Klaus-Thomas Kronmüller

Hippocampal volume and 2-year outcome in depression

Although the hippocampus has been found to be smaller in people with depression, the clinical relevance of this is unclear. We investigated hippocampal volume (using high-resolution magnetic resonance imaging) and 2-year outcome in 57 patients with major depression. The left and right hippocampal volumes of patients with a depression relapse were significantly smaller than those of healthy controls. Our results support the hypothesis that the hippocampus is crucial in the outcome of depression.

Hippocampal volume in first episode and recurrent depression

Abnormalities in limbic-thalamic-cortical networks are hypothesized to modulate human mood states. In the present study differences in hippocampal volumes of patients with a first episode of depression, recurrent major depression and healthy control subjects were examined with high-resolution magnetic resonance imaging (MRI). Male patients with a first episode of major depression had a significantly smaller left hippocampal volume than male control subjects. Also, these patients had a significant left-right asymmetry in hippocampal volume. Female patients showed no significant alterations in hippocampal volumes. The results support the hypothesis that the hippocampus plays an important role in the pathophysiology of the early phase of major depression, especially for male patients. Implications for the neurodevelopmental and the neurodegenerative model of hippocampal change are discussed.

Anxiety and depression in patients with chronic temporomandibular pain and in controls

OBJECTIVES The purpose of this study was to assess the prevalence of anxiety and depression in temporomandibular disorders (TMD) patient subgroups and in controls with or without chronic facial pain (CFP). METHODS Our sample consisted of 61 men and 161 women. All TMD patients had suffered from pain for at least 6 months and were divided into two subgroups-an exclusively myofascial pain group and an exclusively joint pain group. Subjects without signs or symptoms of TMD but with and without CFP served as controls. All subjects were examined by calibrated examiners in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders. The German version of the Hospital Anxiety and Depression Scale was used for assessment of anxiety and depression. Analysis of covariance was used to determine the effects of sex, age, and subgroup on anxiety and depression scores. Additional t-tests were performed and the subgroups were then compared with those from a general population sample. RESULTS Females from the exclusively myofascial pain group were significantly more depressed than those from the general population or from the exclusively joint pain group. Male controls with CFP were significantly more depressed than female CFP controls. For anxiety, no significant effect of sex or subgroup was found. CONCLUSIONS Depression may play an important role in women with chronic myofascial pain whereas anxiety does not seem to be relevant for either females or males. Further anxiety screening of patients with temporomandibular pain could not be justified.

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.

Psychometric evaluation of the Psychotic Symptom Rating Scales.

BACKGROUND The aims of this study were to examine the psychometric properties of a German version of the Psychotic Symptom Rating Scales (PSYRATS) in a sample of patients with schizophrenic spectrum disorders and affective disorders with delusions and to validate subscales of the PSYRATS with other ratings of psychotic symptoms. SAMPLING AND METHODS Two hundred patients with schizophrenic spectrum disorder and affective disorders with delusions were examined. Psychometric properties of the PSYRATS items and scales were determined, and the scores of the PSYRATS scales and subscales were compared to the Positive and Negative Syndrome Scale (PANSS) and other ratings of psychotic symptoms. RESULTS The PSYRATS items and scales were found to have excellent interrater reliability. Two factors for the delusions scale (DS) and 4 factors of the auditory hallucinations scale were found. Subscales of the DS and auditory hallucinations scale were replicated by factor analysis, and the validity of the subscales was supported. CONCLUSIONS The German version of the PSYRATS is a reliable and valid assessment tool for delusions and hallucinations. The findings support the validity of the PSYRATS subscales. The DS is also applicable for patients with affective disorders.

„Expressed Emotion” (EE), Ehequalität und das Rückfallrisiko depressiver Patienten

ZusammenfassungDie Langzeitverläufe depressiver Erkrankungen scheinen in erheblichem Maße von der Qualität der ehelichen bzw. partnerschaftlichen Beziehung abhängig zu sein. Ziel der vorliegenden Studie ist die Überprüfung bereits früher mitgeteilter Befunde, nach denen sich ein in Partnerschaften depressiver Patienten gefundenes „Expressed-Emotion” (EE) auch im Bereich depressiver Störungen als rückfallbedeutsam erweist. Gleichzeitig sollen 2 weitere Befundgruppen früherer Studien erneut überprüft werden: a) die möglichen Zusammenhänge zwischen Partner-EE und Schwere der Depression sowie b) die Rückfallbedeutsamkeit der von Patienten erlebten Qualität ihrer ehelichen Beziehung. Zusammengefaßt lassen die dargestellten Analysen folgende Schlußfolgerungen zu: Mit dem von uns bestimmten Partner-EE lassen sich Rückfälle depressiver Patienten nicht voraussagen. Der EE-Index hängt nicht mit dem Symptomstatus der Patienten zusammen. Wie in 2 Vorläuferstudien lassen sich auch durch uns 2 spezifische Selbstratingmerkmale von Patienten erneut als rückfallprädiktiv validieren: die „Ehezufriedenheit” der Patienten und die von ihnen „wahrgenommene Kritik” durch den Partner. Zusätzlich erweist sich eine Diskrepanz beider Partner hinsichtlich der Einschätzung ihrer Ehezufriedenheit als rückfallprädiktiv. In der Diskussion wird auf die klinisch-praktische Bedeutung der Ergebnisse eingegangen.SummaryLong-term course of depression appears to be clearly correlated to marital quality and quality of the relationship with spouses. Aim of the present study is the replication of results, indicating that expressed emotion (EE) is an important factor in prediction of relapse in depression. Additionally, the correlation between EE shown by spouses and the severeness of depressive symptomatology as well as the importance of marital quality as seen by patients for relapse are investigated. Results of our study indicate that spouses EE does not predict relapse, and status of EE does not correlate with the extent of depressive symptoms. However, patient self ratings of satisfaction with marital relationship and of perceived criticism are related to relapse frequency. Additionally, discrepant ratings of marital satisfaction given by spouses predict relapse to some extent. Implications for research in affective disorders and clinical practice are discussed.

The validity of self-rated psychotic symptoms in depressed inpatients ☆

BACKGROUND Self-ratings of psychotic experiences might be biased by depressive symptoms. METHOD Data from a large naturalistic multicentre trial on depressed inpatients (n=488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale. RESULTS At discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P<0.001) and with the BDI total score (0.64, P<0.001). Moderate correlations were found for the MADRS (0.34, P<0.001), HAMD (0.37, P<0.001) and AMDP depression score (0.33, P<0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P<0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P<0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P=0.02). CONCLUSIONS In depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.

Expressed emotion, perceived criticism and 10-year outcome of depression.

Outcome studies of patients suffering from depression indicate a high relapse rate and a tendency towards chronicity. A family atmosphere characterised by expressed emotion (EE) and perceived criticism (PC) was reported to be a robust predictor of outcome in affective disorders. The aim of the study was to analyze the association between EE, PC and long-term outcome of depression. Fifty inpatients with major depression were followed up 1, 2 and 10 years after discharge from the hospital. After 10 years, 26 patients (56.5%) had at least one recurrence. Spousal EE, assessed with the Five-Minute Speech Sample (FMSS), and the Perceived Criticism Index (PCI) were not significant prognostic factors for depression outcome. The significance of EE and PC for the long-term course of depression has to be questioned. The findings indicate a need to examine factors that may partly mediate the effect of EE and PC on the outcome of depression.

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.

Einfluss von Persönlichkeitsfaktoren und -struktur auf den Verlauf der Major-Depression

ZusammenfassungInwieweit Persönlichkeitsmerkmalen eine verlaufsprädiktive Bedeutung bei schwer depressiv erkrankten Patienten zukommt, wurde in den letzten Jahren kontrovers diskutiert. Im Rahmen der Heidelberger Studie zur Rückfallprädiktion der Depression wurde die Bedeutung von Persönlichkeitsfaktoren für den 2-Jahres-Verlauf der Depression prospektiv an einer Stichprobe von N=50 Patienten untersucht. Über die Hälfte aller Patienten zeigte in diesem Zeitraum einen Rückfall. Klassische Verlaufsprädiktoren wie die Anzahl der Vorepisoden konnten repliziert werden. Für die überprüften Persönlichkeitsmerkmale ergaben sich differenzielle Prädiktionseffekte für die 1- und die 2-Jahres-Katamnese. Persönlichkeitstraits wie Neurotizismus erwiesen sich für das 1. Katamnesejahr als verlaufsprädiktiv und prädizieren demnach ein Frührezidiv besser als Rückfälle zu einem späteren Zeitpunkt. Für den 2-Jahres-Verlauf ging eine Persönlichkeitsstruktur im Sinne des Typus melancholicus mit einem günstigeren Störungsverlauf einher. Die Typus-melancholicus-Persönlichkeitsstruktur ist demnach eher zur Vorhersage des mittelfristigen Verlaufes der Depression geeignet. Der Vergleich mit klassischen Prädiktoren ergab, dass Persönlichkeitsfaktoren von diesen unabhängig Verlaufsvarianz aufklären. Implikationen der Ergebisse für die Rückfallprävention und die psychotherapeutische Behandlung werden diskutiert.SummaryThe extent to which personality characteristics predict the course of severe depression has been controversially discussed. In a sample of 50 depressed inpatients, the significance of personality characteristics for the prediction of relapse was studied prospectively over 2 years. More than half of the patients studied suffered relapses within this period. Well-known predictors such as the number of previous episodes were confirmed. The personality characteristics studied showed different predictive effects at 1- and 2-year follow-up. Neurosis proved predictive of the 1-year course and outcome but not the 2-year course. In the 2nd year of follow-up, a melancholic personality structure was associated with favourable outcome. This personality type therefore seems to be more appropriate as a predictor of long-term outcome. Comparison with predictive factors described earlier showed that in this study, personality traits influence outcome independently and were not confused by other predictors. Implications for relapse prevention and psychotherapeutic management are discussed.