30-Month Follow-Up of Individual Placement and Support (IPS) and Cognitive Remediation for People with Severe Mental Illness: Results from a Randomized Clinical Trial.

Background: The individual placement and support (IPS) model for persons with severe mental illness has proven to be more effective than traditional vocational approaches in improving competitive work over 18 months. In this study, the longer-term effects of IPS over 30 months were investigated in a Danish setting. Method: In a randomized clinical trial, we compared the effects of IPS, IPS enhanced with cognitive remediation and work-related social skills training (IPSE), and service as usual (SAU). At three locations in Denmark, 720 patients with serious mental illnesses were randomly assigned to the three groups. Competitive employment, education, and hospital admissions were tracked for 30 months using Danish national registers. Results: The beneficial effects of IPS on competitive employment and education at the 18-month follow-up were sustained over the 30-month follow-up period. Participants receiving IPS or IPSE were more likely to obtain competitive employment or education than those who received service as usual (IPS 65%, IPSE 65%, SAU 53%, p = 0.006), and they worked on average more weeks competitively (IPS 25 weeks, IPSE 21 weeks, SAU 17 weeks; IPS vs. SAU p = 0.004 and IPSE vs. SAU p = 0.007). Moreover, participants in the two IPS groups had fewer outpatient visits during the 30-month follow-up. However, this was only statistically significant when comparing IPSE with SAU p = 0.017. Conclusion: In conclusion, IPS and IPS enhanced with cognitive remediation and work-related skills training demonstrated that the vocational effects of the interventions are retrained over 30 months in a Danish context.

Predictors of return to work for people on sick leave with depression, anxiety and stress: secondary analysis from a randomized controlled trial.

PURPOSE: Knowledge about predictors of return to work (RTW) in people on sick leave with common mental disorders (CMDs) may inform the development of effective vocational rehabilitation interventions for this target group. In this study, we investigated predictors of RTW at 6 and 12 months in people on sick leave with depression, anxiety disorders or stress-related disorders. METHODS: We have performed a secondary analysis, utilizing data from two RCTs that evaluated the efficacy of an integrated health care and vocational rehabilitation intervention. Data were obtained from mental health assessments, questionnaires and registers. Using Cox regression analysis, the relationship between baseline variables and RTW was analysed at 6 and 12 months after randomization within the group of CMD as a whole and within the subgroups of depression, anxiety and stress-related disorders. RESULTS: Symptom burden and employment status at baseline predicted RTW in the CMD group (n = 1245) and in the three diagnostic subgroups at both time points. RTW self-efficacy predicted RTW in the depression group but not in the anxiety or stress subgroups. CONCLUSION: Many predictors of RTW were similar over time and, to some extent, across the CMD subgroups. Findings highlight the need not only to take health-related and psychological factors into account when developing vocational rehabilitation interventions but also to consider workplace strategies and options for support.

The Effectiveness of Peer Support in Personal and Clinical Recovery: Systematic Review and Meta-Analysis.

OBJECTIVE: Peer support has been shown to support personal recovery from mental illness. It is unclear whether the effects of peer support across different mental illnesses depend on the organizational setting. The authors reviewed the effectiveness of peer support for both personal recovery and clinical recovery of adults with any mental illness and evaluated the effectiveness of peer support in different settings. METHODS: A systematic review of randomized controlled trials (RCTs) was conducted in PubMed, PsycInfo, CINAHL, Cochrane Library, and Web of Science. A meta-analysis of outcomes of personal and clinical recoveries at the end of interventions was conducted. RESULTS: In total, 49 RCTs with 12,477 participants with any mental illness were included. Most of the trials had a high risk for bias. Results of the meta-analysis indicated that peer support in general had a small positive effect on personal recovery (standard mean difference [SMD]=0.20; 95% CI=0.11-0.29) and decreased anxiety symptoms (SMD=-0.21; 95% CI=-0.40 to -0.02), with most trials evaluating peers added to mental health-related hospital services. No data for peers in established service roles were available for the meta-analysis. Peer-designed interventions developed to be provided independently of hospital services and delivered in community settings had a modest effect on self-advocacy. A small nonsignificant effect on personal recovery for peer support delivered online was also observed. CONCLUSIONS: The effect on personal recovery from mental illness was most evident in peer support added to hospital services. High-quality RCTs with comparable cocreated interventions and clear descriptions of mechanisms of change are needed to further investigate peer support efficacy.

Predictors of Return to Work for People with Anxiety or Depression Participating in a Randomized Trial Investigating the Effect of a Supported Employment Intervention.

Purpose Common mental disorders have a severe impact on society and individuals; rates of unemployment and disability pensions are high. Knowing which factors facilitate or hinder people's return to work is important when designing effective vocational rehabilitation interventions. Methods We conducted secondary analyses on data from 289 participants with depression or anxiety included in the Individual Placement and Support modified for people with mood and anxiety disorders (IPS-MA) trial. Associations of baseline characteristics and employment or education after 24 months were tested in univariate logistic regression analyses, variables with a p-value below 0.1 were included in multivariate analyses. Results In the univariate analyses, self-reported level of functioning (p = 0.032), higher age (p = 0.070), and higher level of readiness to change (p = 0.001) were associated with the outcome and included in the multivariate analysis. Only age (p = 0.030) and readiness to change (p = 0.003) remained significantly associated with return to work or education after 24 months in the multivariate analysis. Conclusion Higher age and lower readiness to change were associated with a lower chance of having returned to work or education. Factors modifying the effect of higher age should be identified, just as vocational rehabilitation should focus on improving factors related to people's readiness to change.

Stigma towards people with mental illness in the Nordic countries - a scoping review.

INTRODUCTION: Stigma affects people with mental illness globally, however, it is proposed that stigma is less prevalent in wealthier countries and that people hold more positive attitudes in Northern and Western Europe. Even so, accounts from surveys in Denmark and Sweden reveal that stigma is very much prevalent. AIM: This scoping review aims to shed light on the body of literature regarding mental-health-related stigma in the Nordic Countries and identify knowledge gaps. METHODS: We searched four electronic databases in December 2017 and again in June 2020. All types of empirical studies (qualitative, quantitative, and mix-methods) examining the stigma of people with mental illness were included. RESULTS: In total, 61 studies were included. Overall, findings from the Nordic countries resemble global findings. Studies are primarily descriptive, and mostly survey studies of attitudes toward people with mental illness in the general population. Few studies focus on discrimination, and those who do, measure intended behavior in hypothetical situations rather than actual acts of discrimination in real-life situations. Studies were mostly conducted on a community or organizational level; no studies were identified on a system level. Experienced stigma and discrimination by patients, but also relatives, were a focus in one-third of the studies. Very few studies of interventions to reduce stigma and discrimination were identified. CONCLUSION: More studies into stigma on a system or institutional level are needed. Ways to measure acts of discrimination should be invented. Furthermore, interventions to reduce stigma and discrimination should be developed, targeting all levels of society.

Predictors of return to work for people on sick leave with common mental disorders: a systematic review and meta-analysis.

PURPOSE: To support the return to work following common mental disorders knowing which factors influence the return to work is important. We aimed to identify factors predicting return to work for people on sick leave with disorders like stress, anxiety, and depression. METHODS: A systematic review and meta-analyses were conducted regarding return to work at any time point, < 3 months, 3-12 months, and > 12 months of sick leave, respectively, and diagnostic subgroups. RESULTS: The meta-analyses included 29 studies. Predictors decreasing return to work probability at any time point were higher age, being male, neuroticism and openness, previous sickness absence, and higher symptom scores. Predictors increasing return to work probability were positive return to work expectations, high return to work- and general self-efficacy, conscientiousness, and high workability index. Return to work within < 3 months of sick leave was associated with positive return to work expectations. Return to work after > 12 months was increased by higher education. Higher age was associated with decreased return to work probability after > 12 months. No significant predictors were found in diagnostic subgroups. CONCLUSION: Results are overall consistent with earlier reviews. Future studies should focus on specific time points, diagnostic subgroups, and work-related factors. PROSPERO REGISTRATION ID: CRD42018073396.

A Systematic Review of Individual Placement and Support, Employment, and Personal and Clinical Recovery.

OBJECTIVE: The objective of this review was to assess associations between Individual Placement and Support (IPS), employment, and personal and clinical recovery among persons with severe mental illness at 18-month follow-up. METHODS: A systematic literature search identified randomized controlled trials (RCTs) comparing IPS with services as usual. Outcomes were self-esteem, empowerment, quality of life, symptoms of depression, negative or psychotic symptoms, anxiety, and level of functioning. A total of six RCTs reported data suitable for meta-analyses, and pooled original data from five studies were also analyzed. RESULTS: Meta-analyses and analyses of pooled original data indicated that receipt of the IPS intervention alone did not improve any of the recovery outcomes. Participants who worked during the study period, whether or not they were IPS participants, experienced improved negative symptoms, compared with those who did not work (standardized mean difference [SMD]=-0.41, 95% confidence interval [CI]=-0.56, -0.26). For participants who worked, whether or not they were IPS participants, improvements were also found in level of functioning and quality of life (SMD=0.59, 95% CI=0.42, 0.77 and SMD=0.34, 95% CI=0.14, 0.54, respectively). CONCLUSIONS: Employment was associated with improvements in negative symptoms, level of functioning, and quality of life.

Vocational Outcomes of the Individual Placement and Support Model in Subgroups of Diagnoses, Substance Abuse, and Forensic Conditions: A Systematic Review and Analysis of Pooled Original Data.

PURPOSE: To investigate the effect of Individual Placement and Support (IPS) according to diagnoses of schizophrenia, bipolar disorder, major depression, substance use disorders, or forensic psychiatric conditions. METHODS: A systematic search of the literature was conducted in June 2017 and repeated in December 2020. The systematic review included 13 studies. Analyses of pooled original data were based on the six studies providing data (n = 1594). No studies on forensic psychiatric conditions were eligible. Hours and weeks worked were analyzed using linear regression. Employment, and time to employment was analyzed using logistic regression, and cox-regression, respectively. RESULTS: The effects on hours and weeks in employment after 18 months were comparable for participants with schizophrenia, and bipolar disorder but only statistically significant for participants with schizophrenia compared to services as usual (SAU) (EMD 109.1 h (95% CI 60.5-157.7), 6.1 weeks (95% CI 3.9-8.4)). The effect was also significant for participants with any drug use disorder (121.2 h (95% CI 23.6-218.7), 6.8 weeks (95% CI 1.8-11.8)). Participants with schizophrenia, bipolar disorder, and any drug use disorder had higher odds of being competitively employed (OR 2.1 (95% CI 1.6-2.7); 2.4 (95% CI 1.3-4.4); 3.0 (95% CI 1.5-5.8)) and returned to work faster than SAU (HR 2.1 (95% CI 1.6-2.6); 1.8 (95% CI 1.1-3.1); 3.0 (95% CI 1.6-5.7)). No statistically significant effects were found regarding depression. CONCLUSIONS: IPS was effective regarding schizophrenia, bipolar disorder, and substance use disorder; however, the effect on hours, and weeks worked was not statistically significant regarding bipolar disorder. For people with depression the impact of IPS remains inconclusive. Non-significant results may be due to lack of power. TRIAL REGISTRATION: PROSPERO protocol nr. CRD42017060524.

Trajectories of symptoms of anxiety and depression among people on sick leave with mood or anxiety disorders: Secondary analysis from a randomized controlled trial.

BACKGROUND: Depression and anxiety are heterogenous disorders often combined into one entity in studies. Few studies have compared trajectories of depression and anxiety among clinically ill. We aimed to identify specific trajectories of depression, and anxiety and predictors of trajectory membership. METHODS: Latent growth mixture modelling was carried out on data from the IPS-MA trial (n = 261), a supported employment intervention for people with mood or anxiety, to identify trajectories of depression and anxiety. Logistic regression was used to estimate predictors for trajectory membership. Associations between trajectory class and remission of comorbid depression or anxiety and return to work were also tested. RESULTS: We identified three trajectories of depression and anxiety symptoms respectively; moderate-decreasing (60%), moderate-stable (26%), and low-stable (14%) depression and mild-decreasing (59%), moderate-decreasing (33%), and moderate-stable (8%) anxiety. The depression model showed low precision in class separation (entropy 0.66), hence, predictors of class membership were not estimated. For anxiety, lower age and higher levels of depressive symptoms were associated with a less desirable trajectory. Remission of comorbid depressive symptoms after two years differed significantly between classes (p < 0.000). Fewer had returned to work in the two moderate classes compared to the mild-decreasing anxiety class. LIMITATIONS: Depression model not reliable. Only 80% of participants from original study included. Not able to distinguish between anxiety disorders. CONCLUSION: Trajectories of anxiety confirm that, even after two years, a rather large proportion in the moderate-stable class had symptoms of moderate anxiety, moderate comorbid depressive symptoms, and less probability of having returned to work. TRIAL REGISTRATION: ClinicalTrials.govNCT01721824.

Cost-effectiveness analysis of a supported employment intervention for people with mood and anxiety disorders in Denmark - the IPS-MA intervention.

OBJECTIVES: We aimed to investigate the cost-utility and cost-effectiveness of a modified Individual Placement and Support intervention for people with mood and anxiety disorders (IPS-MA). METHODS: Costs were assessed from a societal perspective. Health care costs were derived from registers and combined with data on use of IPS-MA services, municipal social care, and labour market services. EQ-5D was used to compute QALY. Missing data were imputed in a sensitivity analysis. We also computed the cost per gain in hours worked. Incremental cost-effectiveness ratios (ICER) were computed and bootstrapped to obtain confidence intervals for QALY and gain in hours worked. RESULTS: We found no difference in overall costs between groups. A significant saving was found in use of labour market services in the IPS-MA group. But the IPS-MA group had significantly lower wage earnings compared to the control group. The intervention group had a higher, though statistically in-significant, increase in QALYs than the control group. The ICER did not show statistically significant results, but there was a tendency, that IPS-MA could have a positive effect on health-related quality of life without any additional costs. However, participants in the IPS-MA group had a significantly lower gain in hours worked compared to the control group. CONCLUSIONS: Despite a significant saving in use of labour market services, IPS-MA was not cost-effective. Participants in the IPS-MA group worked significantly fewer hours and earned significantly less than participants in the control group at 1-year follow-up.

Cost-utility and cost-effectiveness of individual placement support and cognitive remediation in people with severe mental illness: Results from a randomized clinical trial.

BACKGROUND: Administrators and policymakers are increasingly interested in individual placement and support (IPS) as a way of helping people with severe mental illness (SMI) obtain employment or education. It is thus important to investigate the cost-effectiveness to secure that resources are being used properly. METHODS: In a randomized clinical trial, 720 people diagnosed with SMI were allocated into three groups; (a) IPS, (b) IPS supplemented with cognitive remediation a social skills training (IPSE), and (c) Service as usual (SAU). Health care costs, municipal social care costs, and labor market service costs were extracted from nationwide registers and combined with data on use of IPS services. Cost-utility and cost-effectiveness analyses were conducted with two primary outcomes: quality-adjusted life years (QALY) and hours in employment. Incremental cost-effectiveness ratios (ICER) were computed for both QALY, using participant's responses to the EQ-5D questionnaire, and for hours in employment. RESULTS: Both IPS and IPSE were less costly, and more effective than SAU. Overall, there was a statistically significant cost difference of €9,543 when comparing IPS with SAU and €7,288 when comparing IPSE with SAU. ICER's did generally not render statistically significant results. However, there was a tendency toward the IPS and IPSE interventions being dominant, that is, cheaper with greater effect in health-related quality of life and hours in employment or education compared to usual care. CONCLUSION: Individual placement support with and without a supplement of cognitive remediation tends to be cost saving and more effective compared to SAU.

Trajectories of Return to Work Among People on Sick Leave with Mood or Anxiety Disorders: Secondary Analysis from a Randomized Controlled Trial.

Purpose The return to work (RTW) of people with mood and anxiety disorders is a heterogeneous process. We aimed to identify prototypical trajectories of RTW over a two-year period in people on sick leave with mood and anxiety disorders, and investigate if socio-demographic or clinical factors predicted trajectory membership. Methods We used data from the randomized IPS-MA trial (n = 283), evaluating a supported employment intervention for participants with recently diagnosed mood or anxiety disorders. Information on "weeks in employment in the past 6 months" was measured after 1/2, 1, 1 ½ and 2 years, using data from a nationwide Danish register (DREAM). Latent growth mixture modelling analysis was carried out to identify trajectories of RTW and logistic regression analyses were used to estimate predictors for trajectory membership. Results Four trajectory classes of RTW were identified; non-RTW [70% (196/283)] (practically no return to work); delayed-RTW [19% (56/283)] (6 months delay before full RTW); rapid-unstable-RTW [7% (19/283)] (members rapidly returned to work, but only worked half the time); and the smallest class, rapid-RTW [4% (12/283)] (members rapidly reached full employment, but later experienced a decrease in weeks of employment). Self-reported disability score according to the SDS, not living with a partner, and readiness to change on the CQ scale were found to be significantly associated with RTW. Conclusion The trajectories identified support that many do not benefit from vocational rehabilitation, or experience difficulties sustaining employment; enhanced support of this patient group is still warranted.Trial registration: http://www.clinicaltrials.gov (Identifier: NCT01721824).

Effect on return to work or education of Individual Placement and Support modified for people with mood and anxiety disorders: results of a randomised clinical trial.

OBJECTIVES: The effect of Individual Placement and Support (IPS) on return to work or education among people with mood or anxiety disorders is unclear, while IPS increases return to work for people with severe mental illness. We examined the effect of IPS modified for people with mood and anxiety disorders (IPS-MA) on return to work and education compared with services as usual (SAU). METHODS: In a randomised clinical superiority trial, 326 participants with mood and anxiety disorders were centrally randomised to IPS-MA, consisting of individual mentor support and career counselling (n=162) or SAU (n=164). The primary outcome was competitive employment or education at 24 months, while weeks of competitive employment or education, illness symptoms and level of functioning, and well-being were secondary outcomes. RESULTS: After 24 months, 44.4% (72/162) of the participants receiving IPS-MA had returned to work or education compared with 37.8% (62/164) following SAU (OR=1.34, 95% CI: 0.86 to 2.10, p=0.20). We found no difference in mean number of weeks in employment or education (IPS-MA 32.4 weeks vs SAU 26.7 weeks, p=0.14), level of depression (Hamilton Depression 6-Item Scale score IPS-MA 5.7 points vs SAU 5.0 points, p=0.12), level of anxiety (Hamilton Anxiety 6-Item Scale score IPS-MA 5.8 points vs SAU 5.1 points, p=0.17), level of functioning (Global Assessment of Functioning IPS-MA 59.1 points vs SAU 59.5 points, p=0.81) or well-being measured by WHO-Five Well-being Index (IPS-MA 49.6 points vs SAU 48.5 points, p=0.83) at 24 months. CONCLUSION: The modified version of IPS, IPS-MA, was not superior to SAU in supporting people with mood or anxiety disorders in return to work at 24 months. TRIAL REGISTRATION NUMBER: NCT01721824.

The Diagnostic Apathia Scale predicts a dose-remission relationship of T-PEMF in treatment-resistant depression.

OBJECTIVE: The aim of this study was to evaluate the predictive validity of the apathy subsyndrome in patients with therapy-resistant depression in the dose-remission study with transcranial pulsating electromagnetic fields (T-PEMF). METHODS: The apathy subsyndrome consists of the symptoms of fatigue, concentration and memory problems, lack of interests, difficulties in making decisions, and sleep problems. We evaluated 65 patients with therapy-resistant depression. In total, 34 of these patients received placebo T-PEMF in the afternoon and active T-PEMF in the morning, that is, one daily dose. The remaining 31 patients received active T-PEMF twice daily. Duration of treatment was 8 weeks in both groups. The Hamilton Depression Scale (HAM-D17) and the Bech-Rafaelsen Melancholia Scale (MES) were used to measure remission. We also focused on the Diagnostic Apathia Scale, which is based on a mixture of items from the MINI and the HAM-D17/MES. RESULTS: In patients without apathy, the remission rate after T-PEMF was 83.9% versus 58.8% in patients with apathy (p≤0.05). In patients without apathy receiving one active dose daily 94.4% remitted versus 50% for patients with apathy (p≤0.05). In patients without apathy who received two active doses 69.9% remitted versus 66.7% for patients with apathy (p≤0.05). CONCLUSION: Taking the baseline diagnosis of the apathy syndrome into consideration, we found that in patients without apathy one daily dose of T-PEMF is sufficient, but in patients with apathy two daily doses are necessary. Including the apathy syndrome as predictor in future studies would seem to be clinically relevant.

Psychometric analysis of the Melancholia Scale in trials with non-pharmacological augmentation of patients with therapy-resistant depression.

OBJECTIVE: The Melancholia Scale (MES) consists of the psychic core items of the Hamilton Depression Scale (HAM-D6) (depressed mood, interests, psychic anxiety, general somatic, guilt feelings, and psychomotor retardation) and the neuropsychiatric items of the Cronholm-Ottossen Depression Scale. Patients resistant to anti-depressant medication (therapy-resistant depression) have participated in our trials with non-pharmacological augmentation. On the basis of these trials, we have evaluated to what extent the neuropsychiatric subscale of the MES (concentration difficulties, fatigability, emotional introversion, sleep problems, and decreased verbal communication) is a measure of severity of apathia when compared with the HAM-D6 subscale of the MES. METHODS: We have focused on rating sessions at baseline (week 0) and after 2 and 4 weeks of therapy in four clinical trials on therapy-resistant depression with the following augmentations: electroconvulsive therapy, bright light therapy, transcranial magnetic stimulation or pulsed electromagnetic fields, and wake therapy. The item response theory model constructed by Mokken has been used as the psychometric validation of unidimensionality. For the numerical evaluation of transferability, we have tested item ranks across the rating weeks. RESULTS: In the Mokken analysis, the coefficient of homogeneity was above 0.40 for both the HAM-D subscale and the apathia subscale at week 4. The numerical transferability across the weeks was statistically significant (p < 0.05) for both subscales. CONCLUSION: The apathia subscale is a unidimensional scale with acceptable transferability for the measurement of treatment-resistant symptoms, analogue to the psychic core subscale (HAM-D6).

The effect of IPS-modified, an early intervention for people with mood and anxiety disorders: study protocol for a randomised clinical superiority trial.

BACKGROUND: Anxiety and affective disorders can be disabling and have a major impact on the ability to work. In Denmark, people with a mental disorder, and mainly non-psychotic disorders, represent a substantial and increasing part of those receiving disability pensions. Previous studies have indicated that Individual Placement and Support (IPS) has a positive effect on employment when provided to people with severe mental illness. This modified IPS intervention is aimed at supporting people with recently diagnosed anxiety or affective disorders in regaining their ability to work and facilitate their return to work or education. AIM: To investigate whether an early modified IPS intervention has an effect on employment and education when provided to people with recently diagnosed anxiety or affective disorders in a Danish context. METHODS/DESIGN: The trial is a randomised, assessor-blinded, clinical superiority trial of an early modified IPS intervention in addition to treatment-as-usual compared to treatment-as-usual alone for 324 participants diagnosed with an affective disorder or anxiety disorder living in the Capital Region of Denmark. The primary outcome is competitive employment or education at 24 months. Secondary outcomes are days of competitive employment or education, illness symptoms and level of functioning including quality of life at follow-up 12 and 24 months after baseline. DISCUSSION: If the modified IPS intervention is shown to be superior to treatment-as-usual, a larger number of disability pensions can probably be avoided and long-term sickness absences reduced, with major benefits to society and patients. This trial will add to the evidence of how best to support people's return to employment or education after a psychiatric disorder. TRIAL REGISTRATION: NCT01721824.

The time has come to stop rotations for the identification of structures in the Hamilton Depression Scale (HAM-D17)

Objective: To use principal component analysis (PCA) to test the hypothesis that the items of the Hamilton Depression Scale (HAM-D17) have been selected to reflect depression disability, whereas some of the items are specific for sub-typing depression into typical vs. atypical depression. Method: Our previous study using exploratory factor analysis on HAM-D17 has been re-analyzed with PCA and the results have been compared to a dataset from another randomized prospective study. Results: PCA showed that the first principal component was a general factor covering depression disability with factor loadings very similar to those obtained in the STAR*D study. The second principal component was a bi-directional factor contrasting typical vs. atypical depression symptoms. Varimax rotation gave no new insight into the factor structure of HAM-D17. Conclusion: With scales like the HAM-D17, it is very important to make a proper clinical interpretation of the PCA before attempting any form of exploratory factor analysis. For the HAM-D17, our results indicate that profile scores are needed because the total score of all 17 items in the HAM-D17 does not give sufficient information. .

The time has come to stop rotations for the identification of structures in the Hamilton Depression Scale (HAM-D17).

OBJECTIVE: To use principal component analysis (PCA) to test the hypothesis that the items of the Hamilton Depression Scale (HAM-D17) have been selected to reflect depression disability, whereas some of the items are specific for sub-typing depression into typical vs. atypical depression. METHOD: Our previous study using exploratory factor analysis on HAM-D17 has been re-analyzed with PCA and the results have been compared to a dataset from another randomized prospective study. RESULTS: PCA showed that the first principal component was a general factor covering depression disability with factor loadings very similar to those obtained in the STAR*D study. The second principal component was a bi-directional factor contrasting typical vs. atypical depression symptoms. Varimax rotation gave no new insight into the factor structure of HAM-D17. CONCLUSION: With scales like the HAM-D17, it is very important to make a proper clinical interpretation of the PCA before attempting any form of exploratory factor analysis. For the HAM-D17, our results indicate that profile scores are needed because the total score of all 17 items in the HAM-D17 does not give sufficient information.