The course of PTSD in naturalistic long-term studies: High variability of outcomes. A systematic review

<div><p></p><p><i>Background:</i> With a lifetime prevalence of 8% posttraumatic stress disorder (PTSD) is one of the most common mental disorders; nevertheless, its longitudinal course is largely unknown. <i>Aims:</i> Our aim was to conduct a systematic review summarizing available findings on the prospective, naturalistic long-term course of PTSD and its predictors. <i>Methods:</i> Databases MEDLINE and PsycINFO were searched. Main selection criteria were: 1) naturalistic cohort study with a follow-up period of at least 3 years, 2) adult participants with observer-rated or probable PTSD at baseline. <i>Results:</i> Twenty-four cohorts (25 studies) were retrieved (14 with observer-assessed, 10 with probable PTSD). In total, they comprised about 10,500 participants with PTSD at baseline that were included in the long-term follow-ups. Studies investigating patient populations with observer-assessed PTSD found that between 18% and 50% of patients experienced a stable recovery within 3–7 years; the remaining subjects either facing a recurrent or a more chronic course. Outcomes of community studies and studies investigating probable PTSD varied considerably (remission rates 6–92%). Social factors (e.g. support) as well as comorbid physical or mental health problems seem to be salient predictors of PTSD long-term course and special focus should be laid on these factors in clinical settings. <i>Conclusions:</i> Included studies differed notably with regard to applied methodologies. The resulting large variability of findings is discussed. More standardized systematic follow-up research and more uniformed criteria for remission and chronicity are needed to gain a better insight into the long-term course of PTSD.</p></div

Forest plot of studies included in meta-analysis of all-cause mortality associated with clinical depression in individuals with diabetes.

<p>Forest plot of studies included in meta-analysis of all-cause mortality associated with clinical depression in individuals with diabetes.</p

Depression as a Risk Factor for Mortality in Individuals with Diabetes: A Meta-Analysis of Prospective Studies

<div><p>Objective</p><p>To quantify the impact of depression measured by self-reports and depression measured by clinical interview on all-cause mortality in individuals with diabetes and to analyze the strength of both associations, the influence of covariates, and possible differences between studies assessing self-rated depressive symptoms and those using a clinical interview to measure depression as predictors of mortality.</p><p>Research Design and Methods</p><p>PUBMED and PsycINFO were searched up to July 2013 for prospective studies assessing depression, diabetes and mortality. The pooled hazard ratios were calculated using random-effects models.</p><p>Results</p><p>Sixteen studies met the inclusion criteria. After adjustment for demographic variables depression measured by self-reports was associated with an increased all-cause mortality risk (pooled HR = 2.56, 95% CI 1.89–3.47), and the mortality risk remained high after additional adjustment for diabetes complications (HR = 1.76, 95% CI 1.45–2.14,). Six studies reporting adjusted HRs for depression measured by clinical interviews supported the results of the other models (HR = 1.49, 95% CI 1.15–1.93).</p><p>Conclusions</p><p>Both depression measured by self-report and depression measured by clinical interview have an unfavorable impact on mortality in individuals with diabetes. The results, however, are limited by the heterogeneity of the primary studies. It remains unclear whether self-reports or clinical interviews for depression are the more precise predictor.</p></div

Forest plots of studies included in meta-analysis of all-cause mortality associated with depressive symptoms in individuals with diabetes.

<p>Forest plots of studies included in meta-analysis of all-cause mortality associated with depressive symptoms in individuals with diabetes.</p

Economic Evaluation of Brief Psychodynamic Interpersonal Therapy in Patients with Multisomatoform Disorder

<div><p>Background</p><p>A brief psychodynamic interpersonal therapy (PIT) in patients with multisomatoform disorder has been recently shown to improve health-related quality of life.</p><p>Aims</p><p>To assess cost-effectiveness of PIT compared to enhanced medical care in patients with multisomatoform disorder.</p><p>Method</p><p>An economic evaluation alongside a randomised controlled trial (International Standard Randomised Controlled Trial Number ISRCTN23215121) conducted in 6 German academic outpatient centres was performed. Incremental cost-effectiveness ratio (ICER) was calculated from the statutory health insurance perspective on the basis of quality adjusted life years (QALYs) gained at 12 months. Uncertainty surrounding the cost-effectiveness of PIT was presented by means of a cost-effectiveness acceptability curve.</p><p>Results</p><p>Based on the complete-case analysis ICER was 41840 Euro per QALY. The results did not change greatly with the use of multiple imputation (ICER = 44222) and last observation carried forward (LOCF) approach to missing data (ICER = 46663). The probability of PIT being cost-effective exceeded 50% for thresholds of willingness to pay over 35 thousand Euros per QALY.</p><p>Conclusions</p><p>Cost-effectiveness of PIT is highly uncertain for thresholds of willingness to pay under 35 thousand Euros per QALY.</p></div

Utility scores at baseline and nine months follow up and QALYs gained per group.

<p>Utility scores at baseline and nine months follow up and QALYs gained per group.</p

Consort chart of Patients with Multisomatoform Disorder in a Trial of Short-Term Psychodynamic Interpersonal Therapy.

<p>Consort chart of Patients with Multisomatoform Disorder in a Trial of Short-Term Psychodynamic Interpersonal Therapy.</p

Cost- effectiveness acceptability curves for Psychodynamic Interpersonal Therapy (PIT).

<p>Cost- effectiveness acceptability curves for Psychodynamic Interpersonal Therapy (PIT).</p

Self report assessment of stress perception and emotional strain in female medical students during their final exam.

<p>Graphs (a)-(f) show self-report data assessed at the following points in time (T): baseline, twelve weeks prior to the exam and before the learning period started (1); within the first and second week after the written part of the exam and before test results were released (2); and twelve weeks after the completion of the exam (3). Graph (g) shows cortisol measurements in saliva samples taken on the day prior to T2. Samples were processed to assess diurnal cortisol secretion as described below in the Materials and Methods section. (a)-(g): N = 18 in exam group, N = 15 in comparison group. Mean values and SEM are shown. Mann Whitney U tests were used to examine differences between group means at distinct points in time, Kruskal-Wallis tests with post-hoc Dunn's tests corrected for multiple comparisons to examine differences between different points in time within one group. P-values < 0.1 –one asterix in brackets, <0.05 –one asterix, < 0.01—two asterix, < 0.001—three asterix.</p

Assessment of immune mediators in female medical students during their final exam.

<p>(a)-(e): N = 18 in exam group, N = 15 in comparison group. Mann Whitney U tests were used to examine differences between group means at distinct points in time, Kruskal-Wallis tests with post-hoc Dunn's tests corrected for multiple comparisons to examine differences between different points in time within one group. Mean values and SEM are shown. P-values < 0.1 –one asterix in brackets, <0.05 –one asterix, < 0.01—two asterix.</p