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While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.
We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.
SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.
The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.
Practice guidelines endorse maintenance antidepressant treatment for recurrent major depressive disorder. In the Vantaa Depression Study, we followed 218 psychiatric patients with major depressive disorder for up to 5 years with a life-chart. Of these patients, 86 (39.4%) had more than three lifetime episodes and an indication for maintenance pharmacotherapy. However, of these, only 57% received treatment and only for 16% of the time indicated. Good adherence to pharmacotherapy in the acute phase independently predicted maintenance treatment. The tertiary preventive impact of maintenance treatment may remain limited, as many patients with major depressive disorder either do not receive it, or receive it for too short a period.
Background. Despite the need for rational allocation of resources and cooperation between different treatment settings, clinical differences in patients with major depressive disorder (MDD) between primary and psychiatric care remain obscure. We investigated these differences in representative patient populations from primary care versus secondary level psychiatric care in the city of Vantaa, Finland.
Method. We compared MDD patients from primary care in the Vantaa Primary Care Depression Study (PC-VDS) (n=79) with psychiatric out-patients (n=223) and in-patients (n=46) in the Vantaa Depression Study (VDS). DSM-IV diagnoses were assigned by the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I in PC-VDS) or Schedules for Clinical Assessment in Neuropsychiatry (SCAN in VDS), and SCID-II interviews. Comparable information was collected on depression severity, Axis I and II co-morbidity, suicidal behaviour, preceding clinical course, and attitudes towards and pathways to treatment.
Results. Prevalence of psychotic subtype and severity of depression were highest among in-patients, but otherwise few clinical differences between psychiatric and primary care patients were detected. Suicide attempts, alcohol dependence, and cluster A personality disorder were associated with treatment in psychiatric care, whereas cluster B personality disorder was associated with primary care treatment. Patients' choice of the initial point of contact for current depressive symptoms seemed to be independent of prior clinical history or attitude towards treatment.
Conclusions. Severe, suicidal and psychotic depression cluster in psychiatric in-patient settings, as expected. However, MDD patients in primary care or psychiatric out-patient settings may not differ markedly in their clinical characteristics. This apparent blurring of boundaries between treatment settings calls for enhanced cooperation between settings, and clearer and more structured division of labour.
Background. Adverse life events and social support may influence the outcome of major depressive disorder (MDD). We hypothesized that outcome would depend on the level of depressive symptoms present at the outset, with those in partial remission being particularly vulnerable.
Method. In the Vantaa Depression Study (VDS), patients with DSM-IV MDD were interviewed at baseline, and at 6 and 18 months. Life events were investigated with the Interview for Recent Life Events (IRLE) and social support with the Interview Measure of Social Relationships (IMSR) and the Perceived Social Support Scale – Revised (PSSS-R). The patients were divided into three subgroups at 6 months, those in full remission (n=68), partial remission (n=75) or major depressive episode (MDE) (n=50). The influence of social support and negative life events during the next 12 months on the level of depressive symptoms, measured by the Hamilton Rating Scale for Depression (HAMD), was investigated at endpoint.
Results. The severity of life events and perceived social support influenced the outcome of depression overall, even after adjusting for baseline level of depression and neuroticism. In the full remission subgroup, both severity of life events and subjective social support significantly predicted outcome. However, in the partial remission group, only the severity of events, and in the MDE group, the level of social support were significant predictors.
Conclusions. Adverse life events and/or poor perceived social support influence the medium-term outcome of all psychiatric patients with MDD. These factors appear to have the strongest predictive value in the subgroup of patients currently in full remission.
There are few prospective studies on risk factors for attempted suicide among psychiatric out- and in-patients with major depressive disorder.
To investigate risk factors for attempted suicide among psychiatric out- and in-patients with major depressive disorder inthe city of Vantaa, Finland.
The Vantaa Depression Study included 269 patients with DSM–IV major depressive disorder diagnosed using semi-structured interviews and followed up at 6- and 18-month interviews with a life chart.
During the 18-month follow-up, 8% of the patients attempted suicide. The relative risk of an attempt was 2.50 during partial remission and 7.54 during a major depressive episode, compared with full remission (P<0.001). Numerous factors were associated with this risk, but lacking a partner, previous suicide attempts and total time spent in major depressive episodes were the most robust predictors.
Suicide attempts among patients with major depressive disorder are strongly associated with the presence and severity of depressive symptoms and predicted by lack of partner, previous suicide attempts and time spent in depression. Reducing the time spent depressed is a credible preventive measure.
Background. Preceding longitudinal course and current somatic and psychiatric co-morbidity of depression have been little investigated in primary care.
Method. Consecutive patients (n=1111) in primary care in the city of Vantaa, Finland, were screened for depression with the PRIME-MD, and positive cases interviewed by telephone. Cases with current depressive symptoms were diagnosed face-to-face with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P). A cohort of 137 patients with unipolar depressive disorders, comprising all patients with at least two depressive symptoms and clinically significant distress or disability, was recruited. The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), medical records, rating scales, and a retrospective life-chart were used to obtain comprehensive cross-sectional and longitudinal information.
Results. Current major depressive disorder (MDD) was the most prevalent depressive disorder (66%); it was usually mild to moderate but recurrent. A quarter of cases (23%) had MDD in partial remission or prodromal phase, and only 10% had true minor depression. Axis I co-morbidity was present in 59%, Axis II in 52%, and chronic Axis III disorders in 47%; only 12% had no co-morbidity. One third of patients presented with a psychological complaint, predicted by higher depression severity and younger age.
Conclusion. From a lifetime perspective, the majority of primary-care patients with depressive disorders suffer from recurrent MDD, although they are currently often in prodromal or residual phase. Psychiatric and somatic co-morbidity are highly prevalent. Treatment of depression in primary care should not rely on an assumption of short-lived, uncomplicated mild disorders.
Background. The descriptive validity of the melancholic features specifier of the DSM-IV major depressive disorder (MDD) is uncertain. Little is known about its relationship to psychiatric co-morbidity, stability across episodes, or strength in predicting course of illness.
Method. The Vantaa Depression Study (VDS) is a prospective, naturalistic cohort study of 269 patients with a new episode of DSM-IV MDD who were interviewed with SCAN and SCID-II between 1 February 1997 and 31 May 1998, and again at 6 and 18 months. Ninety-seven (36%) MDD patients met DSM-IV criteria for the melancholic features specifier, and were contrasted with 172 (64%) subjects with a non-melancholic MDD. The duration of the index episode was examined using a life chart.
Results. We found no difference in rates of any current co-morbid Axis I or II disorders between melancholic and non-melancholic depressed patients. Of those who had melancholic features at the index episode and subsequent episodes during the 18-month follow-up, only 22% (5/23) presented melancholic features during the latter. The non-melancholic subtype switched to melancholic in 25% (8/32) of cases. Differences in the course of melancholic and non-melancholic depression were very minor.
Conclusions. The descriptive validity of the DSM-IV melancholic features specifier may be questionable in MDD. There appear to be no major differences in current co-morbidity, or course of depression between melancholic and non-melancholic patients. The consistency of DSM-IV melancholic features across episodes appears weak.
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