Health-related quality of life of primary care patients with depressive disorders.

BACKGROUND: Depressive disorders are known to impair health-related quality of life (HRQoL) both in the short and long term. However, the determinants of long-term HRQoL outcomes in primary care patients with depressive disorders remain unclear. METHODS: In a primary care cohort study of patients with depressive disorders, 82% of 137 patients were prospectively followed up for five years. Psychiatric disorders were diagnosed with SCID-I/P and SCID-II interviews; clinical, psychosocial and socio-economic factors were investigated by rating scales and questionnaires plus medical and psychiatric records. HRQoL was measured with the generic 15D instrument at baseline and five years, and compared with an age-standardized general population sample (n=3707) at five years. RESULTS: Depression affected the 15D total score and almost all dimensions at both time points. At the end of follow-up, HRQoL of patients in major depressive episode (MDE) was particularly low, and the association between severity of depression (Beck Depression Inventory [BDI]) and HRQoL was very strong (r=-0.804). The most significant predictors for change in HRQoL were changes in BDI and Beck Anxiety Inventory (BAI) scores. The mean 15D score of depressive primary care patients at five years was much worse than in the age-standardized general population, reaching normal range only among patients who were in clinical remission and had virtually no symptoms. CONCLUSIONS: Among depressive primary care patients, presence of current depressive symptoms markedly reduces HRQoL, with symptoms of concurrent anxiety also having a marked impact. For HRQoL to normalize, current depressive and anxiety symptoms must be virtually absent.

Response style and severity and chronicity of depressive disorders in primary health care.

BACKGROUND: Response styles theory of depression postulates that rumination is a central factor in occurrence, severity and maintaining of depression. High neuroticism has been associated with tendency to ruminate. We investigated associations of response styles and neuroticism with severity and chronicity of depression in a primary care cohort study. METHODS: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up with a graphic life chart enabling evaluation of the longitudinal course of episodes. Neuroticism was measured with the Eysenck Personality Inventory (EPI-Q). Response styles were investigated at five years using the Response Styles Questionnaire (RSQ-43). RESULTS: At five years, rumination correlated significantly with scores of Hamilton Depression Rating Scale (r=0.54), Beck Depression Inventory (r=0.61), Beck Anxiety Inventory (r=0.50), Beck Hopelessness Scale (r=0.51) and Neuroticism (r=0.58). Rumination correlated also with proportion of follow-up time spent depressed (r=0.38). In multivariate regression, high rumination was significantly predicted by current depressive symptoms and neuroticism, but not by anxiety symptoms or preceding duration of depressive episodes. CONCLUSIONS: Among primary care patients with depression, rumination correlated with current severity of depressive symptoms, but the association with preceding episode duration remained uncertain. The association between neuroticism and rumination was strong. The findings are consistent with rumination as a state-related phenomenon, which is also strongly intertwined with traits predisposing to depression.

White matter hyperintensities and cognitive performance in adult patients with bipolar I, bipolar II, and major depressive disorders.

PURPOSE: We evaluate for the first time the associations of brain white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) with neuropsychological variables among middle-aged bipolar I (BPI), II (BPII) and major depressive disorder (MDD) patients and controls using a path model. METHODS: Thirteen BPI, 15 BPII, 16 MDD patients, and 21 controls underwent brain MRI and a neuropsychological examination. Two experienced neuroradiologists evaluated WMHs on the MRI scans. We constructed structural equation models to test the strength of the associations between deep WMH (DWMH) grade, neuropsychological performance and diagnostic group. RESULTS: Belonging in the BPI group as opposed to the control group predicted higher DWMH grade (coefficient estimate 1.13, P=0.012). The DWMH grade independently predicted worse performance on the Visual Span Forward test (coefficient estimate -0.48, P=0.002). Group effects of BPI and MDD were significant in predicting poorer performance on the Digit Symbol test (coefficient estimate -5.57, P=0.016 and coefficient estimate -5.66, P=0.034, respectively). LIMITATIONS: Because of the small number of study subjects in groups, the negative results must be considered with caution. CONCLUSIONS: Only BPI patients had an increased risk for DWMHs. DWMHs were independently associated with deficits in visual attention.

Temperament, character and personality disorders.

OBJECTIVE: To study, whether temperament and character remain stable over time and whether they differ between patients with and without personality disorder (PD) and between patients with specific PDs. METHODS: Patients with (n=225) or without (n=285) PD from Jorvi Bipolar Study, Vantaa Depression Study (VDS) and Vantaa Primary Care Depression Study were interviewed at baseline and at 18 months, and in the VDS also at 5 years. A general population comparison group (n=264) was surveyed by mail. RESULTS: Compared with non-PD patients, PD patients scored lower on self-directedness and cooperativeness. Cluster B and C PDs associated with high Novelty Seeking and Harm Avoidance, respectively. In logistic regression models, sensitivity and specificity of Temperament and Character Inventory (TCI) dimensions for presence of any PD were 53% and 75%, and for specific PDs from 11% to 41% and from 92% to 100%, respectively. The 18-month test-retest correlations of TCI-R dimensions ranged from 0.58 to 0.82. CONCLUSIONS: Medium-term temporal stability of TCI in a clinical population appears good. Character scores differ markedly between PD and non-PD patients, whereas temperament scores differ only somewhat between the specific PDs. However, the TCI dimensions capture only a portion of the differences between PD and non-PD patients.

Differences in temperament and character dimensions in patients with bipolar I or II or major depressive disorder and general population subjects.

BACKGROUND: Whether temperament and character differ between bipolar disorder (BD) and major depressive disorder (MDD) patients and general population subjects, or between BD I and BD II patients, remains unclear. METHOD: BD patients (n=191) from the Jorvi Bipolar Study and MDD patients (n=266) from the Vantaa Depression Study (VDS) and the Vantaa Primary Care Depression Study were interviewed at baseline, at 6 and 18 months, and in the VDS at 5 years. A general population comparison group (n=264) was surveyed by mail. BD patients' scores on the Temperament and Character Inventory-Revised were compared at an index interview, when levels of depression and mania were lowest, with scores of MDD patients and controls. BD I (n=99) and BD II (n=92) patients were compared. RESULTS: Compared with controls, both BD and MDD patients had higher harm avoidance [odds ratio (OR) 1.027, p<0.001 and OR 1.047, p<0.001, respectively] and lower persistence (OR 0.983, p=0.006 and OR 0.968, p<0.001, respectively) scores. Moreover, BD patients had lower self-directedness (OR 0.979, p=0.003), MDD patients lower reward dependence (OR 0.976, p=0.002) and self-transcendence (OR 0.966, p<0.001) scores. BD patients scored lower in harm avoidance (OR 0.980, p=0.002) and higher in novelty seeking (OR 1.027, p<0.001) and self-transcendence (OR 1.028, p<0.001) than MDD patients. No differences existed between BD I and II patients. CONCLUSIONS: The patterns of temperament and character dimensions differed less between BD and MDD patients, than patients from their controls. The most pronounced difference was higher novelty seeking in BD than MDD patients. The dimensions investigated are unlikely to differ between BD I and BD II patients.

Conceptions of patients and personnel concerning the substance of post-ward outpatient visits in psychiatric care.

In post-ward outpatient services patients discharged from hospital are provided further care by the same ward personnel. The aim of this study was to describe and analyse the conceptions concerning the substance of post-ward outpatient visits (PWOV). A phenomenographic approach was used. The data were gathered by interviewing post-ward outpatients, personnel at psychiatric wards and in outpatient care and administrative personnel in psychiatric units. Seven main categories of describing the PWOV were formed: natural interaction, continuous assessment, follow-up of the implementation of pharmacotherapy, relapse prevention, search for coping methods, establishing motivation for treatment and family members' participation in care. The patient's health, life situation and coping in everyday life were constantly evaluated and followed up in diverse ways during the PWOV. To make PWOV successful, treatment should be planned individually based on the patient's needs, and the patient should have a close and functional cooperative relationship with the nurse.

Continuity of care in psychiatric post-ward outpatient services--conceptions of patients and personnel concerning factors contributing to the continuity of care.

A structural change of the psychiatric services was started in Finland in the 1980s. Its primary objective was to shift the main emphasis from hospital to outpatient services. Hence, the number of psychiatric beds has declined to a third of the maximum rate, inpatient periods have shortened and the number of outpatient appointments has increased significantly. International research shows that when the emphasis of psychiatric services shifts to outpatient services and hospitalization becomes short-term, diverse individual alternatives are needed to support patients' coping. Several Finnish psychiatric hospitals initiated in the 1990s outpatient services provided at inpatient wards, which means, that after the period of hospitalization, further care is provided to the patient at the same ward where s/he was hospitalized. The purpose of this study was to describe and analyse the conceptions of patients, ward personnel, outpatient services personnel and administrative personnel in psychiatric units concerning the factors improving the continuity of care. A phenomenographic approach was used and the objective was to find the different empirical variations of the conceptions, through which people experience, comprehend and become conscious of the phenomena in the surrounding world. The data were gathered by interviewing post-ward outpatients (n=5), personnel at psychiatric wards and in outpatient services (n=18) and administrative personnel in psychiatric units (n=5). As a result of the analysis seven categories of the factors improving the continuity of care were formed: (1) adherence to a good cooperative relationship; (2) adherence to the care environment; (3) flexibility in tailoring care; (4) active maintenance of contacts in care; (5) constant possibility to contact the ward; (6) up-to-date patient data; and (7) active cooperation between outpatient services and other collaborators.