Suicide attempts in chronically depressed individuals: What are the risk factors?

Chronically depressed individuals have a high suicide risk. However, it is an open question whether previously observed risk factors for suicide attempts also apply to chronic depression or whether there are specific risk factors related to chronic-recurrent illness. We drew from a large group of chronically depressed individuals seeking psychotherapy to investigate demographic and psychological factors related to previous suicide attempts. Participants took part in the SCID and filled out established questionnaires. Among 368 chronically depressed individuals (68.7% women; Mage = 40.95 years), 75 participants (19.4%) reported previous suicide attempts. Men were more likely to have used violent methods. We tested the links of having attempted suicide with different variables using logistic regression analyses. Our findings corroborate previously observed risk factors (e.g. sexual abuse, personality disorders) and suggest other risk factors which could be especially relevant in chronic depression (e.g. depression severity, interpersonal problems, self-injurious behavior, and overall years of depression). Other risk factors from previous studies were not related to suicidal behavior within our sample (e.g. anxiety disorders, PTSD). Thus, mental health professionals should be aware that risk factors for suicidal behavior might vary between diagnosis groups and that chronic illness might be a risk factor in itself.

How to measure sustained psychic transformations in long-term treatments of chronically depressed patients: Symptomatic and structural changes in the LAC Depression Study of the outcome of cognitive-behavioural and psychoanalytic long-term treatments.

Worldwide, the pressure on psychoanalysis to prove the results of its treatments according to the criteria of so-called evidence-based medicine has increased. While a large number of studies on the results of psychoanalytic short-term therapies are now available, such studies are still largely lacking on psychoanalysis and psychoanalytic long-term therapies. In a large multicentre study, the results of psychoanalytical and cognitive-behavioural longterm therapies in chronically depressed patients were compared, Both psychotherapies led to statistically highly significant changes in depressive symptoms three years after the start of the treatments However, the focus of psychoanalytic treatments is not exclusively on reducing psychopathological symptoms, but on changes in the inner world of the patients that are reminiscent of the goal of psychoanalyses that Freud has characterized as developing "the ability to love, work and enjoy life." In the German-speaking community, such transformations are called "structural changes." This article reports results on such structural changes achieved with the help of a sophisticated measuring instrument, the Operationalized Psychodynamic Diagnostics (OPD). These so-called structural changes are compared with symptomatic changes. Three years after the start of the treatments, significantly more patients in psychoanalytical treatments show such structural changes than patients in cognitive-behavioural treatments.

Outcome of Psychoanalytic and Cognitive-Behavioural Long-Term Therapy with Chronically Depressed Patients: A Controlled Trial with Preferential and Randomized Allocation.

OBJECTIVE: For chronic depression, the effectiveness of brief psychotherapy has been limited. This study is the first comparing the effectiveness of long-term cognitive-behavioural therapy (CBT) and long-term psychoanalytic therapy (PAT) of chronically depressed patients and the effects of preferential or randomized allocation. METHODS: A total of 252 adults met the inclusion criteria (aged 21-60 years, major depression, dysthymia, double depression for at least 24 months, Quick Inventory of Depressive Symptoms [QIDS] >9, Beck Depression Inventory II [BDI] >17, informed consent, not meeting exclusion criteria). Main outcome measures were depression self-rating (BDI) and rating (clinician-rated QIDS [QIDS-C]) by independent, treatment-blinded clinicians. Full remission rates (BDI ≤12, QIDS-C ≤5) were calculated. An independent center for data management and biostatistics analyzed the treatment effects and differences using linear mixed models (multilevel models and hierarchical models). RESULTS: The average BDI declined from 32.1 points by 12.1 points over the first year and 17.2 points over 3 years. BDI overall mean effect sizes increased from d = 1.17 after 1 year to d = 1.83 after 3 years. BDI remission rates increased from 34% after 1 year to 45% after 3 years. QIDS-C overall effect sizes increased from d = 1.56 to d = 2.08, and remission rates rose from 39% after 1 year to 61% after 3 years. We found no significant differences between PAT and CBT or between preferential and randomized allocation. CONCLUSIONS: Psychoanalytic as well as cognitive-behavioural long-term treatments lead to significant and sustained improvements of depressive symptoms of chronically depressed patients exceeding effect sizes of other international outcome studies.

Childhood Trauma and Its Relation to Chronic Depression in Adulthood.

There is a large consensus indicating that childhood trauma is significantly involved in the development of depression. The aim of this study was to examine the prevalence of retrospectively recalled childhood trauma in chronically depressed patients and to investigate a more specific relationship between trauma type and depression. We further asked for the influence of multiple experiences of childhood trauma on the vulnerability to a chronic course of depression in adulthood. 349 chronically depressed patients of the German LAC Depression Study completed the Childhood Trauma Questionnaire, a self-report measure of traumatic experiences in childhood. 75.6% of the chronically depressed patients reported clinically significant histories of childhood trauma. 37% of the chronically depressed patients reported multiple childhood traumatization. Experiences of multiple trauma also led to significantly more severe depressive symptoms. Stepwise multiple regression analysis suggested that childhood emotional abuse and sexual abuse were significantly associated with a higher symptom severity in chronically depressed adults. Yet, expanding the regression model for multiple exposures showed that multiplicity was the only remaining significant predictor for symptom severity in chronically depressed patients. Clinical implications suggest a precise assessment of childhood trauma in chronically depressed patients with a focus on emotional abuse, sexual abuse, and multiple exposures to childhood trauma. This trial is registered with registration number ISRCTN91956346.

Psychoanalytic and cognitive-behavior therapy of chronic depression: study protocol for a randomized controlled trial.

BACKGROUND: Despite limited effectiveness of short-term psychotherapy for chronic depression, there is a lack of trials of long-term psychotherapy. Our study is the first to determine the effectiveness of controlled long-term psychodynamic and cognitive-behavioral (CBT) treatments and to assess the effects of preferential vs. randomized assessment. METHODS/DESIGN: Patients are assigned to treatment according to their preference or randomized (if they have no clear preference). Up to 80 sessions of psychodynamic or psychoanalytically oriented treatments (PAT) or up to 60 sessions of CBT are offered during the first year in the study. After the first year, PAT can be continued according to the 'naturalistic' usual method of treating such patients within the system of German health care (normally from 240 up to 300 sessions over two to three years). CBT therapists may extend their treatment up to 80 sessions, but focus mainly maintenance and relapse prevention. We plan to recruit a total of 240 patients (60 per arm). A total of 11 assessments are conducted throughout treatment and up to three years after initiation of treatment. The primary outcome measures are the Quick Inventory of Depressive Symptoms (QIDS, independent clinician rating) and the Beck Depression Inventory (BDI) after the first year. DISCUSSION: We combine a naturalistic approach with randomized controlled trials(RCTs)to investigate how effectively chronic depression can be treated on an outpatient basis by the two forms of treatment reimbursed in the German healthcare system and we will determine the effects of treatment preference vs. randomization. TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN91956346.

Body image distortions in bulimia nervosa: investigating body size overestimation and body size satisfaction by fMRI.

BACKGROUND: Body image distortion is a key symptom of eating disorders. In behavioral research two components of body image have been defined: attitudes towards the body and body size estimation. Only few fMRI-studies investigated the neural correlates of body image in bulimia; those are constrained by the lack of a direct distinction between these different body image components. METHODS: The present study investigates the neural correlates of two aspects of the body image using fMRI: satisfaction rating and size estimation of distorted own body photographs in bulimia nervosa patients (15) and controls (16). RESULTS: Patients were less satisfied with their current body shape than controls and preferred to be thinner. The amount of insula activity reflects the pattern of the satisfaction rating for patients and controls. Patients also overestimated their own body size. For control subjects, an activated cluster in lateral occipital cortex was sensitive for body size distortions, whereas bulimic patients did not demonstrate such a modulation. Furthermore, bulimic subjects did not recruit the middle frontal gyrus (MFG) in contrast to controls during the body size estimation task, maybe indicating a reduced spatial manipulation capacity. Therefore, this activation pattern of lateral occipital cortex and MFG might be responsible for body size overestimation in bulimia. CONCLUSIONS: The present results show that bulimic patients exhibit two distinct deficits in body image representations similar to anorectic patients and that specifically associated neuronal correlates can be identified. Concludingly, our study support psychotherapeutic strategies specifically targeting these two aspects of body image distortions.