M. Linden

Disability and functional burden of disease because of mental in comparison to somatic disorders in general practice patients.

BACKGROUND Severity of illness is not only depending on the symptom load, but also on the burden in life. Mental disorders are among those illnesses, which in particular cause suffering to the individual and society. METHOD To study burden of disease for mental in comparison to somatic disorders, 2099 patients from 40 general practitioners filled in (a) the Burvill scale which measures acute and chronic illnesses in ten different body systems and (b) the IMET scale which measures impairment in ten different areas of life. RESULTS Patients were suffering on average from acute and/or chronic illness in 3.5 (SD: 2.0) body systems and 56.6% of patients complained about acute and/or chronic mental disorders. The most significant negative impact on the IMET total score have acute and chronic mental disorders, followed by chronic neurological and musculoskeletal and acute respiratory and gastrointestinal disorders, while cardiovascular, metabolic, urogenital, haematological and ear/eye disorders have no greater impact. Acute as well as chronic mental disorders cause impairment across all areas of life and most burden of disease (functional burden of disease 1.69), followed by musculoskeletal disorders (1.62). CONCLUSION Mental disorders are among the most frequent health problems with high negative impact across all areas of life. When combining frequency and impairment mental disorders cause most burden of disease in comparison to other illnesses. This should be reflected in the organization of medical care including family medicine.

Fast versus slow onset of depressive episodes: a clinical criterion for subtyping patients with major depression.

PURPOSE The speed of onset of depressive episodes is a clinical aspect of affective disorders that has not been sufficiently investigated. Thus, we aimed to explore whether patients with fast onset of the full-blown depressive symptomatology (≤7 days) differ from those with slow onset (>7 days) with regard to demographic and clinical aspects. SUBJECTS AND METHODS Data were obtained within an observational study conducted in outpatients with major depression who were treated with duloxetine (30-120 mg/day). Onset of depression (without any preceding critical life event) was fast in 416 (less than one week) and slower in 2220 patients. RESULTS Compared to patients with slow onset, those with fast onset of depression had more suicide attempts in the previous 12 months (2.7% versus 1.3%, P=0.046) and less somatic comorbidity (61.7% versus 74.1%, P<0.0001). In addition, they were slightly younger at onset of depression (mean±SD 40.2±14.6 versus 42.8±14.2 years, P<0.001) and used analgesics at baseline significantly less frequently (22.8% versus 33.4%, P<0.0001). DISCUSSION AND CONCLUSION The speed of onset of depression has to be regarded as a relevant clinical characteristic in patients with unipolar depression.

P01-283 - The relation betweeen severity of cardiac illness and anxiety

Background Pathological anxiety is characterized by the absence of a reason for anxiety. However, the presence of fear provoking stimuli does not exclude the possibility for a pathological course of anxiety, i.e. “Pathological Realangst”. An example are hypochondriac anxieties in patients with severe somatic disorders. An open question is to what degree severity of somatic morbidity is related with anxiety. Method In 209 patients (37,8% women) from a cardiology inpatient unit general anxiety, heart-related anxiety, progression anxiety, and job-anxiety were measured. Physicians rated the degree of severity of the somatic (heart-)disorder using the Multidimensional Severity of Morbidity Rating (MSM rating). Relationships between the degree of anxiety and somatic morbidity parameters were investigated. Results Anxiety did not or to a very low degree correlate with objective indicators of somatic morbidity. Subjective suffering showed a moderate significant correlation with heart-related anxiety and progression anxiety, and was also correlated with sick leave duration. Conclusion Severity of somatic illness is a multidimensional phenomenon and not regularly related in a special way with anxiety, except the dimension of subjective suffering. Pathological fears, even when occurring in the context of somatic disorders, are not related to objective endangerment, but have to be described as mental problems.

P03-178 - Participation restrictions at work and at home in primary care patients

Background Health problems are often associated with activity limitations and participation restrictions (ICF, WHO, 2001). An example are problems at work or sick leave. The research question has been whether in these cases activity limitations and participation restrictions refer only to the workplace, or whether and to which degree other areas of life are similarly affected. Method Type and degree of participation restrictions in different domains of life were assessed in 382 primary health care patients (aged 18-65) with the IMET, a questionnaire which measures participation restrictions across several domains of life. Additionally, the patients were interviewed about health-related problems at work. IMET scores were compared between patients with and without health related problems at work. Results 27% of 299 presently employed patients were suffering from workplace problems. These patients had significantly longer durations of sick leave than patients without problems at work and also reported significantly more problems in functioning in general daily activities. Conclusion Workplace problems are a frequent topic in primary health care and related to sick leave. Health related problems at work are indicative for problems in functioning in other areas of life as well. Participation restrictions in non-work areas can be early indicators for participation problems at work.

P03-350 Pharmacotherapy of generalized anxiety disorders under conditions of routine treatment

Background Generalized anxiety disorders (GAD) are characterized by persistent excessive worrying about minor hassles. GAD patients are high utilizers of medical services and medication. According to an analysis of 21 double-blind placebo-controlled trials by of Hidalgo et al. (2007) highest effect sizes are reproted for pregabalin (0.50), hydroxyzine (0.45), venlafaxine XR (0.42), benzodiazepines (0.38), SSRIs (0.36), buspirone (0.17) and herbal medicines (-0.31). The question is how GAD is treated under conditions of routine treatment. This was studied in patients were admitted to inpatient treatment. Method Psychotropic premedication and changes in medication during the inpatient treatment were analyzed in 107 patients. Result Before admission, 27,1% of GAD patients got tricyclic antidepressants, 25,2% SSRI, 8,4% benzodiazepines, 7,4% atypical antidepressants, 1,9% anticonvulsants/pregabaline, 1,9% herbal drugs. Furthermore, 20,6% got betablocker, preferably because of hypertension. During the inpatient stay changes in medication were made according to the clinical discretion of the therapist. At discharge 41,1% of GAD patients received SSRI, 23,4% tricyclic antidepressants, 22,4% pregabaline, 9,4% atypical antidepressants. Conclusion SSRI and tricyclic antidepressants play the major role in the drug treatment of GAD. Under clinical conditions there has been an optimization of treatment by increasing preferably the rate of SSRI treatments and of pregabaline treatment, while reducing benzodiazepine treatment and to some degree tricyclic antidepressants. Literature Hidalgo RB, Tupler LA, Davidson JRT (2007): An effect-size analysis of pharmacologic treatments for generalized anxiety disorder. J Psychopharmacol 21(8):864-872.

W01-01 Training workshop: cognitive psychotherapy and wisdom strategies in the treatment of adjustment disorders

The goal of this training workshop is to give an introduction in recent developments of wisdom psychology and their bearing for cognitive psychotherapy of adjustment disorders. Negative life events like divorce, dead of a beloved one, job loss etc. require enhanced coping. If this is not sufficient it can result in adjustment or other mental disorders. One factor which often contributes to pathological developments in the context of negative life events is embitterment because of the feeling of having been treated unfair, been let down or been humiliated. If embitterment is present then there is a tendency not to recover spontaneously but rather to take a chronic course. There is a new approach in the treatment for such adjustment disorders which is based on recent developments in wisdom psychology. Wisdom has been defined as the capacity to cope with unsolvable and serious problems and questions in life. It has been shown: a. that persons who are not successful in coping with negaive life events lack wisdom capacities, b. that wisdom capacities can be trained, and c. that cognitive treatment which uses wisdom strategies is helpful in the treatment of adjustment disorders and especially those with prolonged embitterment reactions. This training workshop will: • inform about the clincial features of adjustment disorders and especially posttraumatic embitterment disorders; • give an introduction in recent developments of wisdom psychology; • teach the esentials of wisdom psychotherapy.

CS11-03 Disorders of functioning in neurotic disorders

Background The International Classification of Functioning, Disability and Health, ICF, discriminates between functions, activities/capacities, context factors and participation. There is only limited information on disorders of capacity in neurotic disorders. Method 213 inpatients of a department of behavioral and psychosomatic medicine (70% women, median age 45 years) were rated with the “Mini-ICF-Rating for Pychological Disorders, Mini-ICF-P”. This instrument assesses thirteen dimensions of capacity, derived fom the ICF, which can be impaired by mental disorders. Rating varies between 0 (no problem) to 4 (can not fullfill respective requirements at all). 61% of patients suffered from disorders from section F4 (neurotic, adjustment and somatoform disorders) of the ICD-10 (WHO, 1991), 29% from F3 (affective disorders) and 10% from F6 (personality disorders). Results 41% were on sick leave before admission. The average global score of the Mini-ICF-P was 0,84 (SD = 0,56), corresponding to “mild disability”. Highest disability was found for “flexibility” (M = 1,64, SD = 0,94), and lowest for “self maintenance” (M = 0,19, SD = 0,44) and “mobility” (M = 0,43, SD = 0,85). The Mini-ICF-P-score and profile was correlated with rate and duration of sick leave, but also type of disorder (e.g. depression vs. phobias), and course of treatment. Conclusion Comparatively minor disorders of capacity are associated with high rates of sick leave, i.e. disorders of participation. Not only restoration of functons but also of capacities should be targets of treatment.

FC02-05 Severity of somatic morbidity and anxiety: Pathological Realangst

Background Pathological anxiety is typically characterized by the absence of a real threat or danger. But, a persistent reason for anxiety, such as a severe life threatening illness, does not prevent the development of additional pathological anxieties, which has been described as “Pathological Realangst”. The question is to what degree pathological realangst can be explained by the real threat or preexisting anxiety. Method 209 patients (37,8% female) of a cardiology inpatient unit were given the State-Trait-Anxiety-Inventory, the Heart-Anxiety-Questionnaire, and the Progression Anxiety Questionnaire. Treating physicians gave a rating on the severity of somatic morbidity including subjective suffering, short and long term prognosis, impairment in daily living, degree of acute and chronic multimorbitity, and objective parameters of the cardiac condition. Result Global or specific ratings on the severity of somatic morbidity did not correlate with general or heart related anxiety. Correlation coefficients ranged between .001 and a maximum of .22 (heart anxiety and subjective suffering). Conclusion The results speak against the assumption that the threat by the illness is the explanation for the present anxiety. Instead, anxious patients who are suffering from a somatic illness are also afraid of their health status and present this as cause of their anxiety. Inspite of the persistent threat this anxiety is pathological i.e. realangst. It should be treated like other anxiety disorders, although it is more difficult to convince the patient and possibly their treating physicians that the present anxiety is not “normal” but pathological and in need of treatment.

P02-248 Work place phobia and type of job

Background Conditions at the work place affect in many ways the well being of empoyees. One frequent reaction is anxiety because opf threads by superiors, colleagues or customers, the possibility of failing and not fullfilling job demands, accidents, or the possiblity to lose the job. Method 230 patients (71% female) from a psychosomatic inpatient unit were interviewed with as DSM-based half standardized interview in respect to work related anxiety. Results 58% of the patients reported about work related anxieties. Across all areas generalized work related worrying is most frequent (26% service, 35% office/civil servants). Anxieties related to specific situations at work were most frequent in patients working in schools/education (32%) and in production/construction workers (28%). Anxiety related to feelings of insufficency and adjustment related anxiety were most often seen in office workers/civil servant (37% and 26%). Hypochondriac anxieties were mostly reported by school/education employees (18%) and construction/production workers (17%) but to a much lower degree by health workers (6%). Work related phobic reactions were reported by 17% of all patients and most frequent by office workers/civil servants (22%), followed by health workers (21%), service jobs (16%), construction/producrtion workers (11%) and patients working in schools and education (9%). Conclusion Work related anxieties are frequently seen in patients with mental and psychosomatic disorders. There are different types of anxieties which are differently related to different types of jobs.