[Chronic course and psychosocial disability caused by depressive illnesses in general practice patients during a one year period. Results of a study by the World Health Organization]

[Participation-oriented psychotherapy for patients with mental disorders who are able or unable to work : Results of a survey of practicing psychotherapists]

BACKGROUND

Treatment of (chronic) mental disorders must focus on both reducing symptoms and improving social and work participation by social medicine treatments and counselling. The objective of this study was to compare psychotherapy patients who are fit or unfit for work to describe similarities and differences regarding patient status and interventions.

METHODS

Interviews were performed with 73 cognitive behavior therapists and 58 psychodynamic psychotherapists about 188 and 134 recent cases they had seen, respectively. The case reports referred to patients who were on average 42 years old (65% females).

RESULTS

There were no differences between patients with no or short-term sick leave (up to 6 weeks, n = 156) and patients with longer sick leave (7 weeks or more, n = 140) with respect to basic characteristics of treatment (side effects, therapeutic alliance). Patients with a longer sick leave duration had more severe capacity and participation impairments and received more specific work participation-oriented treatments, whereas general saluto-therapeutic activities (sports-club, counselling, family-support) were similarly undertaken in patients with shorter or longer sick leave.

DISCUSSION

Therapists chose intervention options according to indication: in patients with work participation problems, more work-related treatments are undertaken, whereas interventions for general mental health improvement are distributed independent of specific work participation problems.

Work-related medical rehabilitation in patients with mental disorders: the protocol of a randomized controlled trial (WMR-P, DRKS00023175)

BACKGROUND

Various rehabilitation services and return-to-work programs have been developed in order to reduce sickness absence and increase sustainable return-to-work. To ensure that people with a high risk of not returning to work can participate in working life, the model of work-related medical rehabilitation was developed in Germany. The efficacy of these programs in patients with mental disorders has been tested in only a few trials with very specific intervention approaches. To date, there is no clear evidence of the effectiveness of work-related medical rehabilitation implemented in real-care practice.

METHODS/DESIGN

Our randomized controlled trial will be conducted in six rehabilitation centers across Germany. Within 15 months, 1800 patients with mental disorders (300 per rehabilitation center) will be recruited and assigned one-to-one either to a work-related medical rehabilitation program or to a conventional psychosomatic rehabilitation program. Participants will be aged 18-60 years. The control group will receive a conventional psychosomatic rehabilitation program without additional work-related components. The intervention group will receive a work-related medical rehabilitation program that contains at least 11 h of work-related treatment modules. Follow-up data will be assessed at the end of the rehabilitation and 3 and 12 months after completing the rehabilitation program. The primary outcome is a stable return to work. Secondary outcomes cover several dimensions of health, functioning and coping strategies. Focus groups and individual interviews supplement our study with qualitative data.

DISCUSSION

This study will determine the relative effectiveness of a complex and newly implemented work-related rehabilitation strategy for patients with mental disorders.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00023175 , September 29 2020).

Patients Characteristics and Psychosocial Treatment in Psychodynamic and Cognitive Behavior Therapy

Introduction: The most prevalent psychotherapy schools are psychodynamic (PDT) and cognitive behavior therapy (CBT). There are no scientific guidelines on which type of patient should be treated by which therapist, and how they can find the best one. Part of the answer can be derived from data on who is treated in which way. Objective: Objective of this study was to compare patients in routine PDT and CBT to describe similarities and differences in regard to patient status and treatment. Materials and Methods: A research psychotherapist visited 73 cognitive behavior therapists and 58 psychodynamic psychotherapists in their office and asked them to report about the last cases they had seen. There were 188 CBT and 134 PD case reports. Results: There were no significant differences in socio-demographics between PDT and CBT patients. The average number of treatment session so far was significantly higher in PDT than CBT. There were longer duration of illness, more parallel medical treatments and higher rates of sick leave in CBT patients. While assessment of capacities with the Mini-ICF-APP showed no differences, more participation restrictions were found in CBT patients. Correspondingly there were more sociomedical interventions, especially in regard to work. Conclusions: The differences between PDT and CBT may be explained by the fact that PDT requires analytical capabilities on the side of the patient, which may exclude patients with social problems, while CBT is coping oriented which allows the inclusion of all kinds of patients. Still, in both treatment modes, complex patients are treated with multidimensional interventions.

Parameters of education and the course of depression: an analysis in the Turkish sociocultural context

BACKGROUND

Major depression (MD) is often marked by an unfavourable course. Education repeatedly was found to be associated with better mental health variables, but longitudinal data are scarce. This evaluation seeks to identify the predictive role of specific aspects of education on the course of depression in a socioculturally defined setting.

METHODS

A sample of 69 unipolar MD outpatients in university and primary health care in Antalya, Turkey were observed naturalistically for a mean 11-month period. The baseline examination included several psychosocial variables, among them the highest attained schooling degree (DEG), possible further but unfulfilled educational aspirations (UEA), and the participants' parental educational level (PEL). The depressive symptomatology was assessed with the HAM-D-17 at baseline and at four-monthly follow-ups. A binary variable differentiated 'non-remissive' from 'remissive' courses, the latter displaying at least temporal partial remissions.

RESULTS

Forty-two per cent of the sample displayed a non-remissive one-year course of MD. Half of the participants reported UEA. This was more prevalent among women, and qualitative information added causal gender-specific perceptions. In logistic regression, DEG proved prognostic impact, but was exceeded by the combination of UEA and PEL as the strongest predictor model (Cox & Snell R(2) = 0.217). This remained when controlled for place of examination, gender and initial severity of depression. As risk factors for low education, a pattern of female gender and large family size (itself predicted by rural descent) emerged.

CONCLUSIONS

Low education proved to be a risk factor for an unfavourable course of MD. Not only actual experienced schooling, but also unfulfilled academic aspirations and a low parental educational level appear to be of crucial impact.

The role of caregivers' depressive symptoms and asthma beliefs on asthma outcomes among low-income Puerto Rican children

OBJECTIVE

To examine the relationship between depressive symptoms and asthma beliefs (self-efficacy and empowerment), child asthma outcomes, and caregiver's quality of life among Puerto Rican caregivers of children with asthma.

METHODS

The caregivers of 221 children with persistent bronchial asthma were stratified into those with no/low or high levels of depressive symptoms. Differences between the groups in caregiver self-efficacy, family empowerment, child asthma outcomes, and quality of life were examined.

RESULTS

Caregivers with more depressive symptoms reported lower self-efficacy, less empowerment, less symptom-free days and nights for their children, and a lower quality of life compared to caregivers with no or fewer depressive symptoms.

CONCLUSIONS

Depressive symptoms among Puerto Rican caregivers were associated with asthma beliefs, children's asthma symptoms, and caregiver quality of life. Our findings reinforce the importance of physician screening skills in recognizing caregiver depression in parents of asthma patients.

Disorders of functions and disorders of capacity in relation to sick leave in mental disorders

BACKGROUND

With the publication of the International Classification of Functioning, Disability and Health (ICF), the description of functional health as opposed to symptoms of illness has gained in importance.

AIMS

To study the interrelation between disorders of functions, capacity and participation in mental disorders.

METHOD

Two hundred and thirteen psychosomatic inpatients were assessed with the Mini-ICF-Rating for Mental Disorders (Mini-ICF-P), the Symptom Checklist (SCL-90-R) and an interview on sick leave.

RESULTS

The highest scores in the Mini-ICF-P were found for 'flexibility' (M = 1.64, SD = 0.94), 'structuring of tasks' (M = 1.12, SD = 1.05) and 'endurance' (M = 1.12, SD = 1.02), the lowest for 'self maintenance' (M = 0.19, SD = 0.44), 'mobility' (M = 0.43, SD = 0.85) and 'adherence to regulations' (M = 0.74, SD = 0.98). The correlation between Mini-ICF-P and SCL-90-R GSI is r = 0.51 (p < 0.001), between sick leave and GSI is r = -0.05 and between sick leave and Mini-ICF-P r = 0.34 ( p < 0.001).

CONCLUSION

Disorders of capacity are more closely related to disorders of participation/sick leave than disorders of functions.

A comparative study of nonspecific depressive symptoms and minor depression regarding functional impairment and associated characteristics in primary care

BACKGROUND

Milder forms of depression are highly prevalent in the clinical setting as well as in primary care. However, it is still unclear whether there are distinguishable groups among the various subthreshold syndromes and to what extent they are associated with impairment, thus requiring treatment. Therefore, the study aimed at comparing the degree of impairment in 2 groups of subthreshold depressive patients (nonspecific and minor depressive) with nondepressive patients and with major depressive patients. Another aim of the study was to evaluate the spectrum hypothesis of depressive syndromes.

SAMPLING AND METHODS

A sample of 619 primary care patients was studied using the self-administered Patient Health Questionnaire (PHQ). After defining subthreshold depressive syndromes on a criterion basis, frequencies, sociodemographic factors, and impairment of nondepressive, subthreshold depressive, and major depressive patients were compared.

RESULTS

Nonspecific depressive symptoms (NDS) were diagnosed in 9.1% of the study subjects and minor depression in 6.2%. Subjects with subthreshold depressive disorders did not differ from each other or from subjects with major depression regarding sociodemographic risk factors such as age, sex, or marital status. Yet, a continually increasing impairment from NDS to minor depression to major depression could be found. Moreover, the investigated groups differed with regard to the severity index.

CONCLUSIONS

The results of the study are in accordance with the spectrum hypothesis of depressive syndromes ranging from NDS to minor depression to major depression. Patients with subsyndromal depression showed significant functional impairment to the extent that at least some of these patients probably had a disorder requiring treatment.

Arbeitsunfähigkeit bei psychischen Störungen

Sick leave certifications allow patients to stay away from work without negative consequences. German regulations state that patients can be granted sick leave when duties can no longer be fulfilled or may endanger health status and when there is a causal relationship between illness and disability. Relevant is not the presence of illness but of a disability which interferes with work requirements. In Germany, an average of 4% of workers are on sick leave at any given time, corresponding to about 2 weeks per year and person. The level of sick leave depends not only on the patient's health status but also on social factors. Mental disorders are a major reason for sick leave. Sick leave can have negative effects by fostering chronicity. In 75% of cases, physicians have been found to grant sick leave incorrectly. It must be kept in mind that not illness per se but only disorders of participation justify sick leave.

Sind Bonussysteme auf eine leitlinienkonforme haus- und nerven�rztliche Depressionsbehandlung �bertragbar?

In the outpatient treatment of depression, the potential of diagnostic and therapeutic methods is seldom exhausted resulting in variable quality of treatment and partly insufficient cost effectiveness. Implementation of a guideline-oriented reimbursement system seems to be an option to improve quality of treatment. Corresponding incentive systems have been outlined and evaluated for the health care of somatic diseases such as diabetes. Acting on these experiences, an attempt was made to utilize them for the area of psychiatric disorders. Taking depression as an example, a model for a quality-oriented, guideline-based reimbursement system for general and specialist practice is presented.

[Epidemology and treatment of depressive disorders]

5-10% of the general population suffer from depressive disorders, one third of which are chronic. Depression impairs the quality of life, and 30.8% of patients show reduced working capacity. Patients are on average 10.9 days per month on sick leave. About half of the depressed patients undergo treatment, contacting general practitioners at an average of 14.5 times, psychotherapists 2 times and psychiatrists 1.4 times per year. Approximately 100 million daily doses of specific antidepressants are prescribed per year in Germany, an amount enough to treat 1% of the general population, which is indicative of an insufficient treatment rate. Pharmacotherapy has been found to be more effective than psychotherapy in acute episodes. However, psychotherapy patients show better long term results in respect to relapses and social adaptation. Due to the large number of depressed patients, general practitioners are the primary therapists. Referral to psychiatrists or psychotherapists is indicated in cases of chronic and complicated courses.