Elisabeth Schramm

Prevalence and treatment of insomnia in general practice. A longitudinal study

SummaryThe aim of the study was to assess prevalence and treatment modalities of insomnia in general practice. To investigate the course of insomnia, a longitudinal study design was adopted. Two thousand five hundred and twelve patients (age 18–65 years) were investigated with a questionnaire in general practice (T1). Four months later (T2) and again 2 years later (T3) a questionnaire was sent to all patients who had complained about severe insomnia at the time of the first inquiry. To assess insomnia, operationalized diagnostic criteria were applied (DSM-III-R). Eighteen point seven percent suffered from severe, 12.2% suffered from moderate and 15% suffered from mild insomnia. In the course of 2 years insomnia appeared as a chronic health problem. A high comorbidity of severe insomnia was found with chronic somatic and psychiatric disorders, especially with depression. Of the severely insomniac patients, 23.9% used prescribed hypnotics habitually, mainly benzodiazepines. The use of prescribed hypnotics remained rather stable during the whole study period. More than half of the patients reported a daily use of the hypnotics for 1–5 years or longer, but only 22% of the severely insomniac patients reported at the time of the third inquiry a significant improvement of insomnia due to the administration of sleeping pills. Thus, the long-term administration of benzodiazepine hypnotics seems to be an inadequate treatment strategy in chronic insomnia. Whether the occurrence of rebound insomnia after benzodiazepine withdrawal may be one of the main factors for chronic hypnotic use requires discussion. Although insomnia may be an important symptom of many somatic and psychiatric disorders, the general practitioner was unaware in more than half of the cases that the patients suffered from a sleep problem. Severe insomniac patients displayed a higher mean number of medical consultations compared with good sleepers or patients with mild insomnia, indicating that insomnia constitutes a significant burden for the primary care physicians.

Subcortical brain alterations in major depressive disorder: findings from the ENIGMA Major Depressive Disorder working group.

The pattern of structural brain alterations associated with major depressive disorder (MDD) remains unresolved. This is in part due to small sample sizes of neuroimaging studies resulting in limited statistical power, disease heterogeneity and the complex interactions between clinical characteristics and brain morphology. To address this, we meta-analyzed three-dimensional brain magnetic resonance imaging data from 1728 MDD patients and 7199 controls from 15 research samples worldwide, to identify subcortical brain volumes that robustly discriminate MDD patients from healthy controls. Relative to controls, patients had significantly lower hippocampal volumes (Cohen’s d=−0.14, % difference=−1.24). This effect was driven by patients with recurrent MDD (Cohen’s d=−0.17, % difference=−1.44), and we detected no differences between first episode patients and controls. Age of onset ⩽21 was associated with a smaller hippocampus (Cohen’s d=−0.20, % difference=−1.85) and a trend toward smaller amygdala (Cohen’s d=−0.11, % difference=−1.23) and larger lateral ventricles (Cohen’s d=0.12, % difference=5.11). Symptom severity at study inclusion was not associated with any regional brain volumes. Sample characteristics such as mean age, proportion of antidepressant users and proportion of remitted patients, and methodological characteristics did not significantly moderate alterations in brain volumes in MDD. Samples with a higher proportion of antipsychotic medication users showed larger caudate volumes in MDD patients compared with controls. This currently largest worldwide effort to identify subcortical brain alterations showed robust smaller hippocampal volumes in MDD patients, moderated by age of onset and first episode versus recurrent episode status.

Prevalence of insomnia in elderly general practice attenders and the current treatment modalities

This study aimed to assess the prevalence and treatment modalities of elderly practice attenders. A total of 330 patients aged over 65 years were investigated with a questionnaire in general practice. To assess insomnia, operationalized diagnostic criteria according to DSM‐III‐R were applied. Twenty‐three percent of the elderly patients suffered from severe, 17% from moderate and 17% from mild insomnia. More than 80% of the patients reported suffering from insomnia for 1–5 years or longer, which indicates a chronic course. Elderly patients showed unrealistic expectations concerning duration of sleep and spend more time in bed than they realistically can expect to sleep. More than half of the elderly patients reported habitual daytime napping. Sleep‐disturbed elderly patients did not differ significantly from good sleepers in their habit of taking daytime naps, but even when taking daytime naps, good sleepers slept significantly longer than the sleep‐disturbed patients. A significant association was found between insomnia and mental disorders, i.e., depression and organic brain syndrome according to the diagnosis of the general physician. In about half of the cases the primary care physician was not aware that the elderly patient suffered from severe insomnia. More than half of the elderly severe insomniacs took prescribed hypnotics habitually, mainly benzodiazepines.

Self-stigma in Women With Borderline Personality Disorder and Women With Social Phobia

Little is known about how women with borderline personality disorder (BPD) and women with social phobia react to mental illness stigma. The goal of this study was to assess empirically self-stigma and its correlates in these groups. Self-stigma and related constructs were measured by self-report questionnaires among 60 women with BPD and 30 women with social phobia. Self-stigma was inversely related to self-esteem, self-efficacy, and quality of life and predicted low self-esteem after controlling for depression and shame-proneness. Stereotype awareness was not significantly correlated with self-esteem or quality of life. While there was no difference in stereotype awareness between women with BPD and women with social phobia, women with BPD showed higher self-stigma than women with social phobia. Self-stigma is associated with low self-esteem and other indices of poor psychological well-being. In comparison to women with social phobia, women with BPD suffer from more self-stigma. This may reflect intense labeling processes as being mentally ill due to repeated hospitalizations, frequent interpersonal difficulties, and visible scars.

Cortical abnormalities in adults and adolescents with major depression based on brain scans from 20 cohorts worldwide in the ENIGMA Major Depressive Disorder Working Group

The neuro-anatomical substrates of major depressive disorder (MDD) are still not well understood, despite many neuroimaging studies over the past few decades. Here we present the largest ever worldwide study by the ENIGMA (Enhancing Neuro Imaging Genetics through Meta-Analysis) Major Depressive Disorder Working Group on cortical structural alterations in MDD. Structural T1-weighted brain magnetic resonance imaging (MRI) scans from 2148 MDD patients and 7957 healthy controls were analysed with harmonized protocols at 20 sites around the world. To detect consistent effects of MDD and its modulators on cortical thickness and surface area estimates derived from MRI, statistical effects from sites were meta-analysed separately for adults and adolescents. Adults with MDD had thinner cortical gray matter than controls in the orbitofrontal cortex (OFC), anterior and posterior cingulate, insula and temporal lobes (Cohen’s d effect sizes: −0.10 to −0.14). These effects were most pronounced in first episode and adult-onset patients (>21 years). Compared to matched controls, adolescents with MDD had lower total surface area (but no differences in cortical thickness) and regional reductions in frontal regions (medial OFC and superior frontal gyrus) and primary and higher-order visual, somatosensory and motor areas (d: −0.26 to −0.57). The strongest effects were found in recurrent adolescent patients. This highly powered global effort to identify consistent brain abnormalities showed widespread cortical alterations in MDD patients as compared to controls and suggests that MDD may impact brain structure in a highly dynamic way, with different patterns of alterations at different stages of life.

Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: A randomized pilot study

BACKGROUND The only psychotherapy specifically designed and evaluated for the treatment of chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), has never been directly compared to another depression-specific psychological method. METHODS Thirty patients with early-onset chronic depression were randomized to 22 sessions of CBASP or Interpersonal Psychotherapy (IPT) provided in 16 weeks. Primary outcome was the score on the 24-item Hamilton Rating Scale for Depression (HRSD) assessed posttreatment by an independent blinded evaluator. Secondary endpoints were, among others, remission (HRSD≤8) rates and the Beck Depression Inventory (BDI). The study included a prospective naturalistic 12-month follow-up. RESULTS Intent-to-treat analyses of covariance (ANCOVA) revealed that there was no significant difference in posttreatment HRSD scores between the CBASP and the IPT condition, but in self-rated BDI scores. We found significantly higher remission rates in the CBASP (57%) as compared to the IPT (20%) group. One year posttreatment, no significant differences were found in the self-reported symptom level (BDI) using ANCOVA. LIMITATIONS The study used only a small sample size and no placebo control. The generalizability of the results may be limited to patients with a preference for psychological treatment. CONCLUSIONS While the primary outcome was not significant, secondary measures showed relevant benefits of CBASP over IPT. We found preliminary evidence that in early-onset chronic depression, an approach specifically designed for this patient population was superior to a method originally developed for the treatment of acute depressive episodes. Long-term results suggest that chronically depressed patients may need extended treatment courses.

Theory of mind deficits in chronically depressed patients

Background: Poor theory of mind (ToM) performance has been found in patients with mood disorders, but it has not been examined in the subgroup of chronic depression where ToM deficits may be even more persistent than in acute depressive episodes. The aim of this study was to compare the ToM performance of chronically depressed patients with a healthy control group and to clarify the relation of ToM to other cognitive functions. Methods: ToM performance was assessed in 30 chronically depressed patients and 30 matched healthy controls by two cartoon picture story tests. In addition, logical memory, alertness, and executive functioning were evaluated. Results: Chronically depressed patients were markedly impaired in all ToM‐ and neuropsychological tasks compared to healthy controls. Performance in the different ToM tests was significantly correlated with at least one other cognitive variable. After controlling for logical memory and working memory, no ToM tasks predicted being a patient. Conclusions: Patients with chronic depression present significant deficits in “reading” social interactions, which may be associated with general cognitive impairments. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.

Feasibility and Outcome of Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronically Depressed Inpatients: A Pilot Study

Patients received optimized pharmacotherapy in addition to the CBASP program in compliance with current national and international guidelines for depression treatment [13, 14] and according to clinical expert supervision ( table 1 ). Ten inpatients with severe chronic depression according to DSM-IV were included in this pilot study. Exclusion criteria were limited to a history of bipolar I disorder, comorbid substance dependence with less than 3 months of abstinence, and mental disorders due to organic factors. The SCID I and II [15, 16] were used for diagnosis. Early trauma and life events were assessed by using the Childhood Trauma Questionnaire (CTQ) [17, 18] . Follow-up data were collected 6 months after discharge. Table 1 summarizes the baseline demographics and characteristics of the 10 inpatients. Concerning feasibility, all patients completed the treatment. Self-rating questionnaires for evaluating the experience and acceptance of the program revealed that patients found the overall concept ‘helpful’ or ‘very helpful’. Satisfaction with the CBASP group therapy was rated as ‘high’ or ‘very high’. In addition, the acceptance of the CBASP concept by the treatment team was high. The CBASP concept proved to be feasible and there were no major difficulties integrating the concept into the daily clinical routine. The 24-item version of the Hamilton Depression Rating Scale (HAMD) [19] served as the primary outcome measure and the Beck Depression Inventory (BDI) [20] as the secondary measure. T tests for paired samples revealed significant improvements and large effect sizes in the primary outcome HAMD-24 (HAMD pre : 31.80 8 4.87; HAMD post : 14.90 8 9.40; ES pre-post : d = 2.26, T(9) = 6.33, p = 0.000) and in the BDI (BDI pre : 35.50 8 6.16; BDI post : 17.88 8 11.21; ES pre-post : d = 1.95; T(7) = 4.75, p = 0.002). Treatment response was defined a priori as a reduction in symptom severity of at least 50% on the HAMD, and remission was defined as a score of 10 or less on the HAMD scale. Figure 1 a illustrates the treatment response for each patient, demonstrating that no patient deteriorated. Six out of the 10 patients were classified as responders and 4 of these fulfilled the remission criterion. Exploratory analyses revealed that the nonresponders had a significantly higher number of personality disorders ( M = 3.25) than responders ( M = 0.66; U = 2.00; p = 0.038). In addition, the Impact Message Inventory (IMI-R) [21, 22] was used to assess the stimulus character of a patient rated by the therapist before and after treatment. The mean scores of the IMI-R are illustrated in figure 1 b and showed that the patients could change their stimulus character to be more friendly and dominant. Finally, the 6-month naturalistic follow-up assessments were completed by 9 out of the 10 patients. Outpatient psychotherapy was continued by 6 patients (CBASP: 3, cognitive-behavioral therapy: 2, schema therapy: 1), 9 patients were still on pharmacotherapy, and 6 patients regularly attended the CBASP support group. In figure 1 a, the HAMD follow-up scores for each patient in relaCognitive behavioral analysis system of psychotherapy (CBASP) was initially developed as an outpatient treatment for chronic depression [1, 2] . It integrates cognitive-emotional, behavioral, interpersonal, and psychodynamic theories and strategies by addressing directly the specific psychopathology of chronic depression. In most of the studies being conducted in outpatient settings CBASP proved to be an effective treatment [3–5] , especially in patients with early onset [5] , early trauma [4] , and in combination with medication [3] . The recently published REVAMP trial found no difference between CBASP, brief supportive therapy, or continued optimized pharmacotherapy for augmentation of antidepressant nonresponse; however, the validity of these findings is limit ed by the low number of therapy sessions used in this study [6, 7] . Given the high degree of suicidality, comorbidity, and therapy resistance in chronic depression [8–11] , however, many of these patients require inpatient treatment [12] . Here, we report on a first specialized program for chronic depression adapting CBASP to an inpatient setting. The aim of this study was to evaluate the feasibility and shortas well as long-term outcome of this program. The CBASP inpatient treatment was established at our department in 2008 and is based on the outpatient CBASP concept by McCullough [1, 2] . However, we modified his approach by implementing a multidisciplinary structured treatment program combining individual and group therapies. The manualized CBASP inpatient treatment is limited to 3 months (24 individual sessions). The new CBASP group therapy focuses on a modified approach for conducting situation analysis and on Kiesler’s circle training with the extensive use of role playing and shaping. The entire treatment team was trained in CBASP; regular workshops and weekly supervisions for both the team and the individual therapists were conducted. Specific CBASP elements were also implemented in other accompanying treatments such as nurse encounters, physiotherapy, music therapy, and occupational group therapy. A patient support group was established to avoid relapse after discharge. Received: February 3, 2010 Accepted after revision: August 26, 2010 Published online: March 10, 2011

Long-term effect of combined interpersonal psychotherapy and pharmacotherapy in a randomized trial of depressed patients

Zobel I, Kech S, van Calker D, Dykierek P, Berger M, Schneibel R, Schramm E. Long‐term effect of combined interpersonal psychotherapy and pharmacotherapy in a randomized trial of depressed patients.

Overcoming Treatment Resistance in Chronic Depression: A Pilot Study on Outcome and Feasibility of the Cognitive Behavioral Analysis System of Psychotherapy as an Inpatient Treatment Program

Background: The Cognitive Behavioral Analysis System of Psychotherapy (CBASP), initially developed as an outpatient treatment for chronic depression (CD), has been adapted as a multidisciplinary 12-week inpatient program for CD. Methods: Seventy inpatients with CD and treatment resistance were included in a noncontrolled trial. The Hamilton Depression Rating Scale served as the primary outcome measure. Prospective naturalistic follow-up assessments were conducted 6 and 12 months after discharge. Results: Dropout rate was 7.1%; 90.4% perceived the program as helpful. Pre-post comparisons yielded strong effect sizes; 75.7% of the intention-to-treat sample responded, and 40.0% remitted. Nonremission was associated with experiencing temporary deterioration of symptoms during treatment. After 6 months 75.0% and after 12 months 48.0% of patients sustained response. Conclusions: The CBASP program appears as a feasible acute treatment for treatment-resistant CD inpatients with promising outcome. However, the continuation of treatment after discharge should be optimized especially for patients with subjective deterioration during treatment.