Dietmar Kramer

Are Treatment Preferences Relevant in Response to Serotonergic Antidepressants and Cognitive-Behavioral Therapy in Depressed Primary Care Patients? Results from a Randomized Controlled Trial Including a Patients’ Choice Arm

Background: Little is known about the influence of depressed patients’ preferences and expectations about treatments upon treatment outcome. We investigated whether better clinical outcome in depressed primary care patients is associated with receiving their preferred treatment. Methods: Within a randomized placebo-controlled single-centre 10-week trial with 5 arms (sertraline; placebo; cognitive-behavioral group therapy, CBT-G; moderated self-help group control; treatment with sertraline or CBT-G according to patients’ choice), outcomes for 145 primary care patients with mild-to-moderate depressive disorders according to DSM-IV criteria were investigated. Preference for medication versus psychotherapy was assessed at screening using a single item. Post-baseline difference scores for the Hamilton Depression Rating Scale (HAMD-17) were used to assess treatment outcome (mixed-model repeated-measures regression analysis). Results: Depressed patients receiving their preferred treatment (n = 63), whether sertraline or CBT-G, responded significantly better than those who did not receive their preferred therapy (n = 54; p = 0.001). The difference in outcome between both groups was 8.0 points on the HAMD-17 for psychotherapy and 2.9 points on the HAMD-17 for treatment with antidepressants. Results were not explained by differences in depression severity or dropout rates. Conclusions: Patients’ relative preference for medication versus psychotherapy should be considered when offering a treatment because receiving the preferred treatment conveys an additional and clinically relevant benefit (HAMD-17: +2.9 points for drugs; +8.0 points for CBT-G) in outcome.

Screening for depression in the older long-term unemployed

BackgroundMisdiagnosis and undertreatment of depression in older, long-term unemployed people may not only pose a serious medical problem, but may also be an obstacle for their vocational reintegration. Screening for depression could be a first step to increasing treatment rates within this high-risk group. Therefore, the WHO-5 Well-Being Index was tested for its validity in unemployment offices.MethodologyThree hundred and sixty-five participants in a German programme for the vocational reintegration of long-term unemployed people were screened with the WHO-5 Well-Being Index. In 104 of these subjects, ICD-10 diagnoses were made using DIA-X Structured Clinical Interview.ResultsUsing the DIA-X data as a gold standard, the WHO-5 Well-Being Index obtained satisfactory results for sensitivity (82.5%) and specificity (70.3%) as a screening tool for affective disorders when used with an adjusted cut-off-point of ≤12. While none of the 18.5% male participants diagnosed with major depression received treatment, half of the 24% of female participants with major depression received treatment.ConclusionScreening with the WHO-5 within unemployment offices is useful to detect people with depressive disorders. Many of them do not receive optimal treatment and can be motivated to seek professional help. Reducing depression by better treatment will also increase the chances of reemployment.

Beside the Geriatric Depression Scale: the WHO-Five Well-being Index as a valid screening tool for depression in nursing homes

The aim of the study was to compare criterion validities of the WHO‐Five Well‐being Index (WHO‐5) and the Geriatric Depression Scale 15‐item version (GDS‐15) and 4‐item version (GDS‐4) as screening instruments for depression in nursing home residents.

Validität der Geriatrischen Depressionsskala bei Altenheimbewohnern: Vergleich von GDS-15, GDS-8 und GDS-4

OBJECTIVE To assess and compare the validity of the German 15-item version and shortened versions of the Geriatric Depression Scale (GDS) for early detection of depression in nursing home residents with mild to moderate cognitive impairment (MMSE ≥ 15). METHODS Data from 92 patients were analysed. The Structural Clinical Interview for DSM-IV (SCID) was used as the gold standard. The diagnoses covered in this assessment were current major depression (MD) and minor depression (MinD). The performance of the GDS scales was evaluated using receiver operating characteristics (ROC). Main outcome measures were AUC (area under curve) values, as well as sensitivity and specificity. RESULTS Overall diagnostic validity of the GDS-15 was better for MD than for MinD (AUC: 89.7 % and 73.4 %, respectively). In assessing MD, AUC values as well as sensitivity and specificity were comparable for the GDS-15 and the GDS-8. A cut-off point ≥ 5 on the GDS-8 gave optimum performance (sensitivity: 76.9 %, specificity: 88.6 %). For the best cut-off point ≥ 2, the corresponding values of the GDS-4 were 53.8 % and 92.4 %. CONCLUSIONS The GDS-8 appears to be a less time-consuming alternative for the nursing home setting. However, the GDS-4 is not suitable for this population.

Outpatient Psychotherapy Reduces Health-Care Costs: A Study of 22,294 Insurants over 5 Years.

Background The project “Quality Assurance in Ambulatory Psychotherapy in Bavaria” (QS-PSY-BAY) focuses on the quality assurance of outpatient psychotherapy (OPT) in Germany in terms of symptom reduction and cost reduction under naturalistic conditions. In this study, we examined the effectiveness of psychotherapy in terms of pre–post cost reduction. Method The health-care costs of N = 22,294 insurants over a 5-year period were examined in a naturalistic longitudinal design. Six participating health insurance funds provided data on costs related to inpatient treatment, outpatient treatment, drugs, and hospitalization and work disability days. Results We found that the average annual total costs for inpatient and outpatient treatments as well as drug costs and work disability days increased from the second to the first year before OPT. Besides a large and significant reduction of work disability days (41.8%), hospitalization days (27.4%), and inpatient costs (21.5%) from the first year before versus the first year following OPT, we found evidence for long-term effects: the number of work disability days in the second year after OPT was lower (23.8%), and drug costs were higher than in the second year before OPT (41.5%). Conclusion We conclude that OPT as a part of the health insurance system is an investment which can pay off in the future especially in terms of lower inpatient costs and work disability.

Abbrüche antragspflichtiger ambulanter Psychotherapien: Häufigkeit, Risikofaktoren, Outcome

OBJECTIVE Because premature discontinuation of psychotherapy limits the effectiveness of the interventions, in a naturalistic design we examined the prevalence, predictors, and outcome of premature discontinuation. METHODS The sample included N = 584 patients with various mental disorders. Risk factors were identified using regression analysis. As outcome Patient Health Questionnaire scales were considered. We compared pre and post averages as well as post averages of premature discontinuation versus regular termination. RESULTS Risk factors were: female and/or unemployed patient, low patient and/or therapist ratings regarding therapy success, and extraordinarily high therapist ratings of the therapeutic alliance. Despite premature discontinuation we found significant reductions of depression, anxiety, somatic symptoms, and stress (ES = 0.30, …, 0.44). Compared to regular termination though, patients with premature discontinuation were more impaired at last measurement (ES = 0.17, …, 0.37). CONCLUSION Not each premature discontinuation is a psychotherapeutic failure. Warning signals for looming premature discontinuation are low ratings of therapy success while psychotherapeutic treatment.

Wissens- und Einstellungsänderung zu Depression und Suizidalität bei Altenpflegekräften: Evaluation eines Fortbildungsprojektes@@@Improvement of knowledge and attitudes towards depression and suicidality in geriatric caregivers: Evaluation of an advanced training program

Depressive disorders rank among the most frequent mental disorders in the elderly. Especially in the elderly, depressive disorders are still underrecognized and not sufficiently treated. In view of the associated risks and complications, early and timely recognition of depressive disorders is essential to avoid exacerbation and chronic manifestation of the depressive symptoms and to antagonize the increased suicide risk as well as negative effects on concomitant somatic diseases. More than any other occupational group, geriatric caregivers have a key position in the contact with clients, relatives and treating primary care providers. Therefore, 3487 geriatric caregivers from 448 outpatient nursing services throughout Bavaria participated in 196 four-hour training courses about depressive disorders and suicidality in the elderly between March 2006 and August 2007. Aim of this activity was to reduce attitudes enclosed in a wall of prejudice and to teach specific knowledge about depression and suicidality in the elderly. This training was evaluated using specially tailored questionnaires which were completed immediately before and after the continuing education as well as three months later (at follow-up). The analysis included the individual changes of 473 participants in longitudinal sections. Pronounced knowledge deficits and reservations were found regarding pharmacotherapy with antidepressants and suicidality. In this context, significant changes in all categories were present. Especially pronounced effects were found for the attitudes towards depression and suicidality as well as treatability with antidepressants. These changes were stable, as indicated by the follow-up evaluation.Depressionen gehören zu den häufigsten psychischen Erkrankungen im Alter. Besonders bei alten Menschen werden diese nach wie vor nur unzureichend erkannt und nicht suffizient behandelt. Ein möglichst frühzeitiges Erkennen depressiver Erkrankungen ist angesichts der damit verbundenen Risiken und Komplikationen essentiell, insbesondere um eine Exazerbation oder Chronifizierung der depressiven Symptomatik zu vermeiden und der erhöhten Suizidgefahr sowie negativen Auswirkungen auf bestehende somatische Erkrankungen entgegenzuwirken. Wie keine andere Berufsgruppe nehmen Altenpflegekräfte eine Schlüsselposition im Kontakt mit Klienten, Angehörigen sowie behandelnden Hausärzten ein. Daher wurden zwischen März 2006 und August 2007 insgesamt 3.487 Altenpflegekräfte aus 448 ambulanten Pflegediensten in ganz Bayern in 196 vierstündigen Fortbildungen zu den Themen Depression und Suizidalität im Alter geschult. Ziel der Maßnahme war es, vorurteilsbehaftete Einstellungen abzubauen und spezifisches Wissen über Depression und Suizidalität im Alter zu vermitteln. Die Maßnahme wurde anhand speziell konzipierter Fragebogen evaluiert, die unmittelbar vor und nach der Fortbildung (Prä und Post) sowie nach drei Monaten (Follow-up) ausgegeben wurden. In die Auswertung gingen die individuellen Veränderungen von 473 Teilnehmern im Längsschnitt ein. Ausgeprägte Vorbehalte und Wissenslücken betrafen die Themenkomplexe „Pharmakotherapie mit Antidepressiva“ und „Umgang mit Suizidalität“. Es zeigten sich signifikante Veränderungen in allen Fragekategorien. Besonders deutliche Effekte wurden hinsichtlich der Einstellung gegenüber Depression und Suizidalität sowie der Behandelbarkeit mit Antidepressiva erreicht. Diese Veränderungen erwiesen sich bis zum Follow-up als stabil.AbstractDepressive disorders rank among the most frequent mental disorders in the elderly. Especially in the elderly, depressive disorders are still underrecognized and not sufficiently treated. In view of the associated risks and complications, early and timely recognition of depressive disorders is essential to avoid exacerbation and chronic manifestation of the depressive symptoms and to antagonize the increased suicide risk as well as negative effects on concomitant somatic diseases. More than any other occupational group, geriatric caregivers have a key position in the contact with clients, relatives and treating primary care providers. Therefore, 3487 geriatric caregivers from 448 outpatient nursing services throughout Bavaria participated in 196 four-hour training courses about depressive disorders and suicidality in the elderly between March 2006 and August 2007. Aim of this activity was to reduce attitudes enclosed in a wall of prejudice and to teach specific knowledge about depression and suicidality in the elderly. This training was evaluated using specially tailored questionnaires which were completed immediately before and after the continuing education as well as three months later (at follow-up). The analysis included the individual changes of 473 participants in longitudinal sections. Pronounced knowledge deficits and reservations were found regarding pharmacotherapy with antidepressants and suicidality. In this context, significant changes in all categories were present. Especially pronounced effects were found for the attitudes towards depression and suicidality as well as treatability with antidepressants. These changes were stable, as indicated by the follow-up evaluation.

Wissens- und Einstellungsänderung zu Depression und Suizidalität bei Altenpflegekräften: Evaluation eines Fortbildungsprojektes

Depressive disorders rank among the most frequent mental disorders in the elderly. Especially in the elderly, depressive disorders are still underrecognized and not sufficiently treated. In view of the associated risks and complications, early and timely recognition of depressive disorders is essential to avoid exacerbation and chronic manifestation of the depressive symptoms and to antagonize the increased suicide risk as well as negative effects on concomitant somatic diseases. More than any other occupational group, geriatric caregivers have a key position in the contact with clients, relatives and treating primary care providers. Therefore, 3487 geriatric caregivers from 448 outpatient nursing services throughout Bavaria participated in 196 four-hour training courses about depressive disorders and suicidality in the elderly between March 2006 and August 2007. Aim of this activity was to reduce attitudes enclosed in a wall of prejudice and to teach specific knowledge about depression and suicidality in the elderly. This training was evaluated using specially tailored questionnaires which were completed immediately before and after the continuing education as well as three months later (at follow-up). The analysis included the individual changes of 473 participants in longitudinal sections. Pronounced knowledge deficits and reservations were found regarding pharmacotherapy with antidepressants and suicidality. In this context, significant changes in all categories were present. Especially pronounced effects were found for the attitudes towards depression and suicidality as well as treatability with antidepressants. These changes were stable, as indicated by the follow-up evaluation.Depressionen gehören zu den häufigsten psychischen Erkrankungen im Alter. Besonders bei alten Menschen werden diese nach wie vor nur unzureichend erkannt und nicht suffizient behandelt. Ein möglichst frühzeitiges Erkennen depressiver Erkrankungen ist angesichts der damit verbundenen Risiken und Komplikationen essentiell, insbesondere um eine Exazerbation oder Chronifizierung der depressiven Symptomatik zu vermeiden und der erhöhten Suizidgefahr sowie negativen Auswirkungen auf bestehende somatische Erkrankungen entgegenzuwirken. Wie keine andere Berufsgruppe nehmen Altenpflegekräfte eine Schlüsselposition im Kontakt mit Klienten, Angehörigen sowie behandelnden Hausärzten ein. Daher wurden zwischen März 2006 und August 2007 insgesamt 3.487 Altenpflegekräfte aus 448 ambulanten Pflegediensten in ganz Bayern in 196 vierstündigen Fortbildungen zu den Themen Depression und Suizidalität im Alter geschult. Ziel der Maßnahme war es, vorurteilsbehaftete Einstellungen abzubauen und spezifisches Wissen über Depression und Suizidalität im Alter zu vermitteln. Die Maßnahme wurde anhand speziell konzipierter Fragebogen evaluiert, die unmittelbar vor und nach der Fortbildung (Prä und Post) sowie nach drei Monaten (Follow-up) ausgegeben wurden. In die Auswertung gingen die individuellen Veränderungen von 473 Teilnehmern im Längsschnitt ein. Ausgeprägte Vorbehalte und Wissenslücken betrafen die Themenkomplexe „Pharmakotherapie mit Antidepressiva“ und „Umgang mit Suizidalität“. Es zeigten sich signifikante Veränderungen in allen Fragekategorien. Besonders deutliche Effekte wurden hinsichtlich der Einstellung gegenüber Depression und Suizidalität sowie der Behandelbarkeit mit Antidepressiva erreicht. Diese Veränderungen erwiesen sich bis zum Follow-up als stabil.AbstractDepressive disorders rank among the most frequent mental disorders in the elderly. Especially in the elderly, depressive disorders are still underrecognized and not sufficiently treated. In view of the associated risks and complications, early and timely recognition of depressive disorders is essential to avoid exacerbation and chronic manifestation of the depressive symptoms and to antagonize the increased suicide risk as well as negative effects on concomitant somatic diseases. More than any other occupational group, geriatric caregivers have a key position in the contact with clients, relatives and treating primary care providers. Therefore, 3487 geriatric caregivers from 448 outpatient nursing services throughout Bavaria participated in 196 four-hour training courses about depressive disorders and suicidality in the elderly between March 2006 and August 2007. Aim of this activity was to reduce attitudes enclosed in a wall of prejudice and to teach specific knowledge about depression and suicidality in the elderly. This training was evaluated using specially tailored questionnaires which were completed immediately before and after the continuing education as well as three months later (at follow-up). The analysis included the individual changes of 473 participants in longitudinal sections. Pronounced knowledge deficits and reservations were found regarding pharmacotherapy with antidepressants and suicidality. In this context, significant changes in all categories were present. Especially pronounced effects were found for the attitudes towards depression and suicidality as well as treatability with antidepressants. These changes were stable, as indicated by the follow-up evaluation.

P02-229 - Screening for depression in nursing homes: Validity of the WHO (Five) Well-Being Index

OBJECTIVE Depression is common in nursing home residents, but is still underrecognized. Screening for depression could be a first step to increase recognition rates within this high-risk group. Therefore, we investigated the validity of the WHO (Five) Well-Being Index (WHO-5) for early detection of depression in nursing home residents. METHODS The Structural Clinical Interview for DSM-IV (SCID) was used as the gold standard for the validation of the WHO-5. The diagnoses covered in this assessment were both current major depression as well as minor depression according to DSM-IV research criteria. RESULTS In our sample of 92 nursing home residents in Munich aged 65-97 years, (73.9% female, 26.1% male) 14.1% fulfilled the criteria of major depression and again 14.1% fulfilled the criteria of minor depression in the SCID. Overall diagnostic validity (area under the ROC curve) of the WHO-5 was .90 (95% confidence interval: .84- .97). The best cut-off-point according to Youdens index yielded a sensitivity of .92 and a specificity of .79. CONCLUSIONS The diagnostic accuracy of the WHO-5 in our study is promising. The WHO-5 might be an efficient screening tool for nursing home residents, but results have to be replicated in a larger sample.

P01-71 - Are treatment preferences relevant for response to serotonergic antidepressants and cognitive-behavioural therapy in depressed primary care patients?

Objectives Little is known about the influence of patients’ preferences and expectations about offered treatments for depression on treatment outcome. Therefore, we investigated whether in primary care patients with depressive disorders receiving a preferred treatment is associated with a better clinical outcome. Methods Within a randomized, placebo-controlled, single-centre, 10-week trial with five arms (sertraline; placebo; cognitive-behavioural group therapy (CBT-G); moderated self-help group control; treatment with sertraline or CBT-G according to patients’ choice), 145 primary care patients with mild-to-moderate depressive disorders according to DSM-IV criteria were investigated. Preference for medication versus psychotherapy was assessed at the time of patients’ screening using a single item. To assess therapy outcome, the post-baseline sum scores of the Hamilton Depression Rating Scale (HAMD-17) were used. Results Depressed patients receiving their preferred treatment (sertraline or CBT-G) (N=63) responded significantly better than those who did not receive their preferred therapy (N=54) (p = 0.001). The difference in outcome between both groups was 8.0 points on HAMD-17 for psychotherapy and 2.9 points on HAMD-17 for treatment with antidepressants. This result is not explained by differences in depression severity or drop-out rates. Conclusions Patients’ preference for pharmaco- versus psychotherapy should be considered when offering a treatment because receiving the preferred treatment conveys an additional and clinically relevant benefit (HAMD-17: +2.9 points for drugs; +8.0 points for CBT-G) in outcome.