Department of Psychiatry and Psychotherapy, University of Aachen
Department of Psychiatry and Psychotherapy, University of Freiburg
Department of Psychiatry and Psychotherapy, University of Aachen
Department of Psychiatry and Psychotherapy, University of Freiburg
Department of Psychiatry and Psychotherapy, University of Düsseldorf
State Hospital Weinsberg
Department of Psychiatry, Psychotherapy and Psychosomatics, Protestant Hospital, Gelsenkirchen
State Hospital Bayreuth
Department of Psychiatry and Psychotherapy, Hospital of Gummersbach
Hospital of Psychiatry and Psychotherapy, Offenburg
State Hospital Wiesloch
Department of Psychiatry and Psychotherapy, University of Münster
Department of Psychiatry and Psychotherapy, Johanniter Hospital of Oberhausen
State Hospital Bayreuth
Department of Psychiatry and Psychotherapy, University of Freiberg
Department of Psychiatry and Psychotherapy, University of Düsseldorf, Germany
Correspondence: Dr Frank Schneider, Department of Psychiatry and Psychotherapy, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany. E-mail: fschneider{at}ukaachen.de
Declaration of interest F.S., W.G. and M.B. were involved in the development of the DGPPN guidelines. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To evaluate the treatment of depression in in-patients of German psychiatric hospitals with respect to treatment outcome and adherence to guidelines.
Method We recruited 1202 in-patients with depression from ten different hospitals. Quality data concerning treatment were collected at admission, during the treatment course and at discharge.
Results The level of depression was significantly decreased and most patients were satisfied with treatment. Many aspects of the treatment routine adhered to guideline recommendations. Adherence to guidelines could be improved with respect to adjustment of antidepressant dosage, reduction of benzodiazepine prescription, enhanced use of electroconvulsive therapy and wider use of interpersonal therapy.
Conclusions The study reveals a high standard of psychiatric treatment of in-patients with depression. Nevertheless there is still room for improvement. Differences between hospitals in adherence to guidelines indicates the need for individual application of quality management tools.
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INTRODUCTION |
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METHOD |
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Assessment tools
In order to take into account the complexity of treatment for depression,
we assessed structure, process and outcome quality aspects
(Donabedian, 1966;
Fig. 1). For assessing
psychopathology, we chose the self-rating Beck Depression Inventory (BDI;
Beck et al, 1961), the
expert-rating Hamilton Rating Scale for Depression (HRSD, 21-item version;
Hamilton, 1967) and the Global
Assessment of Functioning Scale (GAF;
American Psychiatric Association,
1994). The ZUF8
(Schmidt et al, 1989)
measures patients satisfaction with treatment. Interactive video-based
rater training on use of the HRSD was conducted in every hospital, with an
average intraclass coefficient of 0.63 (F=2.7, d.f.=19,418;
P < 0.001). To assess general information about patients and the
treatment process we modified the German documentation system BADO according
to the special needs of care of in-patients with depression. The BADO is a
standard instrument for quality assurance of psychiatric in-patient care
developed by the German Association of Psychiatry, Psychotherapy and Neurology
(DGPPN) (Cording et al,
1995). The modified version consists of three forms: admission (27
items) course of treatment (7 items) and discharge (29 items).
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Hospital sample
To draw representative conclusions, hospitals in different regions, of
various type and size were chosen (Table
1). Owing to differences in average number of admissions and for
internal organisational reasons, the number of recruited patients differed
between hospitals. Half of the patients (50.2%, n=603) were treated
in state psychiatric hospitals, 28.6% (n=344) in general hospitals
and 21.2% (n=255) in university hospitals. About half of the sample
(48.3%) was treated in north Germany and about half (51.7%) in south
Germany.
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Hospitals were invited to cooperate voluntarily in this study. They were asked to use the documentation tools to recruit 150 patients. They had the benefit of detailed comparative feedback (benchmarking) on their treatment routine.
Adherence to guidelines
To evaluate adherence to guidelines, we selected some high-priority
guideline recommendations for treatment of in-patient depression
(Table 2) and compared these
with treatment routine as assessed in this study. Since there are a variety of
national and international guidelines for treatment of depression, we chose
the internationally accredited American Psychiatric Association guidelines
(American Psychiatric Association,
2000) as well as the nationally accepted German DGPPN guidelines
(Deutsche Gesellschaft für
Psychiatrie, Psychotherapie und Nervenheilkunde, 2000). To ensure
that we had specified updated recommendations, we also considered current
literature (Furukawa et al,
2002; Smith et al,
2002; Benkert & Hippius,
2003; Guaiana et al,
2003; UK ECT Review Group,
2003). Psychotherapy was defined as at least one individual or
group session with a psychotherapeutic rationale.
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Statistical analysis
We used different measures to analyse therapy outcome. Individual effect
sizes d were calculated for the expert-rated level of depression
(HRSD) by taking individual differences in scores before and after treatment
and then dividing them by the pooled standard deviation. According to Cohen
(1988), effect sizes can be
classified into small (d < 0.40), medium (0.40 < d
< 0.80) and high (d > 0.80). Response to treatment was defined
according to Jacobson et al
(1984) with the reliable
change index (RCI). We calculated RCIs for each patient by dividing the
difference between expertrated level of depression (HRSD) at admission and
discharge by the standard error of measurement
,
with s.d.1=standard deviation of HRSD score at admission and
rxx'=testretest reliability of the HRSD). An
RCI score > 1.96 indicates statistically reliable improvement
(response).
Group differences of categorical data were assessed using the
2 statistic. Group differences of continuous data were
examined using analysis of variance (ANOVA). The frequency distribution of
length of stay, ZUF8, HRSD and BDI scores did not follow a normal
distribution. Therefore non-parametric tests such as the MannWhitney
U-test, Wilcoxon and KruskalWallace H-test were used
to analyse differences between groups.
Since a considerable number of BDI self-ratings were lacking (BDI at admission, 15.4%; BDI at discharge, 28.6%), we quoted the number of missing cases separately (Table 3). For the same reason we used the HRSD expert ratings as the main measure of depression.
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RESULTS |
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Psychopathology
Average levels of depression at admission were high according to
self-ratings (BDI, mean=26.9, s.d.=11.7, median=27.0) and moderate according
to expert ratings (HRSD, mean=22.8, s.d.=8.9, median=22.0;
Table 3).
The levels of self-rated and expert-rated depression at admission were
correlated (Spearmans r=0.43, P < 0.001). The
level of depression at admission differed significantly between hospitals,
with the mean HRSD score ranging from 15 to 29 (2=151.2,
d.f.=9, P < 0.001). Global functioning (GAF) was restricted at
admission (mean=45.8; s.d.=13.5, median=48.0;
Table 3) and also differed
between hospitals (range 38.353.5;
2=111.2, d.f.=9,
P < 0.001). Of those included in the study, 27.3% had fallen ill
in the year of admission.
The two most frequent diagnoses were single depressive episode (42.0%) and depressive episode within recurrent depressive disorder (40.0%), followed by adjustment disorder (12.2%), depressive episode within bipolar depressive disorder (4.8%) and dysthymia (1.1%). Psychiatric comorbidity was reported for 25.1% of patients, with drug addiction problems (12.0%), axis II disorders (6.3%) and anxiety disorders (6.0%) as the largest diagnostic groups (World Health Organization, 1993). The highest rate of psychiatric comorbidity was found for patients with dysthymia (58.3%), followed by patients with recurrent depressive disorder (28.5%). Comorbid physical illness was found in 33.5% of the total sample, with the highest rate for patients with recurrent depressive disorder (40.5%), followed by patients with bipolar depressive disorder (37.9%). Vascular disease (17.7%) was the most frequent reported category, followed by nutritional and metabolic disorders (10.2%) and orthopaedic diseases (5.6%; World Health Organization, 1993).
Treatment process
General treatment strategy
Most patients (n=982, 81.7% of the total sample) were treated with
a combination of pharmacotherapy and psychotherapy. A combination of
pharmacotherapy, psychotherapy and electroconvulsive therapy (ECT) was used
for 53 patients (4.4% of the total sample). Of the 782 patients with
moderate-to-severe depression (HRSD > 17), 95.8% received pharmacotherapy;
91.9% of the 160 patients with severe acute stressors and 93.4% of the 76
patients with comorbid axis II disorder were treated with psychotherapy.
Prescription of antidepressants
A total of 93.4% of the sample received pharmacotherapy during in-patient
treatment. Of those, 94.1% were discharged with antidepressant medication. As
shown in Table 4, the most
frequently prescribed antidepressants were mirtazapine, venlafaxine and
reboxetine (47.8% of patients receiving pharmacotherapy), followed by
selective serotonin reuptake inhibitors (SSRIs) (30.2%) and tri- and
tetracyclics (26.6%). Monoamine oxidase inhibitors (MAOIs) were prescribed
rarely (2.8%) and not to first-episode patients. For 17.5% of patients, more
than one antidepressant had been prescribed.
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The proportion of patients discharged with antidepressants
(2=23.0, d.f.=9, P=0.006) and the prescription of
different antidepressant groups differed between hospitals (tricyclics:
2=54.5, d.f.=9, P < 0.001
(Fig. 2); SSRIs:
2=135.9, d.f.=9, P < 0.001; other antidepressants:
2=44.4, d.f.=9, P < 0.001; MAOIs:
2=51.8, d.f.=9, P < 0.001).
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Electroconvulsive therapy
Electroconvulsive therapy was given to 5.2% of patients. Of the 437 with
severe depressive symptoms at admission (HRSD > 24), 24 (5.5%) received
ECT. Out of 108 psychotic patients, 9 (8.3%) were treated with ECT. There is a
difference between hospitals concerning the application of ECT
(2=286.5, d.f.=9, P < 0.001): four of the ten
participating hospitals did not use ECT at all. Further investigation revealed
that three of those four hospitals have ECT facilities but do not offer this
treatment to patients with depression because of ethical considerations and
low demand by patients.
Psychotherapeuqtic rationale
A total of 1105 patients (91.9% of the total sample) received psychotherapy
during inpatient treatment. Cognitivebehavioural therapy was most
frequently applied (57.1% of psychotherapy patients), followed followed by
psychodynamic therapy (22.8%), client-centred therapy (9.9%) and interpersonal
therapy (8.8%). The ten hospitals differed with respect to the proportion of
patients receiving psychotherapy (2=118.3, d.f.=9, P
< 0.001) as well as psychotherapeutic rationale (
2=137.0,
d.f.=9, P < 0.001).
Outcome
The mean duration of in-patient treatment was 49.5 days (s.d.=40.5, range
3385), with significant differences between hospitals
(2=81.7, d.f.=9, P < 0.001). The average level of
global functioning (GAF) of the patients increased significantly during
in-patient treatment from 45.8 (s.d.=13.5) to 70.2 (s.d.=13.8) at discharge
(Z=-28.2, P < 0.001). The mean self-rated level of
depression (BDI) decreased from 27.0 (s.d.=11.6) to 11.4 (s.d.=10.0,
Z=-23.2, P < 0.001), the mean expertrated level of
depression (HRSD) from 22.8 (s.d.=8.9) to 7.1 (s.d.=6.3, Z=-28.2,
P < 0.001; Table
3). The response ratio for the level of depression (RCI (HRSD)
> 1.96) was 76.9%. Two patients (0.2%) deteriorated during treatment (RCI
(HRSD) < -1.96). The average effect size d for expert-rated level
of depression (HRSD) was 2.1 (s.d.=1.2). Hospitals differed with respect to
the mean level of depression at discharge (HRSD range 4.59.7,
2=120.4, d.f.=9, P < 0.001) and the depression
effect sizes (
2=88.1, d.f.=9, P < 0.001). Only 866
out of 1202 patients (72%) rated their satisfaction with treatment at
discharge. Of those patients, 85.9% were satisfied.
Adherence to guidelines and outcome
There are significant differences between responders (RCI (HRSD) > 1.96)
and non-responders (RCI (HRSD) < 1.96) with respect to adherence to
treatment guidelines (Table 2).
Patients with a comorbid axis II disorder who received psychotherapy were more
likely to respond to treatment (84% responders) than axis II patients who had
not received psychotherapy (61.1% responders, 2=4.0, d.f.=1,
P < 0.05). Adherence to treatment guidelines for tricyclic
antidepressant dosage made a difference to treatment response among patients
receiving tricyclic medication (
2=6.6, d.f.=1, P <
0.05), with a higher rate of correct tricyclic dosage decisions in the
response group (78.3%) than in the non-response group (60.8%). The mean
duration of treatment of those with comorbid substance misuse given
benzodiazepines at discharge was significantly shorter (n=28,
mean=32.1 days, range=5124) than the mean duration of treatment of
similar patients not receiving benzodiazepines at discharge (n=116,
mean=49.1 days, range 4163, U=1030.0, P=0.003). The
response rates among patients given psychotherapy were higher for
interpersonal therapy (84.5%) and cognitivebehavioural therapy (83.2%)
than for client-centred therapy (70.7%) or psychodynamic therapy (69.1%,
2=25.2, d.f.=8, P=0.001).
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DISCUSSION |
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Treatment outcome
The mean treatment outcome was high: the effect sizes (d=1.5) for
BDI expert rating and for HRSD self-rating (d=2.3) can be considered
large (Cohen, 1988). Most
patients showed a significant decrease in the level of depression during
treatment (76.9%) and only two patients deteriorated. The results are
comparable with other evaluation studies of depression treatment in Germany
(Hautzinger & deJong-Meyer,
1996; Härter et
al, 2004). The decrease in psychopathology and in global
functioning during in-patient treatment is not only statistically but also
clinically significant. The average global functioning at discharge (GAF=70.2)
can be described as having some mild symptoms or some difficulty in
social, occupational or school functioning, but generally functioning pretty
well... (American Psychiatric
Association, 1994, p. 759), justifying discharge from in-patient
treatment. The mean depression score at discharge was on a threshold towards a
non-clinical level of depression (BDI=11.5, HRSD=7.1). Many patients were
satisfied with treatment (85.9%). Nevertheless, since self-report data on
patients satisfaction are missing for 28.1% of patients, interpretation
is limited. There might have been a selection effect of extraordinarily
compliant patients.
Adherence to treatment guidelines
General therapeutic strategies have mainly been chosen according to
guideline recommendations (Table
2). Most patients with moderate-to-severe depression received
pharmacotherapy (95.8%). Psychotherapy can be considered a second core element
of German in-patient treatment of depression. Most patients with a comorbid
axis II disorder (93.4%) or acute stressors (91.9%) were treated with
psychotherapy, according to guideline recommendations.
The results also reflect a routine of antidepressant prescribing which is highly concordant with guideline recommendations (Table 2). Only 2.8% of the sample and no first-episode patients were prescribed MAOIs but a large number of patients received at least one of the recommended antidepressants SSRIs, tri-/tetracyclics or antidepressants such as mirtazapine, venlafaxine and reboxetine (Table 4). The preference for antidepressants such as mirtazapine, venlafaxine and reboxetine over SSRIs and tri-/tetracylics corresponds to the prescription trends in the USA (Ackerman et al, 2002).
The results concerning dosage of antidepressants give an optimistic picture for the in-patient setting compared with international and out-patient findings. Only 15% of decisions regarding antidepressant dosage did not satisfactorily meet guideline recommendations (Table 2, Fig. 3). Studies from the USA (e.g. Dawson et al, 1999) have reported that up to 50% of antidepressant dosages were not in accordance with recommendations. For out-patient settings, similar rates were reported (44%), with worse treatment outcome for patients receiving too low a dosage of antidepressants (Simon et al, 1995).
The high rate of benzodiazepine prescribing at discharge (up to 56%) is a point for discussion. Combination therapy with benzodiazepines is said to decrease dropout rates but at the same time there are concerns about dependence and accident proneness (Furukawa et al, 2002). Treatment guidelines advise clearly against benzodiazepines for patients with comorbid drug addiction. In contrast, almost 20% of this subgroup were still taking benzodiazepines at discharge. The duration of treatment may account for this deviation from guideline recommendations. Possibly benzodiazepine withdrawal had not yet been completed and benzodiazepines may have been continued in subsequent out-patient treatment. The fact that only half of the patients with comorbid drug addiction and benzodiazepine prescription at discharge continued out-patient treatment does not support this assumption.
The data reflect a restricted routine use of ECT in Germany. This is not in line with guideline recommendations and research findings that showed ECT to be an effective treatment for patients with severe and psychotic symptoms and those not responding to antidepressant medication (American Psychiatric Association, 2000; UK ECT Review Group, 2003). These results are in accordance with Müller et al (1998), who showed that the application of ECT in German hospitals was much more influenced by social factors and psychiatrists attitudes than by medical factors.
According to guideline recommendations (Table 2), cognitivebehavioural therapy and interpersonal therapy are the most effective specific treatment strategies for major depressive disorder. While cognitivebehavioural therapy was the most applied therapeutic modality in the present study, interpersonal therapy still seems to be relatively unknown in German psychiatric hospitals.
Our results emphasise the importance to outcome of adherence to treatment guidelines. Adherence to guidelines for tricyclic antidepressant dosage, psychotherapeutic treatment and cognitivebehavioural and interpersonal therapy as main therapeutic rationales seems to correspond to higher response rates.
Methodological issues
There was a difference between self- and expert-rated levels of depression
in this study, indicating the importance of different methods of assessment in
the treatment of depression. As in out-patient settings, patients seemed to
rate themselves as more depressed than their therapists did
(Schneider et al,
2004). Unfortunately many self-rating data are missing and hence
the validity is restricted.
Significant differences between hospitals were found with respect to patients characteristics at admission (case mix) as well as variables of treatment process and outcome. This corresponds with a number of other studies (e.g. Härter et al, 2004) and suggests that fair comparisons of treatment process and outcome between hospitals can only be conducted by statistically considering the case mix.
There are different definitions of adherence to guidelines in the current literature. In a Dutch study by Tiemeier et al (2002), adherence to guidelines for psychiatric treatment was assessed using vignettes. Adherence was defined by an expert panel based on the three leading Dutch guidelines, resulting in 73% guideline-adherent intentions-to-treat by the participating psychiatrists. Fortney et al (2001) found only 29% of an American sample of out-patients with depression to be treated according to guidelines. In that study adherence to guidelines was defined as antidepressant medication corresponding with Agency for Healthcare Research and Quality guidelines or as a certain number of visits to a specialist health provider. Since psychiatric treatment is a complex phenomenon, with many variables influencing treatment process and outcome (Frick et al, 1999; Sitta et al, 2003), and the specificity of guideline recommendations is limited, a single score for adherence to guidelines seems too restrictive. For that reason we selected single guideline recommendations to verify the recommendations in real clinical settings. Even this method does not compare with real-life settings since differences between hospitals became obvious. The question To what extent is in-patient depression treatment adherent to guidelines? should be rephrased as How does a psychiatric hospital deal with specific guideline recommendations with respect to specific groups of patients? Our results as well as the results of Tiemeier et al (2002) and Fortney et al (2001) may be a useful starting point for quality management since they focus on single treatment aspects.
In order to effectively improve the quality of treatment for in-patients with depression, there is a need to:
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication November 3, 2003. Revision received September 23, 2004. Accepted for publication September 30, 2004.
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