Effects of pharmacotherapy and psychotherapy in depressed primary-care patients: a randomized, controlled trial including a patients' choice arm.

Mild depressive syndromes are highly prevalent among primary-care patients. Evidence-based treatment recommendations need to be derived directly from this diagnostically heterogeneous group. The primary aim was to assess the efficacy of sertraline and cognitive-behavioural group therapy for treatment of depressed primary-care patients, the secondary aim was to evaluate if receiving treatment according to free choice is associated with a better outcome than randomization to a particular treatment. We conducted a randomized, placebo-controlled, single-centre, 10-wk trial with five arms: sertraline (flexible dosages up to 200 mg/d) (n = 83); placebo (n = 83); manual-guided cognitive-behavioural group therapy (one individual session and nine group sessions per 90 min) (n = 61); guided self-help group (control condition, n = 59); and treatment with sertraline or cognitive-behavioural group therapy according to patients' choice (n = 82). From 1099 consecutively screened adult patients, 368 formed the intent-to-treat population with milder forms of depression. Primary outcome was a global efficacy measure combining z-converted Hamilton Depression Rating Scale and clinician-rated Inventory for Depressive Symptomatology scores. Sertraline was superior to placebo (p = 0.03). Outcome for guided self-help groups was worse compared to cognitive-behavioural group therapy (p = 0.002) and compared to all other treatment arms including pill placebo (secondary analyses). Outcome in the patients' choice arm was similar to that in the sertraline and cognitive-behavioural group therapy. Overall, sertraline is efficacious in primary-care patients with milder forms of depression. The superiority of cognitive-behavioural group therapy over guided self-help groups might partly be explained by 'nocebo' effects of the latter.

[Speed of onset of depressive episodes: a clinical criterion helpful for separating uni- from bipolar affective disorders]. / Geschwindigkeit des Depressionsbeginns: Ein Unterscheidungsmerkmal hinsichtlich uni- versus bipolarer affektiver Störungen.

OBJECTIVE: Depressive episodes can begin abruptly or start very slowly (over weeks). This relevant clinical feature of affective disorders has not been systematically investigated so far. The aim of this study was to analyze speed of onset of depressive episodes in patients with unipolar depression (UD) and bipolar affective disorders (BD). METHODS: 158 adult patients with UD (N = 108) and BD (N = 50) were examined using the structured "Onset-of-Depression Inventory". Only patients without acute critical life events preceding the onset were included in the study. RESULTS: There was a significant positive correlation between speed of onset of the present and that of the preceding depressive episode (rho = 0.66; p < 0.001). The association between speed of onset and speed of decay of depressive episodes failed to be significant (rho = 0.20; p = 0.09). Patients with bipolar disorder were found to develop depressive episodes significantly faster than patients with major depression (p < 0.001): Whereas depressive episodes started in 58% of patients with bipolar disorder within one week, this was only the case in 7.4% of patients with major depression. CONCLUSIONS: Within subjects, the speed of onset of depression is similar across different episodes. In the absence of acute critical life events, rapid onset of depressive episodes (within one week) is typical for bipolar depression, but not for unipolar depression. A rapid onset of depressive episodes might point to BD in patients with solely depressive episodes in the past and to subgroups with different neurobiological pathogenetic mechanisms.

Onset of depressive episodes is faster in patients with bipolar versus unipolar depressive disorder: evidence from a retrospective comparative study.

OBJECTIVE: Depressive episodes can have a very fast onset (< 1 hour) or start very slowly (> 1 month). This interesting aspect, pointing to different neurophysiological pathomechanisms, has not been systematically evaluated so far. The aim of this study was to describe speed of onset of depressive episodes in a consecutive sample of patients with at least 1 depressive episode and to investigate potential differences between patients with major depression versus bipolar affective disorders concerning this variable. METHOD: We examined 158 consecutive adult patients with major depression (N = 108) and bipolar disorder (N = 50) diagnosed according to criteria of the International Statistical Classification of Diseases, 10th revision, by applying the structured Onset-of-Depression Inventory. Patients with acute critical life events preceding the onset were excluded from final analyses. Data were collected between December 2001 and January 2007. RESULTS: There was a significant positive association between speed of onset of the present depressive episode and that of the preceding depressive episode (rho = 0.66, p < .001). Patients with bipolar disorder developed full-blown depressive episodes significantly faster than patients with major depression (p < .001): Whereas depressive episodes began within 1 week in 58% of patients with bipolar disorder, this was the case in only 7.4% of patients with major depression. CONCLUSION: Intraindividually, the speed of onset of depression is similar across different episodes. In the absence of acute critical life events, fast onset of depressive episodes (within 1 week) is common in bipolar disorder but rare in major depression. This aspect might be useful to identify depressive episodes occurring within a bipolar affective illness and might characterize a subgroup of patients with a distinct neurobiology.