Compulsive sexual behavior disorder in an inpatient sample with substance use disorder.

Background: Several studies indicate that compulsive sexual behavior disorder (CSBD) shares core elements with substance use disorder (SUD). These findings support the assumption of common mechanisms in addiction, which may lead to a higher tendency in patients with SUD to have comorbid CSBD. Nevertheless, this relationship between CSBD and SUD is poorly understood to date. Aim: This study aimed to compare the prevalence of CSBD and its subtype pornography use disorder (PUD) between a SUD group and a matched control group. Herein, we aimed to test whether patients with SUD are more likely to have a comorbid CSBD/PUD. We further hypothesized that a higher CSBD/PUD prevalence in patients with SUD is accompanied by more pronounced CSBD- and PUD-related personal characteristics. Methods: We assessed CSBD, PUD, and related personal characteristics in an inpatient SUD sample (N = 92) and a healthy control sample matched by age, gender, and educational level. Outcomes: Primary outcomes were the diagnoses of CSBD/PUD as assessed by questionnaires. CSBD/PUD-related personal characteristics were the early onset of problematic pornography consumption, relationship status as a single person, a high sexual motivation, a high level of time spent watching pornography, and a high degree of problematic pornography consumption (Problematic Pornography Consumption Scale, short version). Results: There was no significant difference between groups regarding CSBD prevalence (SUD sample, 3.3%; control sample, 7.6%) and PUD prevalence (SUD sample, 2.2%; control sample, 6.5%). We found relationship status as a single person and the sexual motivation dimension of importance of sex to be the only CSBD-related personal characteristics that were more pronounced in the SUD sample than the matched control group. Clinical Implications: Results indicate no higher tendency for patients with SUD to develop comorbid CSBD/PUD, yet important vulnerabilities (eg, emotional dysregulation) should be considered when treating addictive disorder to prevent possible symptom displacement. Strengths and Limitations: A strength of the study is that we compared a sample of patients with SUD with a matched control sample and used an instrument based on ICD-11 criteria for CSBD. Possible limitations are significant differences between the groups because of the restrictions in an inpatient clinic that may have influenced responses (eg, roommates) and that the control group was not screened for SUD. Therefore, the results should be interpreted with some caution. Conclusion: We found no evidence of an overcomorbidity of SUD and CSBD/PUD. However, a higher rate of vulnerability factors for CSBD/PUD in the SUD sample might suggest some similarities between SUD and CSBD/PUD.

Outpatient Psychotherapy Reduces Health-Care Costs: A Study of 22,294 Insurants over 5 Years.

BACKGROUND: The project "Quality Assurance in Ambulatory Psychotherapy in Bavaria" (QS-PSY-BAY) focuses on the quality assurance of outpatient psychotherapy (OPT) in Germany in terms of symptom reduction and cost reduction under naturalistic conditions. In this study, we examined the effectiveness of psychotherapy in terms of pre-post cost reduction. METHOD: The health-care costs of N = 22,294 insurants over a 5-year period were examined in a naturalistic longitudinal design. Six participating health insurance funds provided data on costs related to inpatient treatment, outpatient treatment, drugs, and hospitalization and work disability days. RESULTS: We found that the average annual total costs for inpatient and outpatient treatments as well as drug costs and work disability days increased from the second to the first year before OPT. Besides a large and significant reduction of work disability days (41.8%), hospitalization days (27.4%), and inpatient costs (21.5%) from the first year before versus the first year following OPT, we found evidence for long-term effects: the number of work disability days in the second year after OPT was lower (23.8%), and drug costs were higher than in the second year before OPT (41.5%). CONCLUSION: We conclude that OPT as a part of the health insurance system is an investment which can pay off in the future especially in terms of lower inpatient costs and work disability.

[Typical patterns of depressive disorders during outpatient psychotherapy and their prediction]. / Verlaufsmuster depressiver Störungen bei ambulanten psychotherapeutischen Behandlungen und deren Vorhersage.

OBJECTIVES: Are there typical patterns of outpatient psychotherapy among depressed patients? What characterizes patients with different patterns? METHODS: We examined N= 548 patients with primary depressive disorders using a naturalistic design. Using a latent-state-mixture model and depression measures at baseline, therapy end and 1-year follow-up we found a total of five patterns. Subgroups were compared with respect to sociodemographic and treatment-related variables. RESULTS: Responders with moderate depressive symptoms at baseline and responders with severe symptoms at baseline were most common (54% and 25% of the sample, respectively) compared to late responders (9 %), small-response patients (9 %) and recidivists (4 %). Patterns of change were related to symptom intensity at baseline and ratings of perceived helpfulness at the end of treatment. CONCLUSIONS: Since psychometric scales better predicted change pattern than sociodemographic characteristics, primary and secondary diagnoses, psychometric assessments and feedback systems could be a useful supplement to traditional quality assurance procedures.

Benefits and challenges in practice-oriented psychotherapy research in Germany: the TK and the QS-PSY-BAY projects of quality assurance in outpatient psychotherapy.

OBJECTIVE: Two patient-focused long-term research projects performed in the German outpatient psychotherapy system are focused on in this article. The TK (Techniker Krankenkasse) project is the first study to evaluate a quality assurance and feedback system with regard to its practical feasibility in German routine care. The other study ("Quality Assurance in Outpatient Psychotherapy in Bavaria"; QS-PSY-BAY) was designed to test a new approach for quality assurance in outpatient psychotherapy using electronic documentation of patient characteristics and outcome parameters. In addition this project provides the opportunity to analyze data on health-related costs for the patients undergoing outpatient psychotherapy. METHOD: Both projects and their results indicating high effect sizes are briefly described. RESULTS: From the perspectives of the research teams, advisory boards and other stakeholders, the experiences with these projects are discussed focusing on obstacles, challenges, difficulties, and benefits in developing and implementing the studies. The triangle collaboration of therapists, researchers, and health insurance companies/health service institutions turned out to be fruitful in both studies. CONCLUSIONS: Despite some controversies between the partners the experiences indicate the importance of practiced-research collaborations to provide relevant information about the delivery of outpatient psychotherapy in the health system.

[Non-completion of insurance-funded outpatient psychotherapy: frequency, risk factors, outcome]. / Abbrüche antragspflichtiger ambulanter Psychotherapien: Häufigkeit, Risikofaktoren, Outcome.

OBJECTIVE: Because premature discontinuation of psychotherapy limits the effectiveness of the interventions, in a naturalistic design we examined the prevalence, predictors, and outcome of premature discontinuation. METHODS: The sample included N = 584 patients with various mental disorders. Risk factors were identified using regression analysis. As outcome Patient Health Questionnaire scales were considered. We compared pre and post averages as well as post averages of premature discontinuation versus regular termination. RESULTS: Risk factors were: female and/or unemployed patient, low patient and/or therapist ratings regarding therapy success, and extraordinarily high therapist ratings of the therapeutic alliance. Despite premature discontinuation we found significant reductions of depression, anxiety, somatic symptoms, and stress (ES = 0.30, …, 0.44). Compared to regular termination though, patients with premature discontinuation were more impaired at last measurement (ES = 0.17, …, 0.37). CONCLUSION: Not each premature discontinuation is a psychotherapeutic failure. Warning signals for looming premature discontinuation are low ratings of therapy success while psychotherapeutic treatment.

[Extensions of the outpatient psychotherapy: a study about patient, therapist, treatment, and therapy course characteristics]. / Verlängerungen ambulanter Psychotherapien: Eine Studie zu Patienten-, Therapeuten-, Behandlungs- und Verlaufsmerkmalen.

Due to the treatment costs, extensions of the standard therapy duration are a matter of critical examination. This study investigates which factors characterize patients with treatment extensions in the German health system and how effective these extensions are for a reduction of the patients' symptoms. We analysed a disorder heterogeneous sample of 810 patients. We found that therapy extensions are more common among with more severe mental disorders, when the therapeutic relationship is positive, and little therapy success has been achieved during the standard duration. Overall, the findings suggest that outpatient psychotherapy is mainly extended for patients with a low symptom reduction after the standard therapy duration and that therapy extension allows a symptom reduction that could not have been achieved otherwise.

Beside the Geriatric Depression Scale: the WHO-Five Well-being Index as a valid screening tool for depression in nursing homes.

OBJECTIVE: The aim of the study was to compare criterion validities of the WHO-Five Well-being Index (WHO-5) and the Geriatric Depression Scale 15-item version (GDS-15) and 4-item version (GDS-4) as screening instruments for depression in nursing home residents. METHODS: Data from 92 residents aged 65-97 years without severe cognitive impairment (Mini Mental State Examination ≥15) were analysed. Criterion validities of the WHO-5, the GDS-15 and the GDS-4 were assessed against diagnoses of major and minor depression provided by the Structured Clinical Interview for DSM-IV. Subanalyses were performed for major and minor depression. Areas under the receiver operating curve (AUCs) as well as sensitivities and specificities at optimal cut-off points were computed. RESULTS: Prevalence of depressive disorder was 28.3%. The AUC value of the WHO-5 (0.90) was similar to that of the GDS-15 (0.82). Sensitivity of the WHO-5 (0.92) at its optimal cut-off of ≤12 was significantly higher than that of the GDS-15 (0.69) at its optimal cut-off of ≥7. The WHO-5 was equally sensitive for the subgroups of major and minor depression (0.92), whereas the GDS-15 was sensitive only for major depression (0.85), but not for minor depression (0.54). For specificity, there was no significant difference between WHO-5 (0.79) and GDS-15 (0.88), but both instruments outperformed the GDS-4 (0.53). CONCLUSIONS: The WHO-5 demonstrated high sensitivity for major and minor depression. Being shorter than the GDS-15 and superior to the GDS-4, the WHO-5 is a promising screening tool that could help physicians improve low recognition rates of depression in nursing home residents.

Who receives depression-specific treatment? A secondary data-based analysis of outpatient care received by over 780,000 statutory health-insured individuals diagnosed with depression.

PURPOSE: This study examined the effects of individual and regional characteristics on receiving depression-specific treatment in the statutory health-insured population of Bavaria (83% of the population). METHODS: Data of the Association of Statutory Health Insurance Physicians in Bavaria were analysed for prevalence, diagnosis of and treatment for depression in outpatient care by considering individual and regional characteristics. RESULTS: Prevalence of diagnosed depression was 9.2% for the statutory health-insured population aged 18-100 years. More than half of all individuals diagnosed with depression (F32.x/F33.x) and more than one-third of persons diagnosed with severe depression (F32.2/.3 and F33.2/.3) did not receive depression-specific treatment. Rates of a depression-specific treatment were higher for females, the middle aged, individuals with more severe depression diagnoses, those with psychiatric comorbidity and those without physical comorbidity and for individuals living in more rural areas. CONCLUSIONS: The pathways to depression-specific treatment for persons diagnosed with moderate and severe depression need to be improved. Training for physicians, stepped care approaches, psycho-education for patients and anti-stigma campaigns are possible measures to reach this goal. The knowledge on individual characteristics that influence receiving a depression-specific treatment is important to target the groups at increased risk for under-treatment.

[Screening for depression in nursing homes: validity of the WHO (Five) Well-Being Index]. / Der WHO-5-Fragebogen zum Wohlbefinden als Screeninginstrument für Depression bei Altenheimbewohnern.

OBJECTIVE: Depression is common in nursing home residents, but is still underrecognized. Screening for depression could be a first step to increase recognition rates within this high-risk group. Therefore, we investigated the validity of the WHO (Five) Well-Being Index (WHO-5) for early detection of depression in nursing home residents. METHODS: The Structural Clinical Interview for DSM-IV (SCID) was used as the gold standard for the validation of the WHO-5. The diagnoses covered in this assessment were both current major depression as well as minor depression according to DSM-IV research criteria. RESULTS: In our sample of 92 nursing home residents in Munich aged 65-97 years, (73.9% female, 26.1% male) 14.1% fulfilled the criteria of major depression and again 14.1% fulfilled the criteria of minor depression in the SCID. Overall diagnostic validity (area under the ROC curve) of the WHO-5 was .90 (95% confidence interval: .84- .97). The best cut-off-point according to Youden's index yielded a sensitivity of .92 and a specificity of .79. CONCLUSIONS: The diagnostic accuracy of the WHO-5 in our study is promising. The WHO-5 might be an efficient screening tool for nursing home residents, but results have to be replicated in a larger sample.

[Validity of the geriatric depression scale in nursing home residents: comparison of GDS-15, GDS-8, and GDS-4]. / Validität der Geriatrischen Depressionsskala bei Altenheimbewohnern: Vergleich von GDS-15, GDS-8 und GDS-4.

OBJECTIVE: To assess and compare the validity of the German 15-item version and shortened versions of the Geriatric Depression Scale (GDS) for early detection of depression in nursing home residents with mild to moderate cognitive impairment (MMSE ≥ 15). METHODS: Data from 92 patients were analysed. The Structural Clinical Interview for DSM-IV (SCID) was used as the gold standard. The diagnoses covered in this assessment were current major depression (MD) and minor depression (MinD). The performance of the GDS scales was evaluated using receiver operating characteristics (ROC). Main outcome measures were AUC (area under curve) values, as well as sensitivity and specificity. RESULTS: Overall diagnostic validity of the GDS-15 was better for MD than for MinD (AUC: 89.7 % and 73.4 %, respectively). In assessing MD, AUC values as well as sensitivity and specificity were comparable for the GDS-15 and the GDS-8. A cut-off point ≥ 5 on the GDS-8 gave optimum performance (sensitivity: 76.9 %, specificity: 88.6 %). For the best cut-off point ≥ 2, the corresponding values of the GDS-4 were 53.8 % and 92.4 %. CONCLUSIONS: The GDS-8 appears to be a less time-consuming alternative for the nursing home setting. However, the GDS-4 is not suitable for this population.

Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients' choice arm.

BACKGROUND: Little is known about the influence of depressed patients' preferences and expectations about treatments upon treatment outcome. We investigated whether better clinical outcome in depressed primary care patients is associated with receiving their preferred treatment. METHODS: Within a randomized placebo-controlled single-centre 10-week trial with 5 arms (sertraline; placebo; cognitive-behavioral group therapy, CBT-G; moderated self-help group control; treatment with sertraline or CBT-G according to patients' choice), outcomes for 145 primary care patients with mild-to-moderate depressive disorders according to DSM-IV criteria were investigated. Preference for medication versus psychotherapy was assessed at screening using a single item. Post-baseline difference scores for the Hamilton Depression Rating Scale (HAMD-17) were used to assess treatment outcome (mixed-model repeated-measures regression analysis). RESULTS: Depressed patients receiving their preferred treatment (n = 63), whether sertraline or CBT-G, responded significantly better than those who did not receive their preferred therapy (n = 54; p = 0.001). The difference in outcome between both groups was 8.0 points on the HAMD-17 for psychotherapy and 2.9 points on the HAMD-17 for treatment with antidepressants. Results were not explained by differences in depression severity or dropout rates. CONCLUSIONS: Patients' relative preference for medication versus psychotherapy should be considered when offering a treatment because receiving the preferred treatment conveys an additional and clinically relevant benefit (HAMD-17: +2.9 points for drugs; +8.0 points for CBT-G) in outcome.

[Improvement of knowledge and attitudes towards depression and suicidality in geriatric caregivers: evaluation of an advanced training program]. / Wissens- und Einstellungsänderung zu Depression und Suizidalität bei Altenpflegekräften: Evaluation eines Fortbildungsprojektes.

Depressive disorders rank among the most frequent mental disorders in the elderly. Especially in the elderly, depressive disorders are still underrecognized and not sufficiently treated. In view of the associated risks and complications, early and timely recognition of depressive disorders is essential to avoid exacerbation and chronic manifestation of the depressive symptoms and to antagonize the increased suicide risk as well as negative effects on concomitant somatic diseases. More than any other occupational group, geriatric caregivers have a key position in the contact with clients, relatives and treating primary care providers. Therefore, 3487 geriatric caregivers from 448 outpatient nursing services throughout Bavaria participated in 196 four-hour training courses about depressive disorders and suicidality in the elderly between March 2006 and August 2007. Aim of this activity was to reduce attitudes enclosed in a wall of prejudice and to teach specific knowledge about depression and suicidality in the elderly. This training was evaluated using specially tailored questionnaires which were completed immediately before and after the continuing education as well as three months later (at follow-up). The analysis included the individual changes of 473 participants in longitudinal sections. Pronounced knowledge deficits and reservations were found regarding pharmacotherapy with antidepressants and suicidality. In this context, significant changes in all categories were present. Especially pronounced effects were found for the attitudes towards depression and suicidality as well as treatability with antidepressants. These changes were stable, as indicated by the follow-up evaluation.

Screening for depression in the older long-term unemployed.

BACKGROUND: Misdiagnosis and undertreatment of depression in older, long-term unemployed people may not only pose a serious medical problem, but may also be an obstacle for their vocational reintegration. Screening for depression could be a first step to increasing treatment rates within this high-risk group. Therefore, the WHO-5 Well-Being Index was tested for its validity in unemployment offices. METHODOLOGY: Three hundred and sixty-five participants in a German programme for the vocational reintegration of long-term unemployed people were screened with the WHO-5 Well-Being Index. In 104 of these subjects, ICD-10 diagnoses were made using DIA-X Structured Clinical Interview. RESULTS: Using the DIA-X data as a gold standard, the WHO-5 Well-Being Index obtained satisfactory results for sensitivity (82.5%) and specificity (70.3%) as a screening tool for affective disorders when used with an adjusted cut-off-point of < or = 12. While none of the 18.5% male participants diagnosed with major depression received treatment, half of the 24% of female participants with major depression received treatment. CONCLUSION: Screening with the WHO-5 within unemployment offices is useful to detect people with depressive disorders. Many of them do not receive optimal treatment and can be motivated to seek professional help. Reducing depression by better treatment will also increase the chances of reemployment.

Depression in nursing homes: prevalence, recognition, and treatment.

OBJECTIVE: Depression is very common in people above 65 years living in long-term care. However, little is known about how well depression is recognized and how adequately it is treated. Therefore, the present study aimed at assessing accuracy of the unaided clinical diagnosis of the attending physicians, and the medical treatment situation in nursing home residents. METHODS: A random sample of 97 residents of 10 nursing homes in Munich was examined with the Section A "Affective Syndrome" of the Structured Clinical Interview (SCID) for DSM-IV to detect depression. Information concerning clinical diagnosis and medication was obtained from the subjects' medical records. RESULTS: 14.4% suffered acutely from major depression, 14.4% suffered from minor depression, and 18.6% were diagnosed as depressive according to the physician and nursing records. In total, 27.8% received antidepressants. Merely 42.9% of the subjects with acute major depression were diagnosed by their attending physicians as depressive, and only half of them received an antidepressant; 17.5% received antidepressants without a diagnosis of depression in their physician and nursing records. In accordance with the guidelines, 73.3% of the antidepressants prescribed were SSRIs or newer antidepressants. Only 20.0% were tricyclic antidepressants. CONCLUSIONS: Findings show that depression is relatively frequent in residents of nursing homes. Moreover, it is insufficiently recognized by physicians and is even more seldom adequately treated. Also, a significant proportion of residents receive antidepressants without a documented associated indication. Therefore, the recognition and guideline-based treatment of depression should be improved in this high-risk group.