Jaap Peen

The current status of urban-rural differences in psychiatric disorders.

Peen J, Schoevers RA, Beekman AT, Dekker J. The current status of urban–rural differences in psychiatric disorders.

The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial.

OBJECTIVE The efficacy of psychodynamic therapies for depression remains open to debate because of a paucity of high-quality studies. The authors compared the efficacy of psychodynamic therapy with that of cognitive-behavioral therapy (CBT), hypothesizing nonsignificant differences and the noninferiority of psychodynamic therapy relative to CBT. METHOD A total of 341 adults who met DSM-IV criteria for a major depressive episode and had Hamilton Depression Rating Scale (HAM-D) scores ≥14 were randomly assigned to 16 sessions of individual manualized CBT or short-term psychodynamic supportive therapy. Severely depressed patients (HAM-D score >24) also received antidepressant medication according to protocol. The primary outcome measure was posttreatment remission rate (HAM-D score ≤7). Secondary outcome measures included mean posttreatment HAM-D score and patient-rated depression score and 1-year follow-up outcomes. Data were analyzed with generalized estimating equations and mixed-model analyses using intent-to-treat samples. Noninferiority margins were prespecified as an odds ratio of 0.49 for remission rates and a Cohens d value of 0.30 for continuous outcome measures. RESULTS No statistically significant treatment differences were found for any of the outcome measures. The average posttreatment remission rate was 22.7%. Noninferiority was shown for posttreatment HAM-D and patient-rated depression scores but could not be demonstrated for posttreatment remission rates or any of the follow-up measures. CONCLUSIONS The findings extend the evidence base of psychodynamic therapy for depression but also indicate that time-limited treatment is insufficient for a substantial number of patients encountered in psychiatric outpatient clinics.

Is the prevalence of psychiatric disorders associated with urbanization

ObjectivesIn many countries, the total rate of psychiatric disorders tends to be higher in urban areas than in rural areas. The relevance of this phenomenon is that it may help in identifying environmental factors that are important in the pathogenesis of mental disorders. Moreover, urban preponderance suggests that the allocation of funds and services should take urbanization levels into account.MethodThe Netherlands Mental Health Survey and Incidence Study (NEMESIS) used the Composite International Diagnostic Interview (CIDI) to determine the prevalence of DSM-III-R disorders in a sample of 7,076 people aged 18–64. The sample was representative of the population as a whole. The study population was assigned to five urbanization categories defined at the level of municipalities. The association between urbanization and 12-month prevalence rates of psychiatric disorders was studied using logistic regression taking several confounders into account.ResultsThe prevalence of psychiatric disorders gradually increased over five levels of urbanization. This pattern remained after adjustment for a range of confounders. Comorbidity rates also increased with level of urbanization.ConclusionThis study confirms that psychiatric disorders are more common and more complex in more urbanized areas. This should be reflected in service allocation and may help in identifying environmental factors of importance for the aetiology of mental disorders.

Sensitivity and specificity of the Major Depression Inventory in outpatients.

BackgroundThe Major Depression Inventory (MDI) is a new, brief, self-report measure for depression based on the DSM-system, which allows clinicians to assess the presence of a depressive disorder according to the DSM-IV, but also to assess the severity of the depressive symptoms.MethodsWe examined the sensitivity, specificity, and psychometric qualities of the MDI in a consecutive sample of 258 psychiatric outpatients. Of these patients, 120 had a mood disorder (70 major depression, 49 dysthymia). A total of 139 subjects had a comorbid axis-I diagnosis, and 91 subjects had a comorbid personality disorder.ResultsCrohnbachs alpha of the MDI was a satisfactory 0.89, and the correlation between the MDI and the depression subscale of the SCL-90 was 0.79 (p < .001). Subjects with major depressive disorder (MDD) had a significantly higher MDI score than subjects with anxiety disorders (but no MDD), dysthymias, bipolar, psychotic, other neurotic disorders, and subjects with relational problems. In ROC analysis we found that the area under the curve was 0.68 for the MDI. A good cut-off point for the MDI seems to be 26, with a sensitivity of 0.66, and a specificity of 0.63. The indication of the presence of MDD based on the MDI had a moderate agreement with the diagnosis made by a psychiatrist (kappa: 0.26).ConclusionThe MDI is an attractive, brief depression inventory, which seems to be a reliable tool for assessing depression in psychiatric outpatients.

Social deprivation and psychiatric admission rates in Amsterdam

The main subject of this study was the link between social indicators and the (re)admission rates for, and length of stay in, in-patient mental health care in Amsterdam. In a factor analysis of 15 sociodemographic variables, two principal components analysis factors were distinguished: housing quality and socioeconomic deprivation. The census variables and the factors almost all had high correlations with the crude admission rates as well as the rates standardised for age and sex. In general, the correlations with rates that were also standardised for marital status were significantly lower. This Shows that many correlations between indicators and crude rates are determined to a significant extent by the marital status profile of an area. Socioeconomic deprivation is positively correlated with the proportion of readmissions and inversely correlated with average length of stay.

Cognitive Behavioral Therapy versus Short Psychodynamic Supportive Psychotherapy in the outpatient treatment of depression: a randomized controlled trial

BackgroundPrevious research has shown that Short Psychodynamic Supportive Psychotherapy (SPSP) is an effective alternative to pharmacotherapy and combined treatment (SPSP and pharmacotherapy) in the treatment of depressed outpatients. The question remains, however, how Short Psychodynamic Supportive Psychotherapy compares with other established psychotherapy methods. The present study compares Short Psychodynamic Supportive Psychotherapy to the evidence-based Cognitive Behavioral Therapy in terms of acceptability, feasibility, and efficacy in the outpatient treatment of depression. Moreover, this study aims to identify clinical predictors that can distinguish patients who may benefit from either of these treatments in particular. This article outlines the study protocol. The results of the study, which is being currently carried out, will be presented as soon as they are available.Methods/DesignAdult outpatients with a main diagnosis of major depressive disorder or depressive disorder not otherwise specified according to DSM-IV criteria and mild to severe depressive symptoms (Hamilton Depression Rating Scale score ≥ 14) are randomly allocated to Short Psychodynamic Supportive Psychotherapy or Cognitive Behavioral Therapy. Both treatments are individual psychotherapies consisting of 16 sessions within 22 weeks. Assessments take place at baseline (week 0), during the treatment period (week 5 and 10) and at treatment termination (week 22). In addition, a follow-up assessment takes place one year after treatment start (week 52). Primary outcome measures are the number of patients refusing treatment (acceptability); the number of patients terminating treatment prematurely (feasibility); and the severity of depressive symptoms (efficacy) according to an independent rater, the clinician and the patient. Secondary outcome measures include general psychopathology, general psychotherapy outcome, pain, health-related quality of life, and cost-effectiveness. Clinical predictors of treatment outcome include demographic variables, psychiatric symptoms, cognitive and psychological patient characteristics and the quality of the therapeutic relationship.DiscussionThis study evaluates Short Psychodynamic Supportive Psychotherapy as a treatment for depressed outpatients by comparing it to the established evidence-based treatment Cognitive Behavioral Therapy. Specific strengths of this study include its strong external validity and the clinical relevance of its research aims. Limitations of the study are discussed.Trial registrationCurrent Controlled Trails ISRCTN31263312

Psychiatric disorders and urbanization in Germany

BackgroundEpidemiological studies over the last decade have supplied growing evidence of an association between urbanization and the prevalence of psychiatric disorders. Our aim was to examine the link between levels of urbanization and 12-month prevalence rates of psychiatric disorders in a nationwide German population study, controlling for other known risk factors such as gender, social class, marital status and the interaction variables of these factors with urbanization.MethodsThe Munich Composite International Diagnostic Interview (M-CIDI) was used to assess the prevalence of mental disorders (DSM-IV) in a representative sample of the German population (N = 4181, age: 18–65). The sample contains five levels of urbanization based on residence location.The epidemiological study was commissioned by the German Ministry of Research, Education and Science (BMBF) and approved by the relevant Institutional Review Board and ethics committee. Written informed consent was obtained for both surveys (core survey and Mental Health Supplement). Subjects did not get any financial compensation for their study participation.ResultsHigher levels of urbanization were linked to higher 12-month prevalence rates for almost all major psychiatric disorders (with the exception of substance abuse and psychotic disorders). The weighted prevalence percentages were highest in the most urbanized category. Alongside urbanization, female gender, lower social class and being unmarried were generally found to be associated with higher levels of psychopathology. The impact of urbanization on mental health was about equal (for almost all major psychiatric disorders) in young people and elderly people, men and women, and in married and single people. Only people from a low social class in the most urbanized settings had more somatoform disorders, and unmarried people in the most urbanized settings had more anxiety disorders.ConclusionPsychiatric disorders are more prevalent among the inhabitants of more urbanized areas. probably because of environmental stressors.

Patient preference compared with random allocation in short-term psychodynamic supportive psychotherapy with indicated addition of pharmacotherapy for depression.

Abstract Depressed patients randomized to psychotherapy were compared with those who had been chosen for psychotherapy in a treatment algorithm, including addition of an antidepressant in case of early nonresponse. There were no differences between randomized and by-preference patients at baseline in adherence and outcome. About half of the early nonresponders refused the additional medication. However, no clear effect of medication addition on ultimate outcome could be demonstrated. In total, 37% of the patients achieved remission. The study suggested that randomization of patients does not induce a great influence on outcome. It might be warranted to continue an initially ineffective psychotherapy for depression, because a considerable number of patients do have a pattern of delayed response.

Gender differences in clinical features of depressed outpatients: preliminary evidence for subtyping of depression?

ABSTRACT Background: Gender differences in depression are usually associated with prevalence, severity, and sometimes with specific syndromes or subtypes. However, a lack of differentiation exists between these factors. Aims: To disentangle depression severity and the specific items endorsed by men and women and thus explore the presence of gender-specific subtypes. Method: A group of 963 men and women treated for depression in the period 1993–2002 were matched on demographic characteristics. This resulted in a group of 353 men and 453 women (N = 806) on which all subsequent analyses were performed. Five instruments were used: the Hamilton Depression Rating Scale (HAM-D), SCL-90 subscales for depression (DEP), anxiety (ANX) and somatic complaints (SOMC), and the Quality of Life Depression Scale (QLDS). Total scores and individual-item scores were compared for men and women using ANOVA. A cluster analysis was performed on the three SCL-90 subscales. The distribution of gender over the clusters was tested with Pearson Chi-square. Results: No gender differences were found in depression severity on the HAM-D. Women reported more symptoms on the DEP and the SOMC (p < 0.01). No gender differences were found on the QLDS. Of the SOMC items, 58% differentiated between men and women, whereas 31% of the DEP items and 30% of the ANX items detected gender differences. Using cluster analysis, a five-cluster solution was found with good face validity and reliability. Men and women were distributed differently over the five clusters such that women were overrepresented in those clusters in which the SOMC was high, while men were overrepresented in clusters in which SOMC was low (p < 0.01). Conclusions: It may be useful to delineate syndrome of somatic complaints in the context of depression that is more prevalent among women.

Is urbanicity an environmental risk-factor for psychiatric disorders?

The link between urbanicity and the development of psychiatric disorders is well established. Recently, Kristina Sundquist and colleagues (2004) showed once again, with a strong study design, that there is a link between degree of urbanisation and first admission for psychosis. For men, the risk of first admission for psychosis was 68% higher in the most densely populated areas of Sweden than in the least densely populated areas (on a scale with five categories of urbanisation). For women, the risk was 77% higher. These results were all independent of age, marital status, education, and immigrant status. The results for psychosis contrast with the weak correlations found for depression (12% higher for men and 20% higher for women). Possible explanations given by the investigators for the increased risk in cities compared with rural areas are differences in social support, stressful life events, and familial liability.