnosed with standardized interviews than during the "daily routine." In 117 consecutive inpatients with major depression we assessed the frequency of DSM-IV anxiety disorders and compared it to the routine diagnoses of the discharge letters to analyze underlying principles of such diagnostic strategies. According to SCID-I (DSM-IV) 36 patients fulfilled criteria for a comorbid anxiety disorder, while this was only true for 17 patients according to discharge letters. Logistic regression revealed that clinically recognized cases had higher anxiety levels (higher diagnostic threshold). At the same time, in patients with higher depression scores anxiety syndromes tended not to be seen as separate disorders. This strategy is in line with "classic psychopathology," where severe depression (or melancholia) "included" anxiety symptoms. The borderline between depressive disorders and anxiety disorders is not as clear-cut as DSM-IV and ICD-10 try to indicate.

Factorial structure and internal consistency of the German TEMPS-A scale: validation against the NEO-FFI questionnaire

BACKGROUND

The purpose of the study was to evaluate the psychometric properties of the German version of the TEMPS-A questionnaire. Besides the reliability of the temperament scales, validity was the focus of interest. Therefore, the relationship between the TEMPS-A and the well-established personality questionnaire NEO-FFI, whose factors show theoretical overlap with temperaments, was investigated.

METHOD

A total of 227 students aged between 20 and 42 years were asked to fill in both instruments. Reliability coefficients for the five temperament scales and correlations among the scales of both questionnaires were calculated, as well as multiple linear regression analysis with the five personality factors and gender as independent, and the five temperaments as dependent variables.

RESULTS

Reliability indices for the five temperament scales were satisfactory, with values ranging between 0.63 (depressive) and 0.76 (anxious). Women scored higher on depressive and anxious scales, whereas men had higher scores on hyperthymic temperament. Correlations within the temperament scales showed close relationships between depressive, anxious and cyclothymic temperaments; cyclothymic and irritable temperament were also related. The personality factors of the NEO-FFI predicted temperaments fairly well and explained between 41% and 58% of the variance; the main effects were exerted by neuroticism and extraversion, while the irritable temperament was primarily explained by low agreeableness.

LIMITATION

The study sample was relatively small and selected.

CONCLUSION

The TEMPS-A scale has sufficient reliability and good validity in a non-clinical sample. It opens new possibilities for clinical research at the interface of mental disorders, temperament and personality. Such research is in progress.

Neuropsychologische Diagnostik in der beruflichen Rehabilitation schizophrener Menschen

Until now it is difficult to predict the success of vocational rehabilitation programs for subjects with severe mental illnesses. The growing knowledge about the neuropsychological mechanisms of psychiatric disorders has not been fully integrated into psychiatric rehabilitation research. We reviewed the literature how to use neuropsychological parameters for predicting outcome of vocational rehabilitation programs in subjects with schizophrenia and schizoaffective disorders. Twenty studies were reviewed, which evaluated neuropsychological variables to predict dimensions of rehabilitation success. As a result of this review, we suggest implementing neurocognitive tests, which assess executive functions, working memory, and attention deficits in routine rehabilitation to better plan and coordinate rehabilitation, and to predict rehabilitation outcome.

Lebensqualität bei unipolar depressiven und bipolar affektiven Patienten

OBJECTIVE

To assess subjective quality of life (QOL) of subjects with unipolar depressive and bipolar affective disorders.

METHODS

153 consecutive psychiatric in-patients were assessed with standardized interviews. Prior to discharge QOL was assessed with WHOQOL-bref. With the help of multivariate statistics, the effect of illness and biographical factors on four domains of QOL (physical health, psychological, social relationships and environment) was analyzed.

RESULTS

103 patients suffered from unipolar depression, 51 from bipolar affective disorder (30 fulfilled criteria for a mixed or pure manic episode). With the exception of the domain environment for (mixed) manic patients, all patients reported lower QOL in all domains than was reported for the general population according to the German test manual. Multivariate analyses revealed that the chosen variables explained between 11.1 % (social relationships) and 33.6 % (psychological) of the variance of the QOL domains. The domains "psychological" and "environment" were first of all explained by the presence of a (mixed) manic episode, while the best variable to predict "physical health" was presence of comorbid neurotic disorder. The depression score had little additional effects on QOL.

CONCLUSIONS

We found little support that the QOL domains of the WHOQOL-bref in affective disorder are only hidden depression scores, as has been argued before. Therefore, QOL could be an interesting construct to better understand differences between subjective evaluation and (supposedly) objective psychopathology in bipolar affective disorders.

Die vorzeitige Berentung von unipolar depressiv und bipolar affektiv Erkrankten

OBJECTIVE

Little is known concerning the frequency of disability payments due to depressive and bipolar affective disorders in Germany.

METHOD

177 consecutive psychiatric in-patients were assessed with standardized interviews concerning diagnosis (SCID-I, DSM-IV) and illness history. To compare unipolar depressive and bipolar affective patients, a survival analysis was calculated.

RESULTS

116 patients suffered from unipolar depression, 61 from bipolar affective disorder. Highly significantly, patients with bipolar affective disorders were granted disability payments more frequently and at an earlier age. Half of the bipolar affective patients received disability payments by the age of 46 years, half of the unipolar depressive patients by the age of 58 years.

CONCLUSIONS

In this sample, bipolar affective patients received disability payments frequently and at an early age, which stresses that the prognosis of bipolar affective disorders is not as good as has been assumed for a long time. Early disability payments may lead to poverty and may obstruct access to social rehabilitation.

Affective and schizoaffective mixed states

Although both DSM-IV and ICD-10 define schizoaffective mixed states, they have not received much attention-neither in the clinical nor in research context. We present preliminary results of a prospective study of bipolar affective (n = 100) and bipolar schizoaffective (n = 177) patients. 25% of the bipolar affective and 32% of the bipolar schizoaffective patients had at least one (schizo)mixed episode during the illness course. Nevertheless, (schizo)mixed episodes were rare-only 5.6% of all episodes. There was a trend that patients with (schizo)mixed episodes were more often women and exhibited more disability (reflected by higher rates of disability payments). Nevertheless, these differences failed to reach significance. Overall, schizo-mixed episodes are as frequent as "pure" affective mixed episodes. They might be linked to a less favourable course. Nevertheless, while their diagnostic criteria are problematic, they are systematically underdiagnosed.