Typical disease courses of patients with unipolar depressive disorder after in-patient treatments–results of a cluster analysis of the INDDEP project

IntroductionPreviously established categories for the classification of disease courses of unipolar depressive disorder (relapse, remission, recovery, recurrence) are helpful, but insufficient in describing the naturalistic disease courses over time. The intention of the present study was to identify frequent disease courses of depression by means of a cluster analysis.MethodsFor the longitudinal cluster analysis, 555 datasets of patients who participated in the INDDEP (INpatient and Day clinic treatment of DEPression) study, were used. The present study uses data of patients with at least moderate depressive symptoms (major depression) over a follow-up period of 1 year after their in-patient or day-care treatments using the LIFE (Longitudinal Interval Follow-Up Evaluation)-interview. Eight German psychosomatic hospitals participated in this naturalistic observational study.ResultsConsidering only the Calinski–Harabatz index, a 2-cluster solution gives the best statistical results. In combination with other indices and clinical interpretations, the 5-cluster solution seems to be the most interesting. The cluster sizes are large enough and numerically balanced. The KML-cluster analyses revealed five well interpretable disease course clusters over the follow-up period: “sustained treatment response” (N = 202, 36.4% of the patients), “recurrence” (N = 80, 14.4%), “persisting relapse” (N = 115, 20.7%), “temporary relapse” (N = 95, 17.1%), and remission (N = 63, 11.4%).ConclusionThe disease courses of many patients diagnosed with a unipolar depression do not match with the historically developed categories such as relapse, remission, and recovery. Given this context, the introduction of disease course trajectories seems helpful. These findings may promote the implementation of new therapy options, adapted to the disease courses

Effectiveness of psychotherapeutic consultation in the workplace: a controlled observational trial

Abstract Background This study compares the effectiveness of psychotherapeutic consultation in the workplace (PSIW) with psychotherapeutic outpatient care (PSOC) in Germany. Methods Work ability (WAI), quality of life (SF-12), clinical symptoms (PHQ) and work-related stress (MBI, IS) were assessed in 367 patients seeking mental health care via two routes (PSIW n = 174; PSOC n = 193) before consultation and 12 weeks later. Changes in outcome variables were assessed using covariance analysis with repeated measures (ANCOVA) with sociodemographic variables (propensity score method), therapy dose, setting and symptom severity as covariates. Results The PSIW and PSOC groups included 122 and 66 men respectively. There were 102 first-time users of mental healthcare in the PSIW group and 83 in the PSOC group. There were group differences in outcome variables at baseline (p < 0.05); PSIW patients were less impaired overall. There were no group difference in sociodemographic variables, number of sessions within the offer or symptom severity. There was no main effect of group on outcome variables and no group*time interaction. Work-related stress indicators did not change during the intervention, but work ability improved in both groups (F = 10.149, p = 0.002; baseline M = 27.2, SD = 8.85); follow-up M = 28.6, SD = 9.02), as did perceived mental health (SF-12 MCS), depression (PHQ-9) and anxiety (PHQ-7). Effect sizes were between η2 = 0.028 and η2 = 0.040. Conclusions Psychotherapeutic consultation is similarly effective in improving patients’ functional and clinical status whether delivered in the workplace or in an outpatient clinic. Offering mental health services in the workplace makes it easier to reach patients at an earlier stage in their illness and thus enables provision of early and effective mental health care. Trial registration DRKS00003184 , retrospectively registered 13 January 2012

Improving Access to Mental Health Care by Delivering Psychotherapeutic Care in the Workplace: A Cross-Sectional Exploratory Trial.

Common mental disorders like mood and anxiety disorders and somatoform disorders have high costs, yet under-treatment is still frequent. Many people with common mental disorders are employed, so the workplace is potentially a suitable context in which to provide early treatment. Our study investigates whether a change of setting (workplace versus standard care) improves access to treatment for common mental disorders.Conditional latent profile analysis was applied to identify user profiles for work ability (WAI), clinical symptoms like depression (patient health questionnaire depression, PHQ-9), health-related quality of life (QoL, SF-12), and work-related stress (Maslach Burnout Inventory, irritation scale). Patients were recruited consecutively, via psychotherapeutic consultation in the workplace (n = 174) or psychotherapeutic consultation in outpatient care (n = 193).We identified four user profiles in our model: 'severe' (n = 99), 'moderate I-low QoL' (n = 88), 'moderate II-low work ability' (n = 83), and 'at risk' (n = 97). The 'at risk' profile encompassed individuals with reduced work ability (36.0, 34.73 to 37.37), only mild clinical symptoms (PHQ-9 5.7, 4.92 to 6.53), no signs of work-related stress and good quality of life. A higher proportion of the 'at risk' group than of the 'severe' group sought help via the psychotherapeutic consultation in the workplace (OR 0.287, P < 0.01); this effect remained after controlling for gender.Offering secondary mental health care in the workplace is feasible and accepted by users. Offering treatment in the workplace as an alternative to standard outpatient settings is a viable strategy for improving access to treatment for common mental disorders

Systemic Catecholaminergic Deficiency in Depressed Patients with and without Coronary Artery Disease

Background: Stress and depression are known to contribute to coronary artery disease (CAD) with catecholamines (CA), altering the balance to a pro- and anti-inflammatory stetting and potentially playing a key role in the underlying pathophysiology. This study aimed to elucidate the impact of social stress on the CA system and inflammation markers in patients suffering from CAD and depression. Methods: 93 subjects were exposed to the Trier Social Stress Test (TSST). Based on the results of the depression subscale of the Hospital Anxiety and Depression Scale (HADS, German Version) and the presence/absence of CAD, they were divided into four groups. A total of 21 patients suffered from CAD and depression (+D+CAD), 26 suffered from CAD alone (-D+CAD), and 23 suffered from depression only (+D-CAD); another 23 subjects served as healthy controls (-D-CAD). Subjects were registered at 09:00 AM at the laboratory. A peripheral venous catheter was inserted, and after a 60-min-resting period, the TSST was applied. Prior to and 5, 15, 30, and 60 min after the stress test, plasma epinephrine, norepinephrine, and dopamine concentrations (High Performance Liquid Chromatography (HPLC)) were measured together with the inflammation markers interleukin-6 (IL-6) and monocyte chemotactic protein-1 (MCP-1). High-sensitive C-reactive protein (hs-CRP, Enzyme-linked Immunosorbent Assay (ELISA)) was measured prior to TSST. Results: (+D-CAD) and (+D+CAD) patients showed significantly lower epinephrine and dopamine levels compared to the (-D+CAD) and (-D-CAD) participants at baseline (prior to TSST). Over the whole measurement period after the TSST, no inter-group difference was detected. Partial correlation (controlling for age, gender and Body Mass Index (BMI)) revealed a significant direct relation between MCP-1 and norepinephrine (r = 0.47, p = 0.03) and MCP-1 and epinephrine (r = 0.46, p = 0.04) in patients with -D+CAD at rest. Conclusions: The stress response of the CA system was not affected by depression or CAD, whereas at baseline we detected a depression-related reduction of epinephrine and dopamine release independent of CAD comorbidity. Reduced norepinephrine and dopamine secretion in the central nervous system in depression, known as 'CA-deficit hypothesis', are targets of antidepressant drugs. Our results point towards a CA-deficit in the peripheral nervous system in line with CA-deficit of the central nervous system and CA exhaustion in depression. This might explain somatic symptoms such as constipation, stomach pain, diarrhoea, sweating, tremor, and the influence of depression on the outcome of somatic illness such as CAD

Attachment representation modulates oxytocin effects on the processing of own-child faces in fathers

Oxytocin (OT) plays a crucial role in parental-infant bonding and attachment. Recent functional imaging studies reveal specific attachment and reward related brain regions in individuals or within the parent-child dyad. However, the time course and functional stage of modulatory effects of OT on attachment-related processing, especially in fathers, are poorly understood. To elucidate the functional and neural mechanisms underlying the role of OT in paternal-child attachment, we performed an event-related potential study in 24 healthy fathers who received intranasal OT in a double-blind, placebo-controlled, within-subject experimental design. Participants passively viewed pictures of their own child (oC), a familiar (fC) and an unfamiliar child (ufC) while event-related potentials were recorded. Familiarity of the child’s face modulated a broad negativity at occipital and temporo-parietal electrodes within a time window of 300–400 ms, presumably reflecting a modulation of the N250 and N300 ERP components. The oC condition elicited a more negative potential compared to the other familiarity conditions suggesting different activation of perceptual memory representations and assignment of emotional valence. Most importantly, this familiarity effect was only observed under placebo (PL) and was abolished under OT, in particular at left temporo-parietal electrodes. This OT induced attenuation of ERP responses was related to habitual attachment representations in fathers. In summary, our results demonstrate an OT-specific effect at later stages of attachment-related face processing presumably reflecting both activation of perceptual memory representations and assignment of emotional value

Do Working Conditions of Patients in Psychotherapeutic Consultation in the Workplace Differ from Those in Outpatient Care? Results from an Observational Study

In previous studies, it was found that patients treated at a psychosomatic outpatient clinic (PSOC) for common mental disorders showed more severe symptoms than those who used a psychotherapeutic consultation service at the workplace (PSIW). This study examines whether the higher symptom severity of the PSOC patients in comparison to their PSIW counterparts is also related to higher levels of occupational stress as measured by the demand-control-support model (DCS). N = 253 participants (PSIW n = 100; PSOC n = 153) provided self-reported data on demands, decision latitude, social support, and health before consultation. The association between mental health care setting, symptom level and demands, decision latitude, and social support was assessed by means of a path model. Results of the path model indicated that the higher level of depression in PSOC patients was related to higher levels of demands and lower levels of social support. Demands and social support were found to be indirectly associated with treatment setting. No interaction effect between demands, decision latitude, social support, and depression was found. Results of this study reveal that the working conditions influenced the pathway to care process via symptom severity

Improving Access to Mental Health Care by Delivering Psychotherapeutic Care in the Workplace: A Cross-Sectional Exploratory Trial

<div><p>Objective</p><p>Common mental disorders like mood and anxiety disorders and somatoform disorders have high costs, yet under-treatment is still frequent. Many people with common mental disorders are employed, so the workplace is potentially a suitable context in which to provide early treatment. Our study investigates whether a change of setting (workplace versus standard care) improves access to treatment for common mental disorders.</p><p>Methods</p><p>Conditional latent profile analysis was applied to identify user profiles for work ability (WAI), clinical symptoms like depression (patient health questionnaire depression, PHQ-9), health-related quality of life (QoL, SF-12), and work-related stress (Maslach Burnout Inventory, irritation scale). Patients were recruited consecutively, via psychotherapeutic consultation in the workplace (n = 174) or psychotherapeutic consultation in outpatient care (n = 193).</p><p>Results</p><p>We identified four user profiles in our model: ‘severe’ (n = 99), ‘moderate I—low QoL’ (n = 88), ‘moderate II—low work ability’ (n = 83), and ‘at risk’ (n = 97). The ‘at risk’ profile encompassed individuals with reduced work ability (36.0, 34.73 to 37.37), only mild clinical symptoms (PHQ-9 5.7, 4.92 to 6.53), no signs of work-related stress and good quality of life. A higher proportion of the ‘at risk’ group than of the ‘severe’ group sought help via the psychotherapeutic consultation in the workplace (OR 0.287, P < 0.01); this effect remained after controlling for gender.</p><p>Conclusions</p><p>Offering secondary mental health care in the workplace is feasible and accepted by users. Offering treatment in the workplace as an alternative to standard outpatient settings is a viable strategy for improving access to treatment for common mental disorders.</p></div

Child Maltreatment Is Associated with a Reduction of the Oxytocin Receptor in Peripheral Blood Mononuclear Cells

Background: Child maltreatment (CM) and attachment experiences are closely linked to alterations in the human oxytocin (OXT) system. However, human data about oxytocin receptor (OXTR) protein levels are lacking. Therefore, we investigated oxytocin receptor (OXTR) protein levels in circulating immune cells and related them to circulating levels of OXT in peripheral blood. We hypothesized reduced OXTR protein levels, associated with both, experiences of CM and an insecure attachment representation.Methods: OXTR protein expressions were analyzed by western blot analyses in peripheral blood mononuclear cells (PBMC) and plasma OXT levels were determined by radioimmunoassay (RIA) in 49 mothers. We used the Childhood Trauma Questionnaire (CTQ) to assess adverse childhood experiences. Attachment representations (secure vs. insecure) were classified using the Adult Attachment Projective Picture System (AAP) and levels of anxiety and depression were assessed with the German version of the Hospital Depression and Anxiety scale (HADS-D).Results: CM-affected women showed significantly lower OXTR protein expression with significantly negative correlations between the OXTR protein expression and the CTQ sum score, whereas plasma OXT levels showed no significant differences in association with CM. Lower OXTR protein expression in PBMC were particularly pronounced in the group of insecurely attached mothers compared to the securely attached group. Anxiety levels were significantly higher in CM-affected women.Conclusion: This study demonstrated a significant association between CM and an alteration of OXTR protein expression in human blood cells as a sign for chronic, long-lasting alterations in this attachment-related neurobiological system

Distribution of different user groups in the respective treatment settings.

<p>Severe (n = 99), moderate I (n = 88), moderate II (n = 83), at risk (n = 97)</p

Latent profiles of impairment for four-class solution.

<p>Latent profiles of impairment for four-class solution.</p