Chronic depressions are difficult to treat. A new form of psychotherapy, CBASP, has been specifically developed for this subgroup of depressed patients by James McCullough (USA). In a large multisite randomized controlled trial, the combination of CBASP with antidepressant medication was considerably more effective than antidepressants alone (response rates of 73% versus 48% respectively). Therefore, CBASP is regarded as an evidence based therapy for chronic depression and mentioned in most depression treatment guidelines. Yet, the dissemination of this form of psychotherapy is still limited.

In the Netherlands, 25 therapists were trained by McCullough, and participate in a recently started (June 2007) randomized controlled trial, comparing CBASP with usual care in outpatient psychiatric clinics. The basic structure of the CBASP sessions is cognitive behaviorally oriented. Patients are learned to perform analyses of specific situations, and bring in and discuss a situational analysis form every session. As this approach alone often fails in chronic depressed patients, who are often emotionally detached and avoidant, other techniques are used to develop a therapeutic relationship, and to confront the patient with his/her behavior and opportunities to change. These techniques concern transference issues, and so-called disciplined personal involvement of the therapist.

This presentation will focus on the content of the CBASP therapy and on our experiences in learning and providing CBASP. Additionally, the study design of the randomized controlled trial will be presented.

CBASP is an interesting and promising treatment for chronically depressed patients.

Two thousand eight hundred and three telephone interviews were completed using a standardized assessment instrument for identifying problem and pathological gamblers (SOGS) and alcohol abuse (CAGE).

In Switzerland, the past year prevalence rates were 0.8% for problem gambling and 0.5% for pathological gambling in 2005. No relationship was found between alcohol abuse and gambling behaviour. The past-year prevalence of problem and pathological gambling did not change between 1998 and 2005.

When comparing the percentage of “ problem gamblers” (levels 2 + 3) who probably have an alcohol problem found in 1998 with that found in 2005, results show a statistically significant difference [χ2=4.1; p<.05]. This important change may be related to the fact that slot machines were then present in public bars where alcohol was more readily available, without the controls of the preventive measures implemented in all Swiss casinos after 2002.

Despite widespread openings of casinos in Switzerland since 2002, the prevalence estimates of past-year disordered gambling have remained stable.

The present study addresses the empirical basis for alerting health professionals to potential risk factors for excessive gambling. On the basis of international and Swiss literature on gambling, an explanatory model for the development of gambling problems is developed.

This work is based on the hypothesis that the prediction rule for excessive gambling, based on a sample of the general population and for different types of frequent gambling preferences, differs from the prediction rule for disordered gambling in patients, seeking psychiatric treatment. The goal of this study is, therefore, to contribute to an early identification of disordered gambling behaviour in the general population, as well as in the target group of patients seeking psychiatric treatment.

Various sources of information were analysed separately, in order to develop and test a prediction rule for excessive gambling, namely the 2002 Swiss Health Survey, which is a survey of the general population, involving 19'706 participants, as well as the data of psychiatric patients of the Lausanne/Geneva - region, recruited consecutively from 1996 to 2004 at the Psychiatric Hospital of the University of Lausanne. This patient population comprised a total of 886 patients. Further data from the Centre for Excessive Gambling in Lausanne are presented, covering 105 patients.

Results show that indicators of depressive behaviour as well as smoking are good candidates for the early identification of gambling problems. On the basis of these data it is safe to assume that signs of depressive behaviour should encourage health professionals to enquire about gambling problems.

From 174 consecutively admitted pathological gamblers we identified 4 patients with PD. Standardized medical records include socio-demographic characteristics, past gaming behaviours and gambling-treatment modalities as well as the evolution of PD and the pro-dopaminergic medication history.

All four patients developed PG after the onset of PD treatment. Three patients described a period of chronic exposure to gaming facilities years before and after onset of pro-dopaminergic treatment, with occasional or regular gambling, but without a compulsive component. In one patient, PG appeared suddenly without any previous gaming behaviour after the onset of medication. Despite a high treatment motivation, gambling specific cognitive therapy was unsuccessful.(c) Implication for the Field

The relationship between PD and PG appears to be complex: Confounders such as psychosocial factors or increase in accessibility of gambling opportunities may account for these findings. This case series confirm that pro-dopaminergic treatment can induce PG behaviour, but may be more likely in “at risk” groups. These patients pose specific treatment challenges.

Postmortem and PET studies indicate increased serotonin (5-HT)-5-HT1A receptor density in frontal and temporal cortices in schizophrenia, suggesting up-regulation secondary to diminished 5-HT1A-receptor stimulation. We previously conducted a series of pilot studies of the effects of the addition of tandospirone, a 5-HT1A partial agonist and azapirone derivative, to ongoing treatment with small to moderate doses of typical antipsychotic drugs, on cognitive function in patients with schizophrenia. The addition of tandospirone (30 mg/day), but not placebo, for 4 to 6 weeks was found to improve executive function and verbal learning and memory.

We have conducted a randomly-assigned placebo-controlled double-blind study to investigate the ability of the addition of buspirone to enhance cognitive function in subjects with schizophrenia treated with atypical antipsychotic drugs (AAPDs). Buspirone, 30 mg/day, outperformed placebo in improving the performance on a measure of attention/speeded motor performance and index of general cognitive function. The distinct cognition-enhancing ability of buspirone suggests its usefulness for patients who have large deficits in attention in spite of treatment with AAPDs.

The findings from these clinical studies indicate 5-HT1A receptors are a promising target for the management of psychotic symptoms and cognitive disturbances of schizophrenia. This concept has prompted the development of novel antipsychotic compounds with agonist actions at 5-HT1A receptors, e.g. F156063, SLV313, SSR181507, and bifeprunox. Evidence from basic studies with these drugs suggests an optimal balance of activity at 5-HT1A and dopamine-D2 receptors is required to gain cognitive benefits, which deserves further investigations.

Reports in recent literature regarding PTSD note that: 1) defining symptoms do not always accompany exposure to a potentially traumatic event and 2) symptoms are often observed in the absence of experience with traumatic events. The question arises: is manifesting PTSD symptoms principally a function of experiencing traumatic events or of unrelated psychosocial characteristics.

Data on three sets of variables [PTSD symptoms (Intrusive Experiences and Defensive Avoidance), potentially traumatic experiences (victim of assault, witness of assault, experiencing domestic violence, experiencing interpersonal loss, injured in an accident) and psychosocial characteristics (availability of adult confidant, sense of personal efficacy, emotional reactivity)] were collected by questionnaire from a community sample of 416 older adolescents age 18. Data were analyzed by hierarchical regression procedures.

11% of the sample reported “clinically significant” levels of PTSD symptoms. Each of the trauma and psychosocial variables was significantly correlated with PTSD symptoms. A multiple R of .58 was obtained between the eight independent variables and level of symptoms, accounting for 33% of the variance in symptoms: trauma independently accounted for 8% of the variance in symptoms, psychosocial characteristics independently accounted for 19% of the variance in symptoms, and overlapping influences of trauma and psychosocial characteristics accounted for 6% of the variance in symptoms.

Although manifesting PTSD symptoms is related to exposure to potentially traumatic events, it appears to be primarily a function of psychosocial characteristics, not of exposure to traumatic events.

assessing the incidence, severity and course of self-reported depression and anxiety of CABG patients in long-term follow-up.

53 patients were examined before coronary artery bypass grafting (CABG), 7-10 days and 3 months after CABG. The follow-up response rate after 6 years (T4) was 83%, 37 were assessed and 7 patients died. Spielberger State-Trait Anxiety Questionnaire and Beck Depression Inventory (BDI) were used.

Patients who died between T3 and T4 had significantly more postoperative complications, lower physical and mental well-being after operation and the higher BDI somatic subscale scores than those, who were assessed at T4.

Most of patients without depressive symptoms before operation did not have those afterwards. Mean BDI affective subscale scores were stable within 4 assessments. BDI affective subscale scores were higher among persons with comorbidity. Longer intubation and postoperative complications was associated with higher scores of BDI somatic symptoms. Higher BDI scores were correlated with worse physical well-being rather than mental one. The level of anxiety symptoms was positively correlated with severity of depressive symptoms. However, in the follow-up group the significant reduction of anxiety symptoms after 3 months and 6 years in comparison to preoperative levels were observed.

Positive cardiac effect of CABG did not influence on reduction of depressive symptoms in short and long-term perspective. Preoperative assessment of anxiety and depressive symptoms can indicate risk group and suggest care proceedings during rehabilitation period in order to improve effectiveness of cardiac grafting.

This analysis explores factors associated with health-related quality of life (HRQoL) outcomes following treatment for a depressive episode.

FINDER was a prospective, observational study evaluating HRQoL in 3,468 depressed outpatients receiving antidepressant (AD) treatment. Patients completed the Short-Form-Health-Survey (SF-36) and European-Quality-of-life-5-Dimensions (EQ-5D) questionnaire at baseline, 3 and 6-months. SF-36 is summarised with the Physical and Mental Component Summary (PCS and MCS) scores. AD medication was recorded at each observation, and patients completed ratings on the Hospital Anxiety and Depression Scale (HADS), Somatic Symptom Inventory (SSI-28) and pain severity Visual Analogue Scale (VAS). Multivariate analysis for HRQoL outcomes was performed.

In addition to the respective baseline HRQoL score, somatic symptoms had the strongest association with SF-36 MCS; age and the presence of chronic medical conditions had the strongest association with PCS (all p<0.001). Variables most strongly associated with EQ-5D, besides their respective baseline scores, were somatic symptoms and pain severity, as well as duration of current depression (all p<0.001). AD treatment was significantly associated with

SF-36 MCS and EQ-5D VAS (all p<0.001). Switching medication within class during 6 months was significantly associated with poorer outcomes on all HRQoL measures (all p<0.001) compared to not switching.

HRQoL at treatment initiation and somatic symptoms were associated with the level of improvement in HRQoL observed in depressed outpatients over the course of 6 months. Treatment switching, duration of episode and pain were also important factors to consider.

FINDER was supported by Eli Lilly and Company Limited & Boehringer Ingelheim GmbH

To explore health-related quality of life (HRQoL) outcomes of patients with depression and moderate/severe pain compared to depressed patients with no/mild pain.

FINDER was a 6-month prospective, observational study to investigate HRQoL of 3,468 depressed outpatients receiving antidepressant treatment. Patients completed ratings on pain severity using Visual Analogue Scales (VAS) at the beginning of treatment, 3 and 6-months. Overall VAS pain severity ratings ?30mm were defined as 'no/mild pain', and >30mm as 'moderate/severe pain.' Pain response was defined as rating >30mm at baseline, changing to ?30mm at 6-months. Patients also completed the Short-Form-Health-Survey (SF-36) and European-Quality-of-Life-5-Dimensions (EQ-5D) questionnaire.

56% of patients with depression experienced moderate/severe pain at baseline, and 70% of these had no physical explanation. Those with depression and pain at baseline reported poorer HRQoL on the SF-36 physical component score (but not mental component score) and EQ-5D scores at baseline and 6-months. 47% (n=685) of those with depression and pain at baseline had moderate/severe pain at 6-months. Pain response was highest for those with greater baseline depression. Several socio-demographic, psychiatric and medical history characteristics were associated with decreased pain response according to logistic regression, as was baseline level of pain. In addition, those using analgesics, particularly opioids, were less likely to respond.

There was considerable comorbidity between pain and depression. Almost half of such patients did not demonstrate a pain response within the observation period and may represent a specific subgroup.

FINDER was supported by Eli Lilly and Company Limited & Boehringer Ingelheim GmbH.

This analysis explores outcomes of depressed outpatients observed for 6-months in routine care. Clinically diagnosed patients were grouped with respect to their ‘caseness’ for depression and/or anxiety.

FINDER was a prospective, observational study evaluating health-related quality of life (HRQoL) in 3,468 depressed outpatients receiving antidepressant treatment. Patients completed ratings on the Hospital Anxiety and Depression Scale (HADS) at baseline, 3 and 6 months. HADS subscores of ≤7, 8-10 and >11 at baseline were used to classify patients into ‘non-cases,’ ‘doubtful cases,’ and ‘probable cases’ for depression and anxiety, respectively. HRQoL measures included the Short-Form-Health-Survey (SF-36).

74% of patients with clinically diagnosed depression fulfilled HADS criteria for probable case for anxiety, 66% for probable case for depression and 56% for both, depression and anxiety. After 6-months, 50% of HADS-defined cases for depression at baseline were non-cases for anxiety and depression. Similarly, 40% of cases for anxiety and 41% of cases for both depression and anxiety at baseline were non-cases for anxiety and depression at 6-months. SF-36 physical and mental component scores (PCS, MCS) at 6-months were 51.5(7.6), 46.1(8.6) for non-cases for depression, 51.3(7.8), 46.9(8.3) for anxiety non-cases and 52.0(7.4), 48.2(7.5) for non-cases for comorbid depression and anxiety at 6-months, respectively.

Depression seems to improve more than anxiety or comorbid depression and anxiety, according to HADS. Physicians appear to not always comply with DSM-IV classification criteria when making a diagnosis of clinical depression.

FINDER was supported by Eli Lilly and Company Limited & Boehringer Ingelheim GmbH