Determinants of quality of life improvements in anxiety and depressive disorders-A longitudinal study of inpatient psychotherapy.

Background: Quality of life (QoL) is substantially impaired in patients with anxiety disorders (AD) and depressive disorders (DD) and improvements in symptom burden after psychotherapy are not always paralleled by similar improvements in QoL. So far, little is known about treatment outcome in terms of QoL and predictors of QoL improvements following inpatient psychotherapy with a focus on cognitive behavior therapy (CBT). The current study aimed at investigating the relationship between changes in symptoms and QoL across different life domains. Additionally, predictors of a positive treatment outcome were evaluated. Methods: 122 patients with AD and/or DD undergoing an 8-weeks inpatient CBT program completed self-report measures of psychopathological symptoms and QoL at pre- and post-treatment. Mixed effects models were used to investigate changes, a confirmatory factor analysis was applied to analyze the latent factor structure of the anxiety sensitivity index and binary logistic regression analyses were performed for predictors of QoL improvements. Results: Patients showed moderate to strong decreases in anxious and depressive symptoms and moderate to strong improvements in general QoL, particularly in the psychological and physical QoL subdomains. Changes in symptom burden correlated most strongly with psychological and physical QoL. In addition, poor QoL before treatment and low levels of specific anxiety sensitivity symptoms (items 1 and 5) significantly predicted improvement in QoL. Conclusion: Patients with poor QoL who are not as inhibited to openly express their anxious feelings particularly benefit from inpatient psychotherapy (individual and group) to improve their QoL. In contrast, our research suggests that patients who are too anxious to openly express their nervousness should receive additional social skills training, more focused treatment to build sufficient self-confidence to better engage in the treatment program.

Relapse of obsessive-compulsive disorder after cerebral venous sinus thrombosis: a case report.

Obsessive-compulsive disorder (OCD) is characterized by repetitive, persistent and unwanted thoughts and ritualistic, repetitive behaviors. The pathophysiology of OCD involves many distinct cortical and subcortical regions and it has been reported that OCD may occur as a consequence of traumatic brain injury, infections and tumors as well as cerebrovascular insult such as cerebral venous sinus thrombosis (CVST). We here describe the case of a 36-year-old woman who developed OCD at the age of 13 with almost complete remission of the symptoms after a 1 year-long treatment. Interestingly, after suffering CVST at the superior sagittal sinus at the age of 33, she experienced a relapse of OCD. The patient was successfully treated with Sertraline and Clomipramine. Previous studies revealed cases of OCD following different cerebrovascular accidents, i.e. predominantly arterial stroke. However, the present case is the first to describe OCD after venous thrombosis. Based on our clinical experience, the most effective treatment of OCD after CVST represents the combination of the selective serotonin reuptake inhibitor Sertraline and the tricyclic antidepressant Clomipramine.

Personality functioning in anxiety disorders.

BACKGROUND: The Alternative DSM-5 Model for Personality Disorders as well as the upcoming IDC-11 have established a new focus on diagnosing personality disorders (PD): personality functioning. An impairment of self and interpersonal functioning in these models represents a general diagnostic criterion for a personality disorder. Little is known so far about the impairment of personality functioning in patients with other mental disorders than PD. This study aims to assess personality functioning in patients with anxiety disorders. METHODS: Ninety-seven patients with the diagnosis of generalized anxiety disorder, panic disorder, or phobia, and 16 healthy control persons were diagnosed using the Structured Clinical Interview for DSM-IV (SCID-I and -II) and were assessed by means of the Structured Interview for Personality Organization (STIPO) to determine the level of personality functioning. RESULTS: While all three patient groups showed significant impairment in personality functioning compared to the control group, no significant differences were observed between the different patient groups. In all three groups of anxiety disorders patients with comorbid PD showed significantly worse personality functioning than patients without. Patients without comorbid PD also yielded a significant impairment in their personality functioning when compared to the control group. CONCLUSIONS: Anxiety disorders are associated with a significant impairment in personality functioning, which is significantly increased by comorbid PD. There are no differences in terms of personality functioning between patients with different anxiety disorders.

Effects of Clinical Decision Topic on Patients' Involvement in and Satisfaction With Decisions and Their Subsequent Implementation.

OBJECTIVE: Clinical decision making is an important aspect of mental health care. Predictors of how patients experience decision making and whether decisions are implemented are underresearched. This study investigated the relationship between decision topic and involvement in the decision, satisfaction with it, and its subsequent implementation from both staff and patient perspectives. METHODS: As part of the Clinical Decision Making and Outcome in Routine Care for People With Severe Mental Illness study, patients (N=588) and their providers (N=213) were recruited from community-based mental health services in six European countries. Both completed bimonthly assessments for one year using the Clinical Decision Making in Routine Care Scale to assess the decision topic and implementation; both also completed the Clinical Decision Making Involvement and Satisfaction Scale. RESULTS: Three categories of decision topics were determined: treatment (most frequently cited), social, and financial. The topic identified as most important remained stable over the follow-up. Patients were more likely to rate their involvement as active rather than passive for social decisions (odds ratio [OR]=5.7, p<.001) and financial decisions (OR=9.5, p<.001). They were more likely to report higher levels of satisfaction rather than lower levels for social decisions (OR=1.5, p=.01) and financial decisions (OR=1.7, p=.01). Social decisions were more likely to be partly implemented (OR=3.0, p<.001) or fully implemented (OR=1.7, p=.03) than not implemented. CONCLUSIONS: Patients reported poorer involvement, satisfaction, and implementation in regard to treatment-related decisions, compared with social and financial decisions. Clinicians may need to employ different interactional styles for different types of decisions to maximize satisfaction and decision implementation.

[Pain Symptoms as Predictors of Depressive or Anxiety Disorders in Patients with Physical Illness]. / Schmerzsymptome als Hinweis auf Depressionen und Angsterkrankungen bei PatientInnen an somatischen Krankenhausabteilungen.

OBJECTIVE: The aim of this study was to investigate the frequency of pain symptoms reported by patients of non-psychiatric hospital departments and to explore their association with affective and anxiety disorders. METHODS: Patients of non-psychiatric hospital departments (n = 290) reported pain symptoms by filling in a self-rating questionnaire. Psychiatric examinations were performed by psychiatrists using a structured diagnostic interview. The sum-scores of self-reported pain symptoms were tested for their screening accuracy for anxiety and depression. RESULTS: Patients suffering from affective or anxiety disorders reported significantly more often three or more pain symptoms (63 % vs. 28 %). Using a cut-off value of ≥ 3 of self-reported pain symptoms yielded a sensitivity of 63.1 % and a specificity of 71.7 %. CONCLUSIONS: These findings highlight the relevance of a higher number of pain symptoms as a possible indicator for affective and anxiety disorders. The use of pain symptoms as pre-screening for depression and anxiety might be a useful tool, but needs further research before it can be recommended.

[Depression Symptoms of Mothers and Fathers of Persons with Schizophrenia]. / Die Depressivität von Müttern und Vätern von Schizophreniekranken.

OBJECTIVE: The purpose of the present study was to investigate if depression symptomatology of patients' parents is predicted by the symptoms of schizophrenia. METHODS: 101 mothers and 101 fathers of the same patients suffering from schizophrenia were included into this study. Parents filled in the "Beck Depression Inventory". Patients were assessed by means of the "Positive and Negative Syndrome Scale". For statistical analyses a Multidimensional Random Coefficients Multinomial Logit Model was applied. RESULTS: We found a significant positive association between negative symptoms and depression severity of fathers and mothers. Further, a significant positive association between positive symptoms and depression severity of fathers, but not of mothers was found. CONCLUSION: Our results show that depression of mothers and of fathers is associated with symptoms of schizophrenia even when controlling for potential predictors.

[Projections about the future number of dementia sufferers: increasing life expectancy not sufficiently considered?].

BACKGROUND: Several authors pointed out that in the next decades dementia will affect a considerably increasing number of the elderly. The question was raised if life-expectancy was projected to conservative, resulting in revisions with higher life-expectancy and larger numbers of the oldest population. The present paper analyses the influence of such revisions on the future numbers of dementia sufferers in Austria. SUBJECTS AND METHODS: For this purpose we used meta-analyses of epidemiological studies and the population projections for the period until 2050 of the Austrian Bureau of Statistics as well as of the United Nations Population Division of the year 2001 as well of the year 2005. RESULTS: Using the extrapolations of the Austrian Bureau of Statistics of the year 1999 as well as of the United Nations Population Division of the year 2001, the number of dementia cases in Austria in the year 2050 will rise to about 233 thousands. According to the four years later performed extrapolations of the United Nations Population Division of the year 2005, dementia cases in Austria will raise to about 262 thousands in the year 2050. CONCLUSIONS: In the next decades, the number of persons suffering from dementia will rise considerably. Increasing life-expectancy will result in markedly higher numbers of persons with dementia than estimated from earlier population projections. Nevertheless, this is the first analysis of future dementia cases based on projections from two different dates, but using the same source. We must conclude that the dramatically increasing number of dementia cases requires comprehensive planning of the health and social care system.

Development and evaluation of an Individualized Outcome Measure (IOM) for randomized controlled trials in mental health.

Pre-defined, researcher-selected outcomes are routinely used as the clinical end-point in randomized controlled trials (RCTs); however, individualized approaches may be an effective way to assess outcome in mental health research. The present study describes the development and evaluation of the Individualized Outcome Measure (IOM), which is a patient-specific outcome measure to be used for RCTs of complex interventions. IOM was developed using a narrative review, expert consultation and piloting with mental health service users (n = 20). The final version of IOM comprises two components: Goal Attainment (GA) and Personalized Primary Outcome (PPO). For GA, patients identify one relevant goal at baseline and rate its attainment at follow-up. For PPO, patients choose an outcome domain related to their goal from a pre-defined list at baseline, and complete a standardized questionnaire assessing the chosen outcome domain at baseline and follow-up. A feasibility study indicated that IOM had adequate completion (89%) and acceptability (96%) rates in a clinical sample (n = 84). IOM was then evaluated in a RCT (ISRCTN02507940). GA and PPO components were associated with each other and with the trial primary outcome. The use of the PPO component of IOM as the primary outcome could be considered in future RCTs. Copyright © 2015 John Wiley & Sons, Ltd.

Psychiatric illness and length of stay in general hospitals: do case finding methods matter?

OBJECTIVE: Several prior studies have investigated whether patients with "non-cognitive" mental disorders (i.e., organic disorders, substance abuse, delirium, and psychotic disorders excluded) have longer Length Of Stay (LOS) than mentally healthy individuals in nonpsychiatric hospital settings. These studies yielded contrasting results. The present paper aims to examine whether methods of psychiatric case finding can explain these differences. METHODS: Using the Clinical Interview Schedule (CIS) and the General Health Questionnaire (GHQ), 462 in-patients of medical, surgical, gynecological, and rehabilitation departments were assessed for the presence of psychiatric disorders. RESULTS: In multiple regression analysis, all CIS-cases together did not show an association with LOS. Of the diagnostic groups assessed by CIS only major depression showed a significantly prolonged LOS. Using the GHQ sum-score as a continuous variable, LOS was significantly increased while using the GHQ as a dichotomous variable did not show such an association. After removing those suffering from multiple psychiatric diagnoses (such as major depression co-morbid with organic mental illness), none of the case definitions showed a significant association with LOS. CONCLUSIONS: It seems that different case finding methods yield different results concerning the association of psychiatric disorders with LOS. When interpreting these results the small size of some subsamples must be taken into consideration.

[Prevalence and recognition of depression among inpatients of non-psychiatric hospital departments]. / Prävalenz und Erkennen der Depression an nicht-psychiatrischen Krankenhausabteilungen.

PURPOSE: The purpose of this study is to compare the prevalence of depression among different types of hospital departments. Furthermore, it compares different methods for assessment of its recognition by non-psychiatric physicians. METHODS: 993 inpatients of internal, surgical, gynecological and physical rehabilitation wards of community hospitals were interviewed by research psychiatrists using the Clinical Interview Schedule. Ward physicians were asked to fill in a short questionnaire in order to assess whether they could correctly identify patients with mental illnesses. In addition, routine discharge diagnoses were assessed. RESULTS: Of the total sample, 13.3 % suffered from depression. Depression was most frequent on physical rehabilitation units (24.2 %), followed by surgical (9.8 %) and internal (9.5 %) wards. On gynecological wards, prevalence of depression was lowest (8.7 %). Of those suffering from depression, 45.7 % were identified as mentally ill by non-psychiatric ward physicians when using questionnaire data. Only 21.0 % of the depressed received a psychiatric discharge diagnosis, which equals less than half of those identified by questionnaire. RESULTS: Of the total sample, 13.3 % of patients suffered from depression. Depression was most frequent in physical rehabilitation units (24.2 %), followed by surgical (9.8 %) and internal (9.5 %) wards. In gynecological wards, the prevalence of depression was the lowest (8.7 %). Of those suffering from depression, 45.7 % were identified as mentally ill by non-psychiatric ward physicians when using questionnaire data. Only 21.0 % of the depressed received a psychiatric discharge diagnosis, less than half of those identified by the questionnaire. CONCLUSIONS: Depression is very common among inpatients of physical hospital departments. Unfortunately, depression is frequently overlooked in everyday clinical work. Routine discharge diagnoses give only very limited information about how often ward physicians recognize mental disorders. Furthermore, hospital discharge diagnoses should not be used for planning mental health services.

[Comorbid somatic illnesses in psychiatric inpatients - an analysis of administrative data]. / Somatische Komorbidität im stationär psychiatrischen Bereich - eine Analyse administrativer Daten.

PURPOSE: This study intended to analyze the prevalence of physical diagnoses at psychiatric inpatient hospital wards. METHODS: For this purpose we used partially aggregated administrative data from routine diagnostic documentation of Austrian hospitals. All psychiatric and physical main and secondary diagnoses according to ICD-10 of all psychiatric inpatient units in Austria of the years 2007 were used. RESULTS: Of 79,027 psychiatric hospital admissions 75,224 received a psychiatric and 3803 a somatic main diagnosis at discharge. Diseases of the vascular system (20 %) were the most frequent somatic diagnoses, followed by endocrine and metabolic diseases (16.4 %) and neurological diseases (14.4 %). Among patients suffering from schizophrenia, the most frequent physical diagnoses were endocrine and metabolic diseases. Among those with affective disorders, vascular diseases as well as endocrine and metabolic diseases were found most often. CONCLUSIONS: Physical diagnoses are very common among psychiatric inpatients. Mass screening and specialized prevention programs should be evaluated regarding their effectiveness for this population.

[Burden of mothers and fathers of persons with schizophrenia]. / Die Belastung von Müttern und Vätern von Schizophreniekranken.

OBJECTIVE: Most studies about the burden of schizophrenia carers included only one care-giving relative, usually the patients' mothers. The present study intended to analyse differences of the level of burden between mothers and fathers of the same patients. METHODS: 101 mothers and 101 fathers of the same patients suffering from schizophrenia were included into this study. They were assessed by means of the "Involvement Evaluation Questionnaire" and the "Carers' Needs Assessment for Schizophrenia". RESULTS: Mothers showed significantly higher scores than fathers regarding the subscores "Tensions" and "Urging". Multiple linear regression analyses showed positive associations between the frequency of mothers' as well as fathers' unmet needs and dimensions of caregiver involvement. CONCLUSION: Unmet needs among mothers and fathers have negative effects on their burden. The differences between mothers and fathers indicate the importance of considering the carer's gender in clinical work.

[First contact with psychiatric services: what do relatives caring for schizophrenia patients need?]. / Der erste Kontakt mit einer psychiatrischen Einrichtung: Was brauchen die Angehörigen Schizophreniekranker?

OBJECTIVE: The purpose of the present study was to investigate the problems and needs for interventions among caregivers of patients with schizophrenia who were the first time in contact with psychiatric services. METHODS: 93 family caregivers of schizophrenia patients during the first contact with services were investigated by means of the the "Carer's Needs Assessment for Schizophrenia" (CNA-S). RESULTS: The most frequent problems of caregivers of first contact patients with schizophrenia were insufficient information on mental illness and concerns about the patient's future. Individual psychoeducation was needed significantly more often among caregivers of first contact patients than among those having been previously in contact with psychiatric services. CONCLUSION: Those being the first time in contact with psychiatric services need some specific interventions significantly more often than later.

[Risks for Burden among Relatives Caring for Schizophrenia Patients]. / Prädiktoren für die Belastung von Angehörigen Schizophreniekranker.

OBJECTIVE: Relatives of persons with schizophrenia have an essential role in informal caregiving. This may result in a high level of burden. Aim of the study was to investigate, if the frequency of unmet needs among relatives caring for schizophrenia patients increases the risk for burden among these relatives. METHODS: 135 relatives of patients with schizophrenia or schizoaffective disorder were investigated by means of the "Involvement Evaluation Questionnaire" (IEQ) and the "Carer's Needs Assessment for Schizophrenia" (CNA-S). RESULTS: Multiple linear regression analyses showed positive associations between the frequency of caregivers' unmet needs and the IEQ-subscores "tension" and "worrying". Further, the IEQ-subscore "worrying" was significantly lower among caregivers of outpatients than among caregivers of inpatients or day hospital patients. The IEQ-subscore "urging" was significantly associated with patient's negative symptoms. CONCLUSION: Unmet needs among caring relatives have negative effects on their burden. Further, the patients' type of treatment setting (inpatient, outpatient, day hospital) seems to predict caregivers' burden.

[Association between fear of stigma, depressive and anxiety symptoms in patients with somatoform pain disorder]. / Zusammenhang zwischen Stigmabefürchtung, depressiver und Angstsymptomatik bei Patienten mit somatoformer Schmerzstörung.

OBJECTIVES: There is still poor acceptance for pain without somatic causes, and patients with somatoform pain disorder carry a stigma per se. The aim of this study was to identify predictors of fear of stigma including depression, anxiety and somatisation among patients with somatoform pain disorder. METHODS: 132 patients with somatoform pain disorder were investigated by using the Link Stigma Questionnaire, the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Whiteley-Index, and the Checklist for Somatisation. RESULTS: Multiple linear regression analysis showed a significant positive association between fear of stigma and symptoms of depression and a negative association with patients' age. CONCLUSIONS: This is one of the first studies investigating this question among patients with somatoform pain disorder. Findings might indicate the importance of depressive symptoms for developing fear of stigma.

Dysfunctional pain modulation in somatoform pain disorder patients.

To date, pain perception is thought to be a creative process of modulation carried out by an interplay of pro- and anti-nociceptive mechanisms. Recent research demonstrates that pain experience constitutes the result of top-down processes represented in cortical descending pain modulation. Cortical, mainly medial and frontal areas, as well as subcortical structures such as the brain stem, medulla and thalamus seem to be key players in pain modulation. An imbalance of pro- and anti-nociceptive mechanisms are assumed to cause chronic pain disorders, which are associated with spontaneous pain perception without physiologic scaffolding or exaggerated cortical activation in response to pain exposure. In contrast to recent investigations, the aim of the present study was to elucidate cortical activation of somatoform pain disorder patients during baseline condition. Scalp EEG, quantitative Fourier-spectral analyses and LORETA were employed to compare patient group (N = 15) to age- and sex-matched controls (N = 15) at rest. SI, SII, ACC, SMA, PFC, PPC, insular, amygdale and hippocampus displayed significant spectral power reductions within the beta band range (12-30 Hz). These results suggest decreased cortical baseline arousal in somatoform pain disorder patients. We finally conclude that obtained results may point to an altered baseline activity, maybe characteristic for chronic somatoform pain disorder.

[Gender aspects of psychiatric publications]. / Gender-Aspekte psychiatrischer Publikationen.

OBJECTIVE: Are authors of German language psychiatric journals more often male or female? Are there gender differences regarding scientific topics? METHODS: Analysis of publications of two German-language journals (Neuropsychiatrie, Psychiatrische Praxis) for the period 2008-2009. RESULTS: We could not find any gender differences concerning the number of first authors, but the number of male co-authors was nearly double as high as of female co-authors. Qualitative research methods were used more often by female researchers, but there were no significant differences regarding scientific topics. CONCLUSIONS: Overall, we found fewer gender differences than expected concerning authorship.

[The German language version of the Camberwell Assessment of Need for the Elderly (CANE) among dementia patients]. / Die Erfassung des Bedarfs bei Demenzkranken mittels Camberwell Assessment of Need (CANE) for the Elderly.

OBJECTIVE: The purpose of the present study was to assess the needs of dementia patients using the German language version of the Camberwell Assessment of Need for the Elderly (CANE) and to investigate the internal consistency of German language. METHODS: A sample of 45 dementia patients was investigated using the German CANE. Data were collected from family caregivers. RESULTS: Most dementia patients showed a multitude of problems. In most cases, support was provided more frequently from informal caregivers than from social or medical services. Internal consistency ranged between 0.797 and 0.900 (Cronbach's Alpha). CONCLUSIONS: The high frequency of problems indicates the importance of long-term planning of services for dementia patients. The internal consistency of the German CANE was sufficiently high.

ICD-10 or DSM-IV? Anhedonia, fatigue and depressed mood as screening symptoms for diagnosing a current depressive episode in physically ill patients in general hospital.

OBJECTIVE: To explore the usefulness of "anhedonia", "fatigue" and "depressed mood" as screening symptoms for predicting a depressive episode in physically ill patients. METHOD: 290 patients filled in a modified version of the Patient Questionnaire and were subsequently assessed by psychiatrists with the Composite International Diagnostic Interview (CIDI; ICD-10 version). RESULTS: 63 patients suffered from a current depressive episode according to the CIDI. If at least two of the three symptoms were used for screening positively (ICD-10 algorithm), the sensitivity was 93.2% and the specificity 72.7%, while the simpler algorithm of DSM-IV - requiring depressed mood or anhedonia to be present - yielded a slightly higher sensitivity (95.2%) and a slightly lower specificity (66.5%). One in five patients with a depressive episode did not report "depressed mood". LIMITATION: It remains unclear how relevant the three core symptoms of depression are for the diagnosis of an ICD-10 depression in people who are not physically ill. CONCLUSION: The fact that both diagnostic algorithms yielded comparable results suggests that the more parsimonious DSM-IV algorithm is preferable and "fatigue" could be left out as a screening symptom. Since "depressed mood" was absent in a substantial proportion of patients, special attention has to be paid to "anhedonia". Medical students and non-psychiatric clinicians should be especially trained to ask for anhedonia, so that cases of depression will not be overlooked.

European network for promoting the physical health of residents in psychiatric and social care facilities (HELPS): background, aims and methods.

BACKGROUND: People with mental disorders have a higher prevalence of physical illnesses and reduced life expectancy as compared with the general population. However, there is a lack of knowledge across Europe concerning interventions that aim at reducing somatic morbidity and excess mortality by promoting behaviour-based and/or environment-based interventions. METHODS AND DESIGN: HELPS is an interdisciplinary European network that aims at (i) gathering relevant knowledge on physical illness in people with mental illness, (ii) identifying health promotion initiatives in European countries that meet country-specific needs, and (iii) at identifying best practice across Europe. Criteria for best practice will include evidence on the efficacy of physical health interventions and of their effectiveness in routine care, cost implications and feasibility for adaptation and implementation of interventions across different settings in Europe. HELPS will develop and implement a "physical health promotion toolkit". The toolkit will provide information to empower residents and staff to identify the most relevant risk factors in their specific context and to select the most appropriate action out of a range of defined health promoting interventions. The key methods are (a) stakeholder analysis, (b) international literature reviews, (c) Delphi rounds with experts from participating centres, and (d) focus groups with staff and residents of mental health care facilities.Meanwhile a multi-disciplinary network consisting of 15 European countries has been established and took up the work. As one main result of the project they expect that a widespread use of the HELPS toolkit could have a significant positive effect on the physical health status of residents of mental health and social care facilities, as well as to hold resonance for community dwelling people with mental health problems. DISCUSSION: A general strategy on health promotion for people with mental disorders must take into account behavioural, environmental and iatrogenic health risks. A European health promotion toolkit needs to consider heterogeneity of mental disorders, the multitude of physical health problems, health-relevant behaviour, health-related attitudes, health-relevant living conditions, and resource levels in mental health and social care facilities.