Lars P Hölzel

Risk factors for chronic depression — A systematic review

BACKGROUNDnOne of five patients with an acute depressive episode develops chronic depression. Risk factors for a current depressive episode to become chronic are insufficiently known. This review was conducted to examine which factors represent a risk factor for the development of chronic depression for patients diagnosed with a depressive episode.nnnMETHODnMedline, Psycinfo, ISI Web of Science, CINHAL and BIOSIS Previews were searched up until September 2007, complemented by handsearching in the December 1987 to December 2007 issues of Journal of Affective Disorders and investigating reference lists of included articles and existing reviews. On the basis of a formal checklist, two investigators independently decided which studies to include or exclude.nnnRESULTSn25 relevant primary studies with a total of 5192 participants were included in the systematic review. Overall the methodological quality of the included studies was found to be sufficient. Data synthesis was performed via vote counting. The following risk factors were identified: younger age at onset, longer duration of depressive episode, and family history of mood disorders. Psychological comorbidity i.e. anxiety disorders, personality disorders and substance abuse, low level of social integration, negative social interaction and lower severity of depressive symptoms repeatedly appeared concurrently with chronic depression.nnnLIMITATIONSnMost included studies were cross-sectional thus drawing causal conclusions with regard to risk factors proved to be difficult.nnnCONCLUSIONnRisk factors for a current depressive episode to become chronic were identified. To date only few significant longitudinal studies on this topic are available.

Selective serotonin reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic depression and dysthymia: a systematic review and meta-analysis.

INTRODUCTIONnChronic depression represents a substantial portion of depressive disorders and is associated with severe consequences. This review examined the efficacy and acceptability of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) in the treatment of chronic depression. Additionally, the comparative effectiveness of the two types of antidepressants has been examined.nnnMETHODSnA systematic search was conducted in the following databases: CENTRAL, MEDLINE, EMBASE, ISI Web of Science, BIOSIS, PsycINFO, and CINAHL. Primary efficacy outcome was a response to treatment; primary acceptance outcome was dropping out of the study. Only randomized controlled trials were considered.nnnRESULTSnWe identified 20 studies with 22 relevant comparisons. 19 studies focused on samples with a majority of dysthymic patients. Both SSRIs and TCAs are efficacious in terms of response rates when compared to placebo (Benefit Ratio [BR]=1.49; p<0.001 for SSRIs and BR=1.74; p<0.001 for TCAs) and no statistically significant differences between the active drugs and placebo in terms of dropout rates could be found. No differences in effectiveness were found between SSRIs and TCAs in terms of response rates (BR=1.01; p=0.91), yet, SSRIs showed statistically better acceptability in terms of dropout rates than TCAs (Odds Ratio [OR]=0.41; p=0.02).nnnLIMITATIONSnThe methodological quality of the primary studies was evaluated as unclear in many cases and more evidence is needed to assess the efficacy of SSRIs and TCAs in patients suffering from chronic forms of depression other than dysthymia.nnnCONCLUSIONSnThis systematic review provides evidence for the efficacy of both SSRIs and TCAs in the treatment of chronic depression and showed a better acceptability of SSRIs.

Combination of pharmacotherapy and psychotherapy in the treatment of chronic depression: A systematic review and meta-analysis

BackgroundChronic depression represents a substantial portion of depressive disorders and is associated with severe consequences. This review examined whether the combination of pharmacological treatments and psychotherapy is associated with higher effectiveness than pharmacotherapy alone via meta-analysis; and identified possible treatment effect modifiers via meta-regression-analysis.MethodsA systematic search was conducted in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ISI Web of Science, BIOSIS, PsycINFO, and CINAHL. Primary efficacy outcome was a response to treatment; primary acceptance outcome was dropping out of the study. Only randomized controlled trials were considered.ResultsWe identified 8 studies with a total of 9 relevant comparisons. Our analysis revealed small, but statistically not significant effects of combined therapies on outcomes directly related to depression (BRu2009=u20091.20) with substantial heterogeneity between studies (I²u2009=u200967%). Three treatment effect modifiers were identified: target disorders, the type of psychotherapy and the type of pharmacotherapy. Small but statistically significant effects of combined therapies on quality of life (SMDu2009=u20090.18) were revealed. No differences in acceptance rates and the long-term effects between combined treatments and pure pharmacological interventions were observed.ConclusionsThis systematic review could not provide clear evidence for the combination of pharmacotherapy and psychotherapy. However, due to the small amount of primary studies further research is needed for a conclusive decision.

Patient preference for involvement, experienced involvement, decisional conflict, and satisfaction with physician: a structural equation model test

BackgroundA comprehensive model of the relationships among different shared decision-making related constructs and their effects on patient-relevant outcomes is largely missing. Objective of our study was the development of a model linking decision-making in medical encounters to an intermediate and a long-term endpoint. The following hypotheses were tested: physicians are more likely to involve patients who have a preference for participation and are willing to take responsibility in the medical decision-making process, increased patient involvement decreases decisional conflict, and lower decisional conflict favourably influences patient satisfaction with the physician.MethodsThis model was tested in a German primary care sample (Nu2009=u20091,913). Psychometrically tested instruments were administered to assess the following: patients’ preference for being involved in medical decision-making, patients’ experienced involvement in medical decision-making, decisional conflict, and satisfaction with the primary care provider. Structural equation modelling was used to explore multiple associations. The model was tested and adjusted in a development sub-sample and cross-validated in a confirmatory sample. Demographic and clinical characteristics were accounted for as possible confounders.ResultsLocal and global indexes suggested an acceptable fit between the theoretical model and the data. Increased patient involvement was strongly associated with decreased decisional conflict (standardised regression coefficient Βu2009=u2009−.73). Both high experienced involvement (Βu2009=u2009.34) and low decisional conflict (Bu2009=u2009-.28) predicted higher satisfaction with the physician. Patients’ preference for involvement was negatively associated with the experienced involvement (Bu2009=u2009−.24).ConclusionAltogether, our model could be largely corroborated by the collected empirical data except the unexpected negative association between preference for involvement and experienced involvement. Future research on the associations among different SDM-related constructs should incorporate longitudinal studies in order to strengthen the hypothesis of causal associations.

The Latent Factor Structure of Young's Early Maladaptive Schemas: Are Schemas Organized Into Domains?

OBJECTIVEnIn previous research it has not been clarified whether the first-order schema factors of the Young Schema Questionnaire (YSQ) can be structured into higher order domains. We examined whether investigators subjective choices between complex models of the YSQ or chance as opposed to clinical diversity of the samples may be responsible for the heterogeneity of results reported in the literature.nnnMETHODnWe used confirmatory factor analysis to compare several a priori defined domain models in a sample of 542 undergraduate students (82.8% female; mean age 24.1 years) and 590 nonstudent adults (73.9% female; mean age 34.5 years) form an Internet survey. An additional Monte Carlo simulation study was performed to gain further insights on model selection.nnnRESULTSnThe analyses did not provide unequivocal support for the presence of a second-order domain structure. However, study findings suggested that the structure of the YSQ could be represented by a bifactor model including a first-order generic factor on which all items load and correlated first-order specific schema factors on which only the items load that were meant to measure the respective schemas.nnnCONCLUSIONnIn the YSQ either several second-order domain structures are present that cannot be ranked by statistical measures alone or a first-order generic factor is present making second-order domains dispensable. Future research should include theoretical arguments and incorporate the clinical experience of practitioners.

Effectiveness of psychotherapeutic, pharmacological, and combined treatments for chronic depression: a systematic review (METACHRON)

BackgroundChronic depressions represent a substantial part of depressive disorders and are associated with severe consequences. Several studies were performed addressing the effectiveness of psychotherapeutic, pharmacological, and combined treatments for chronic depressions. Yet, a systematic review comparing the effectiveness of multiple treatment options and considering all subtypes of chronic depressions is still missing.Methods/DesignAim of this project is to summarize empirical evidence on efficacy and effectiveness of treatments for chronic depression by means of a systematic review. The primary objectives of the study are to examine, which interventions are effective; to examine, if any differences in effectiveness between active treatment options exist; and to find possible treatment effect modifiers. Psychotherapeutic, pharmacological, and combined treatments will be considered as experimental interventions and no treatment, wait-list, psychological/pharmacological placebo, treatment as usual, and other active treatments will be seen as comparators. The population of patients will include adults with chronic major depression, dysthymia, double depression, or recurrent depression without complete remission between episodes. Outcomes of the analyses are depressive symptoms, associated consequences, adverse events, and study discontinuation. Only randomized controlled trials will be considered.DiscussionGiven the high prevalence and serious consequences of chronic depression and a considerable amount of existing primary studies addressing the effectiveness of different treatments the present systematic review may be of high relevance. Special attention will be given to the use of current methodological standards. Findings are likely to provide crucial information that may help clinicians to choose the appropriate treatment for chronically depressed patients.

Comparative Safety of Pharmacologic Treatments for Persistent Depressive Disorder: A Systematic Review and Network Meta-Analysis

We aimed to compare the safety of antidepressants for the treatment of persistent depressive disorder (PDD) with each other and with placebo. We conducted a systematic electronic search and included randomized controlled trials that investigated antidepressants for the treatment of PDD in adults. Outcomes were the incidence of experiencing any adverse event, specific adverse events and related treatment discontinuations. We analyzed the data using traditional and network meta-analyses. Thirty-four studies that comprised 4,769 patients and examined 20 individual agents in nine substance classes were included. Almost all analyzed substance classes were associated with higher discontinuation rates than placebo including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), antipsychotics, and the serotonin antagonist and reuptake inhibitor (SARI) trazodone. The odds of experiencing any adverse event were significantly higher for TCAs and serotonin noradrenaline reuptake inhibitors (SNRIs) compared to placebo. Pairwise comparisons among the substance classes revealed that more patients receiving TCAs or SNRIs experienced any adverse event and that more patients receiving TCAs or the SARI trazodone discontinued treatment. The complementary treatment with acetyl-l-carnitine showed lower rates of experiencing any adverse event and related discontinuations than all other comparators. TCAs were primarily associated with (anti-)cholinergic and sedating adverse events. SSRIs primarily showed gastrointestinal adverse events. Patients treated with the antipsychotic amisulpride were more likely to manifest weight gain and endocrine adverse events. The comparative evidence for further agents was insufficient or lacking. The identified safety differences may be used to inform the selection among the antidepressants.

Provision of group psychoeducation for relatives of persons in inpatient depression treatment - a cross-sectional survey of acute care hospitals in Germany

BackgroundDepressive disorders are often recurrent and place a high burden on patients and their relatives. Psychoeducational groups for relatives may reduce relatives’ burden, help prevent relapses in patients, and are recommended by the German “National Disease Management Guideline Unipolar Depression”. Since there is limited knowledge on the provision of psychoeducational groups for relatives of persons in inpatient depression treatment, we conducted a survey among acute care hospitals in Germany.MethodsWe conducted a two-step cross-sectional survey. Step I consisted of a questionnaire asking the heads of all psychiatric/psychosomatic acute care hospitals in Germany (Nu2009=u2009512) whether psychoeducational groups for relatives were provided within depression treatment, and if not, the reasons for not implementing them. In group offering hospitals the person responsible for conducting psychoeducational groups received a detailed questionnaire on intervention characteristics (step II). We performed descriptive data analysis.ResultsThe response rate was 50.2% (Nu2009=u2009257) in step I and 58.4% in step II (Nu2009=u200945). 35.4% of the responding hospitals offered psychoeducational groups for relatives of patients with depressive disorders. According to the estimates of the respondents, relatives of about one in five patients took part in psychoeducational groups in 2011. Groups were mostly provided by two moderators (62.2%) as continuous groups (77.8%), without patients’ participation (77.8%), with up to ten participants (65.9%), consisting of four or fewer sessions (51.5%) which lasted between one and one and a half hours each (77.8%). The moderators in charge were mostly psychologists (43.9%) or physicians (26.8%). Approximately one third used published manuals. Reasons for not conducting such psychoeducational groups were lack of manpower (60.1%), time (44.9%) and financial constraints (24.1%). 25.3% mentioned adequate concepts of intervention as a required condition for initiating such groups.ConclusionsOnly a small proportion of relatives of patients with depressive disorders participated in psychoeducational groups in 2011 in Germany. Mostly short interventions were favoured and main implementation barriers were scarce resources. Brief interventions that fit with healthcare routine should be developed and tested within randomised controlled trials. This could promote the provision of psychoeducational groups for relatives as evidence-based practice in inpatient depression treatment in Germany.

Freiburg Questionnaire of linguistic pragmatics (FQLP): psychometric properties based on a psychiatric sample.

BackgroundAsperger’s Syndrome (AS) is an autism spectrum disorder that is characterized by significant difficulties in social interaction and nonverbal communication, and restricted and repetitive patterns of behavior and interests. Difficulties with respect to pragmatic speech, reading emotional and social cues, differentiating between fact and fiction, and taking into account the influence of context on a statement are commonly described features. However, hitherto established questionnaires did not focus on these symptoms.MethodsIn this study we present a short (11 questions) questionnaire which focuses on self-rated pragmatic speech abilities, the Freiburg Questionnaire of linguistic pragmatics (FQLP). Psychometric properties of the questionnaire were explored in a sample of 57 patients with Asperger’s Syndrome, 66 patients with other psychiatric disorders, and a convenience sample of 56 people.ResultsReliability analysis showed a high Cronbach’s α. Strong correlations could be demonstrated for the FQLP with the Autism Quotient and the Empathy Quotient. Concerning divergent validity a moderate correlation was found between the FQLP and self-rated symptoms of personality disorders. No significant correlation was found between the FQLP and the vocabulary skills. The receiver operating characteristics curve showed an excellent diagnostic accuracy of the FQLP (.97).ConclusionsAs the control group consisted of people without mental disorder and patients with different psychiatric disorders, the results indicate that the construct examined by the FQLP is quite specific to the peculiarities of AS. The FQLP is a reliable, brief and valid instrument. First results regarding sensitivity and specificity are highly promising.

1422 – Culture sensitive analysis of psychosomatic complaints in migrants in germany

Background To ensure an adequate health care of migrants, differentiated information on the association of cultural background and migration related factors and psychosomatic complaints are necessary. Method Cross-sectional questionnaire based survey regarding psychosomatic complaints of migrants from Turkey (nxa0=xa077), Italy (nxa0=xa095), and Spain (nxa0=xa067) and ethnic German resettled from the states of the former Soviet Union (nxa0=xa0196). Questionnaires distributed by non-health specific counselling agencies of welfare associations. Results The cultural background was a relevant factor for psychosomatic complaints, showing Turkish and ethnic German resettled migrants a higher likeliness, also compared to a sample of age corresponding Germans. Whereas Spanish and Italian migrants showed a lower risk for psychosomatic complaints. Also gender, feeling unwell in Germany and fatalism showed a significant association with psychosomatic complaints. Conclusion Migrants in Germany do not have per se a higher risk for psychosomatic complaints. A distinct differentiation by cultural background is necessary.