Pär Svanborg

A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale.

Self‐assessment scales have long been used in psychiatric research even if their validity has often been questioned, one reason being poor the concordance of expert ratings. In clinical practice the use of rating scales is restricted, since they are considered to be time‐consuming and perhaps even to disrupt the clinicians rapport with the patient. In the present study, a self‐assessment scale, the CPRS Self‐rating Scale for Affective Syndromes (CPRS‐S‐A), was constructed by re‐phrasing in a self‐rating format 19 items from the original Comprehensive Psychopathological Rating Scale (CPRS) and covering depression, anxiety and obsessional symptoms. In a group of 30 patients with depression syndromes and anxiety syndromes, the CPRS‐S‐A and the original CPRS were both used on 2 occasions. The patients Global Assessment of Functioning scores ranged from 30 to 76 (mean 58), which suggests a moderate severity of illness, as does the fact that the majority were outpatients. There was a high degree of concordance between the instruments for most items and for the scores on the subscales for both diagnostic groups (i.e., the Montgomery‐Åsberg Depression Rating Scale and the Brief Anxiety Scale, which are both subscales drawn from the CPRS). The time taken to complete the CPRS‐S‐A varied from 5 to 30 min (mean 19 min for depressive and 16 min for anxiety patients on the first occasion, 13 min for both groups on the second), and the self‐rating procedure was readily accepted by both groups of patients. The CPRS‐S‐A would thus seem to be a promising instrument for quantitative rating of symptoms in ambulatory patients, both in clinical practice and in research.

A comparison between the Beck Depression Inventory (BDI) and the self-rating version of the Montgomery Åsberg Depression Rating Scale (MADRS)

BACKGROUND The Beck Depression Inventory BDI is the most often used self-rating instrument for depressive symptoms. In the present study, the BDI was compared with a self-rating version of the Montgomery Asberg Depression Rating Scale (MADRS-S) in 86 psychiatric patients with mainly affective and anxiety disorders. METHODS The patients were interviewed with the SCID-I Interview for a DSM-IV Major depression, and self-assessed the BDI and the MADRS. They were rated to have either mild, moderate or severe depressive symptomatology. After recovery, criteria for DSM-IV Personality disorders were self-assessed. RESULTS The instruments were about equal in differentiating between different Axis-I diagnoses and did not differ according to sensitivity to change during antidepressive treatment. Although the scales were highly intercorrelated (r=0.869), the BDI was demonstrated to tap more maladaptive personality traits compared to the MADRS-S. LIMITATIONS Because the sample consisted of psychiatric patients with prominent psychiatric symptomatology, the discriminative power of the BDI and the MADRS-S should be further evaluated in a sample with milder symptoms. CONCLUSIONS The MADRS-S is equivalent to the BDI as a self-assessment instrument for depression, but the MADRS-S focuses on core depressive symptoms, and is less influenced by maladaptive personality traits.

Capsulotomy for obsessive-compulsive disorder: long-term follow-up of 25 patients.

CONTEXT Capsulotomy is sometimes used as a treatment of last resort in severe and treatment-refractory cases of obsessive-compulsive disorder (OCD). OBJECTIVE To evaluate the long-term efficacy and safety of capsulotomy in OCD. DESIGN Noncontrolled, long-term follow-up trial (mean of 10.9 years after surgery). SETTING University hospital referral center. PATIENTS Twenty-five consecutive patients with OCD who underwent capsulotomy from 1988 to 2000. INTERVENTION Unilateral or bilateral capsulotomy. Lesions were created by means of radiofrequency heating (thermocapsulotomy) or gamma radiation (radiosurgery, gammacapsulotomy). MAIN OUTCOME MEASURE Yale-Brown Obsessive-Compulsive Rating Scale (Y-BOCS) score. RESULTS The mean Y-BOCS score was 34 preoperatively and 18 at long-term follow-up (P < .001). Response (defined as > or = 35% reduction at long-term follow-up compared with baseline) was seen in 12 patients at long-term follow-up. Nine patients were in remission (Y-BOCS score, < 16) at long-term follow-up. Only 3 patients were in remission without adverse effects at long-term follow-up. Response rates did not differ significantly between surgical methods. A mean weight gain of 6 kg was reported in the first postoperative year. Ten patients were considered to have significant problems with executive functioning, apathy, or disinhibition. Six of these 10 patients had received high doses of radiation or had undergone multiple surgical procedures. Results of our magnetic resonance imaging analysis in 11 patients suggest that the OCD symptom reduction may be increased by reducing the lateral extension of the lesions, and a reduction in the medial and posterior extension may limit the risk of adverse effects (ie, smaller lesions may produce better results). CONCLUSIONS Capsulotomy is effective in reducing OCD symptoms. There is a substantial risk of adverse effects, and the risk may vary between surgical methods. Our findings suggest that smaller lesions are safer and that high radiation doses and multiple procedures should be avoided.

Self-assessment of DSM-IV criteria for major depression in psychiatric out- and inpatients.

The Depression Self-Rating Scale (DSRS) is a self-report inventory based on the DSM-IV criteria for major depression. This study aimed to investigate diagnostic concordance of a major depressive disorder (MDD) using the DSRS and the Structured Clinical Interview for DSM-IV, axis I disorders (SCID-I). An additional aim was to investigate whether concordance could be improved by adding different cut-off scores for the Beck Depression Inventory (BDI) or the self-report version of the Montgomery-Asberg Depression Rating Scale (MADRS-S). MDD was determined by means of the SCID-I interview and the DSRS in 83 psychiatric in- and outpatients. Depressive severity was assessed using the BDI and the MADRS-S. A DSRS-version including the A- and C-criteria for an MDD had a sensitivity and a specificity for an expert-rated diagnosis of 86% and 75%, respectively. By using cut-off scores for the BDI or the MADRS-S, specificity could be raised to 85% without loss of sensitivity. The DSRS appears to be a useful instrument in the diagnostic process involving MDD, particularly when used in combination with the BDI or the MADRS-S. The DSRS is thought to be of value in psychiatric outpatient departments, where treatment of patients is often delegated to paramedical staff or nurses. The scale might also be used as an independent diagnostic tool in epidemiological studies in order to achieve an estimate of the prevalence of MDD in different population settings.

Determinants of self-rating and expert rating concordance in psychiatric out-patients, using the affective subscales of the CPRS

To investigate in more detail concordance between the recently developed Comprehensive Psychopathological Rating Scale (CPRS) and the recently developed Self‐Rating Scale for Affective Syndromes (CPRS‐S‐A), a total of 101 psychiatric out‐patients were assessed using these procedures and a diagnostic interview according to DSM‐III‐R. Depressive and anxiety syndromes were the most common diagnoses on Axis I. Approximately one‐third of the patients had a diagnosis of clinical personality disorder on Axis II. The majority of the patients were assessed as predominantly manifesting either Cluster B or Cluster C traits. In general, the correlation between self‐and expert‐ratings was strong (0.83 for the Montgomery‐Åsberg Rating Scale (MADRS) depression subscale and 0.76 for the Brief Scale for Anxiety (BSA) anxiety subscale), but it tended to be weaker in the group of patients with clinical personality disorders. The correlation between the two ratings was also weaker in the group with predominantly Cluster B character traits than in the group with predominantly Cluster C traits or the group with no predominant traits, and weaker in the depressive group than in the anxiety group. However, personality disorder diagnoses were over‐represented in the depressive group. The weaker correlations in the groups mentioned above may have been attributable to psychological factors and qualitative differences in cognitive and communicative style. The CPRS‐S‐A is considered to be a useful and reliable instrument for quantitative rating of symptoms in out‐patients. Our results highlight the potential value of using appropriate self‐assessment forms as complementary tools in clinical practice and research.

The Scandinavian Solutions for Wellness study - a two-arm observational study on the effectiveness of lifestyle intervention on subjective well-being and weight among persons with psychiatric disorders

BackgroundSolutions for Wellness (SfW) is an educational 3-month program concerning nutrition and exercise for persons with psychiatric disorders on psychotropic medication, who have weight problems. This observational study assessed the impact of SfW on subjective well-being, weight and waist circumference (WC).MethodsData was collected at 49 psychiatric clinics. Where the SfW program was offered patients could enter the intervention group; where not, the control group. Subjective well-being was measured by the Subjective Well-being under Neuroleptics scale (SWN), at baseline, at the end of SfW participation, and at a follow-up 6 months after baseline. Demographic, disease and treatment data was also collected.Results314 patients enrolled in the SfW group, 59 in the control group. 54% of the patients had schizophrenia, 67% received atypical antipsychotics, 56% were female. They averaged 41 ± 12.06 years and had a BMI of 31.4 ± 6.35. There were significant differences at baseline between groups for weight, SWN total score and other factors. Stepwise logistic models controlling for baseline covariates yielded an adjusted non-significant association between SfW program participation and response in subjective well-being (SWN increase). However, statistically significant associations were found between program participation and weight-response (weight loss or gain < 1 kg) OR = 2; 95% CI [1.1; 3.7] and between program participation and WC-response (WC decrease or increase < 2 cm) OR = 5; 95% CI [2.4; 10.3]), at 3 months after baseline.ConclusionsSfW program participation was associated with maintaining or decreasing weight and WC but not with improved subjective well-being as measured with the SWN scale.

Early switch strategy in patients with major depressive disorder: a double-blind, randomized study.

Objective Antidepressant switch is a commonly used strategy in the absence of an adequate response, but optimum timing is not well established. We compared the efficacy of an early and a conventional antidepressant switch strategy in patients with major depressive disorder. Methods Patients with no or minimal improvement (<30% reduction in baseline 17-item Hamilton Depression Rating Scale [HAMD17] score) after 4 weeks on escitalopram 10 mg/d were randomized to either early switch strategy with duloxetine 60 to 120 mg/d for 12 weeks (arm A) or conventional switch strategy (arm B): 4 further weeks on escitalopram 10 to 20 mg/d; then, in case of nonresponse (response, ≥50% reduction in HAMD17), switch to duloxetine 60 to 120 mg/d for 8 weeks, or continued escitalopram in responders. Co-primary end points were time to confirmed response and remission (HAMD17, ⩽7). Strategies were compared using Kaplan-Meier, logistic regression, and repeated-measures analyses. Results Sixty-seven percent (566 of 840) of patients showed no or minimal improvement and were randomized to arm A (282 patients) or arm B (284 patients). No between-strategy differences in time to confirmed response (25% Kaplan-Meier estimates, 3.9 vs 4.0 weeks, P = 0.213) or remission (6.0 vs 7.9 weeks, P = 0.075) were found. Rates of confirmed responders were similar (64.9% vs 64.1%); however, more patients randomized to early switch achieved confirmed remission (43.3% vs 35.6%; P = 0.048). Conclusions Although no differences in the primary end points were found, a higher remission rate was seen with the early switch strategy. Our findings suggest that further investigations to reevaluate the conventional approach to antidepressant switch strategy would be worthwhile.

What patient characteristics make therapists recommend psychodynamic psychotherapy or other treatment forms

In order to study factors that psychodynamic therapists considered to be important for recommendation of treatment, psychiatric diagnoses (DSM‐III‐R Axes I and II and the GAF) as well as character traits assessed by the Karolinska Psychodynamic Profile (KAPP) were retrospectively assessed in interview case‐notes of patients applying for psychodynamic psychotherapy. Recommendation of psychotherapy was predicted by the absence of a personality disorder and high GAF scores, but not by the presence of a psychiatric syndrome. The KAPP differentiated between patients with and without disorders on Axis II, but not on Axis I. Patients who were recommended psychodynamic psychotherapy were healthier on all central KAPP variables compared to those who were recommended other treatments, and they were also characterized by predominantly neurotic personality organization, with inhibition as the most prominent defence.

Improving the usefulness of the Karolinska Psychodynamic Profile in research: proposals from a reliability study

The interrater reliability of data obtained by use of the Karolinska Psychodynamic Profile (KAPP) was tested among 60 women seeking treatment for drinking problems. The first rater had a psychodynamic background but was minimally trained rating the KAPP subscales and performing KAPP interviews. Independent, blind ratings of audiotaped interviews by an experienced KAPP rater revealed that 8 of the subscales obtained satisfactory reliability, whereas 6 subscales showed unsatisfactory reliability. Furthermore, data for one subscale (normopathy) showed a zero correlation between raters, probably due to the novelty of the construct. Additionally 3 subscales related to bodily aspects were of little clinical significance among the present study group. Our data were compared with data from previous KAPP reliability studies, and the reasons for similarities and discrepancies of results are discussed.

Lesion Topography in Capsulotomy for Refractory Anxiety – Is the Right Side the Right Side?

Objective: A previous report on bilateral capsulotomy in obsessive-compulsive disorder showed common topographic features of lesions in the right-sided internal capsule in all patients responding to the treatment. The aims of the present study were to test if the same region was involved in anxiety patients responding to surgery and to examine whether lesion area and site correlated with adverse events and effect on target symptoms. Method: Eleven anxiety patients who had undergone bilateral thermocapsulotomy were examined after 8–23 years. A quantitative MRI evaluation of the lesions within the internal capsule was conducted in three axial planes. Results: None of the eight responders had lesions that corresponded to the earlier reported right-sided anatomical denominator. Four patients out of 11 were rated as having significant clinical symptoms indicating frontal lobe dysfunction. The total sum of the lesion area determined in each of the three anatomical levels did not correlate with the degree of anxiety reduction. However, the lesion area appeared to be related to a rating of executive dysfunctioning, apathy and disinhibtion.