Free-communication

www.elsevier.com/locate/jad

Journal of Affective Disorders 78 (2004) S71–S97

Free-communication

doi:10.1016/j.jad.2003.12.006

Name R. Michael Bagby

Address Centre for Addiction and Mental Health, 250 College Street, Toronto M5T 1R8, Canada

Email [email protected]

Authors R. Michael Bagby, Margarita B. Marshall, Andrew G. Ryder, Deborah R. Schuller

Affiliations Centre for Addiction and Mental Health; University of Toronto

Conflict No

Abstract ID 117

Type Free Communication

Title The discriminant validity of the depressive personality disorder: Relations to personality disorders

and dimensional traits

Keywords Personality disorders; Depressive personality disorder; Personality dimensions

Abstract Objectives: Depressive personality disorder (DPD) is listed in the DSM-IVas one of the ‘‘Disorders for

Further Study.’’ One area of investigation centers on its overlap and relation to other personality

disorders (PDs) in the main text of DSM-IV. In this investigation we examined: (1) the rates of co-

morbidity of DPDwith the 10 PDs in the main text of DSM-IVand (2) the convergent and discriminant

validity of DPD in its relation with 30 facet traits of the Five-Factor Model of personality (FFM).

Methods: Participants were 497 subjects (263 women, 234 men) selected from a psychiatric sample

assessed on an outpatient basis. The mean age of participants was 39.90 years (S.D. = 12.38). The

Structured Clinical Interview for DSM-IV Personality Disorders Questionnaire (SCID-II; First et al.,

1997) was used to assess PDs. The Revised NEO Personality Inventory (NEO PI-R; Costa and

McCrae, 1992) was used to assess the FFM personality dimensions and consists of self-report items

answered on a five-point scale. Each domain scale also consists of six lower-order facets scales;

there are five domain and 30 facet scales on the NEO PI-R.

Results: A total of 97 (19.5%) of the participants met diagnostic criteria for at least one of the 10 PDs

in the main text of DSM-IV, and 45 (9.0%) met criteria for DPD. Of the 45 patients who met criteria

for DPD, 28 (62.2%) also meet criteria for one or more main text PDs. The individual disorders with

the highest overlap rates were avoidant (20.0%), borderline (20.0%), obsessive-compulsive (20.0%)

and paranoid (15.6%). Costa and Widiger (2002) proposed that DPD translates into four trait facets

from the FFM—anxiety, depression, self-consciousness and (low) tendermindedness. A series of

regression analyses was performed to examine the convergent and discriminant validity of the DPD

construct using these facets. Linear regressions were performed. If the DPD is distinguishable from

the other PDs, then the four facets uniquely associated with it should produced larger R2 adj values

for DPD compared to the other PDs. The four-facet predictor set accounted for a significant amount

of variance in DPD SCID-II SR scores, F(4,492) = 183.32, P < 0.001, as well as 8 of the 10 main text

PD scores, including paranoid; schizotypal; schizoid; narcissistic; borderline; avoidant; dependent;

and obsessive-compulsive, (all F-values>7.00 (df = 4,492); all P’s < 0.001). The R2 adj value for the

F1

four facets was larger for DPD than it was for the 9 of the 10 disorders, z < 1.95, P < 0.05; the sole

exception was avoidant PD.

Conclusion: The results suggest that although there is some overlap between DPD and the other PDs,

the overlap is not excessive. There is further evidence of discriminant validity for DPD as the four

facets thought to be specifically related to DPD do not correlate as highly with other the other PDs.

The exception here is with avoidant and borderline PDs.

Free-communicationS72

F2

Name Ana Costa

Address Av gago Coutinho, 55 Francelos Av Antonio Sergio Francelos, 4405 700 Gulpilhares, Portugal


Authors Ana Costa, Maria Constanc�a Paul

Affiliations ICBAS, University of Oporto

Conflict No

Abstract ID 113


Title Semi-structured clinical interview for diagnosis of depression in elderly

Keywords Diagnose; Depression; Elderly; Semi-structure interview

Abstract Objectives: The aims of this study are: (1) Present an instrument specifically designed for the

diagnostic of depression in Portuguese elderly that can be used as a guide during a clinical interview

‘‘Semi-Structural Clinical Interview for Diagnosis of Depression in Elderly-ECDDI’’. (2) Present the

main results of two pilot studies concerning two different versions of the instrument.

Methods: Depression in the Portuguese elderly frequently goes unnoticed and untreated since

commonly used depression scales fail to focus on early symptom recognition, do not address

contextual factors, and lack adequate psychometric testing in Portuguese elders. Several instruments

have been recently developed to diagnose better and in a more efficient way late life depression. A

great scientific investment has been devoted to this theme a little all over the world but the absence

of instruments validate for Portugal make particularly necessary a standardized diagnostic instrument

for Portuguese geriatric population.

Results: The ECDDI was tested in a population of institutionalized elders and in a population of old

people living in the community. Participants in the first pilot study were 105 residents of a nursing

home (Lar de Monte dos Burgos, in Porto), mean age 78.7 years, range 65–93, of which 51.4% were

male. Results showed a good reliability of the symptoms scale in the interview (alpha de

Cronbach = 0.88). In the second pilot study participants were 106 individuals living in the

community, mean age 77.72 years, range 65–93, of which 46.2% were male. Results also showed a

good fidelity of the symptoms scale in the interview (alpha de Cronbach = 0.90).

Conclusion: The ECDDI was found to have a good reliability for the diagnosis of depression in the

elderly. At present an improved version of the instrument is one main objective of a doctoral

program started in February last.

Free-communication S73

F3

Name Peter Farvolden

Address Clinical Research Department, Centre for Addiction and Mental Health, 250 College Street, M5T

1R8 Canada


Authors Peter Farvolden, R. Michael Bagby

Affiliations Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto

Conflict No

Abstract ID 118


Title Behavioral activation and inhibition systems, the five factor model and their association with

depression severity and response to treatment

Keywords Behavioural activation; Inhibition; Neuroticism; Extraversion; Depression; Severity; Treatment

outcome

Abstract Objectives: Depression has been hypothesized to be associated with abnormalities in the behavioural

activation (BAS) and behavioural inhibition (BIS) systems. More specifically, depressed individuals

are hypothesized to exhibit underactive BAS and overactive BIS functioning. Kasch et al. (2002)

recently reported that self-reported levels of BAS functioning are related to depression severity and

worse 8-month outcome. Overall, the results suggested that BAS dysregulation exacerbates the

presentation and course of depressive illness. Given the conceptual overlap between the constructs of

BIS/BAS and other personality constructs such as Extraversion (E) and Neuroticism (N), it is

important to examine the discriminant and convergent validity of BIS/BAS as compared to the E and

N dimensions from the FFM. Given that N and E have previously demonstrated an association with

depression severity and treatment outcome, it is important to determine whether or not the BIS/BAS

scales demonstrate incremental validity with respect to N and E in predicting symptom severity and

treatment outcome.

Methods: Self-report BIS/BAS and FFM data were examined in 90 depressed individuals

participating in a randomized controlled trial of cognitive behavioural therapy, interpersonal therapy

and pharmacotherapy for major depressive disorder. Depression severity and response to treatment

were assessed at intake and following 16 weeks of treatment using the Beck Depression Inventory-II

(BDI-II) and the Hamilton Rating Scale for Depression (HAM-D). Correlational techniques were

employed to examine the relations between BIS/BAS (Carver and White, 1994) and N and E.

Regression analysis was used to examine the relations between the BIS/BAS scales and N and E in

the prediction of depression severity and treatment outcome.

Results: In contrast to the findings of Kasch et al. (2002), BAS was not significantly associated with

either baseline symptom severity or treatment outcome. However, there was a small but significant

association between N and baseline symptom severity and treatment response. In a hierarchical

regression model, neither BIS nor BAS added significant incremental validity in the prediction of

treatment outcome beyond the contribution of N. However, there was statistical trend for N to predict

beyond the contribution of BIS/BAS.

Conclusion: The results from this study are consistent with those previous investigations which have

shown N to be associated with baseline severity and treatment outcome. In comparison we were

unable to replicate a previous study looking at BIS and BAS. It is particularly instructive to note that

N predicted beyond the contribution of BIS and BAS, suggesting that it is a predictor independent of

the modest contribution of BAS.


F4

Name Tomas Hajek

Address Department of Psychiatry, Prague Psychiatric Center and Charles University, Dalhousie University,

Ha 181 03 Praha 8, Czech Republic


Authors Tomas Hajek, Milan Kopecek, Martin Alda, Cyril Hoschl

Affiliations Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada

Conflict No

Abstract ID 58


Title Do endogenous corticosteroids change hippocampal volume in men?

Keywords Hippocampus; Corticosteroids; Stress disorders

Abstract Objectives: Decreased hippocampal volume often reported in disorders associated with stress or

elevated levels of cortisol are considered a result of putative neuronal damage mediated by

corticosteroids. If corticosteroids are sufficient to cause neuronal damage in human subjects, then

patients treated with these hormones should exhibit decrease of hippocampal volume during

treatment. This is the first prospective study investigating hippocampal volume and function in

human patients treated with corticosteroids.

Methods: Fourteen subjects treated with corticosteroids underwent neuropsychological tests at the

beginning of treatment and after 2 and 6 months on corticosteroids. In a subsample of nine subjects

we also measured hippocampal volume using MRI.

Results: There was a trend towards worsening in Auditory Verbal Learning Test during treatment.

We did not observe any changes in hippocampal volume after an average of 73 days of treatment

with mean dose of 30.99 mg of prednisone per day, neither during average of 192.5 days of

treatment with mean dose of 24.2 mg of prednisone per day.

Conclusion: We did not find macroscopic changes of hippocampal volume during treatment with

corticosteroids. However, microscopic changes leading to decline in hippocampus mediated memory

functions cannot be ruled out.

F5

Name Tetsuo Harada

Address Laboratory of Environmental Physiology, Faculty of Ozucho, 10-41 Room 413 Residence for staffs

of Ko Kochi 780-8520, Japan


Authors Tetsuo Harada, Masaaki Hirotani, Hitomi Takeuchi, Shoko Fujita, Kazuko Shibuya

Affiliations I would like to participate in ISAS in this occasion

Conflict No

Abstract ID 66


Title Shifting to evening-type of Japanese infants promoting some problems in mental health

Keywords Morningness–eveningness; Japanese infants; Effects of mothers; Depressed mood; Irritating

Abstract Objectives: Diurnal rhythms of Japanese infants are supposed to be shifting to ‘‘evening-type’’ due

to so-called ‘‘24 hours society’’ going on currently. For example, convenience stores and specific

restaurant for family use are open for 24 h and parents can go there to buy something and enjoy meal

with their children. This study aims, first, to examine current diurnal rhythm of Japanese infants,

and, second, to clarify whether diurnal rhythms of mothers affect morningness–eveningness (M–E)

preference of infants and finally to analyze the relationship between M and E preference and mental

symptoms of infants.

Methods: Japanese version of M–E questionnaire originally constructed by Torsvall and Akerstedt

(1980) and another original questionnaire including questions on sleep habits (e.g. Bedtime, wake-

up time, subjective sleep latency) and two questions on mental symptoms: ‘‘How frequently does

your child get angry because of only a little bit trigger in usual life?-(1) often, (2) sometimes, (3)

rarely, (4) not at all’’ and ‘‘How frequently does your child have depressed mood in usual life?–(1)

often, (2) sometimes, (3) rarely, (4) not at all’’, were administered, in June, 2003, to 643 children and

their parents (593 mothers and 50 fathers) aged 0–6 (they answered the two questionnaires both on

themselves and their children) attending one of nine municipal nursery schools in Kochi city.

Results: Average and S.D. ofM–E scores were 19.27F 3.51 (female infants: 19.85F 3.58; male ones:

19.42F 3.60) and their parents (mainly mothers) show very similar distribution of M–E scores to that

of their infants. Their mothers were much more morning-typed (18.89F 8.49) rather than women

students aged 18–32 years living in Kochi (14.39F 3.52, n = 252) (Mann–Whitney U-test:

P < 0.001). M–E scores of the infants do not show standard distribution, but distributes with two

peaks at 18 and 21–22 points. The lower peak of 18 point corresponded with the average value shown

by elementary school children aged 10–11 years in 1998 (Harada and Takeuchi, 2001). Strong positive

correlation between M and E scores of the infants and mothers were shown (Pearson’s correlation test:

r = 0.450, P < 0.001). About 20% of mothers did not decide bedtime of their children, and infants

without bedtime discipline are significantly evening-typed than children whose bed time were decided

by their mothers (Mann–Whitney U-test, P= 0.001). There were negative correlations between the

frequency of the ‘‘depressed mood’’ or the ‘‘angry triggered’’ to occur and M–E scores (Kruskall–

Wallis test, P= 0.002 for depressed mood; P= 0.003 for angry triggered).

Conclusion: Bedtime discipline and diurnal rhythm of parents can affect diurnal rhythms of their

children. Shifting to evening type by Japanese infants can be dangerous to induce some kinds of

‘‘affective disorders’’ like as depressed mood or easy triggering of being angry.


F6

Name Jochanan Huyser

Address Psychiatrische Centrum, Tafelbergweg 25 1105BC, The Netherlands


Authors Bente C. Appelhof, Jochanan Huysera, Mijke Verweijb, Jantien P. Brouwerc, Richard van Dyckb,

Eric Fliersc, Witte J.G. Hoogendijkb, Aart H. Schenea, Jan G.P. Tijssend, Wilmar M. Wiersinga

Affiliations aDepartment of Psychiatry, Academic Medical Centre, University of Amsterdam; bDepartment of

Psychiatry, VU University Medical Centre, Amsterdam; cDepartment of Endocrinology and

Metabolism, Academic Medical Centre, University of Amsterdam; dDepartment

Conflict No

Abstract ID 110


Title Posttreatment dexamethason-CRH test response parameters and occurrence of relapse of major

depression

Keywords Depression; Dexamethason CRH-test; Corticol; Prediction; Relapse

Abstract Objectives: Approximately 50% of patients diagnosed with major depressive disorder will

experience a recurrent course of illness. For patients who have had two episodes of major

depression, the chance of recurrence even rises to 60–90%. Prevention of relapse is an important

goal in the management of major depression. However, knowledge of pathogenic mechanisms and

predictors of relapse is limited at present. Persistent high cortisol response in the combined

dexamethasone/corticotropin-releasing hormone (DEX/CRH) test has been associated with relapse

in patients with remitted depression. The goal of the present study was to test this association.

Methods: All patients approached for participation had previously taken part in a randomized,

double-blind, placebo-controlled clinical trial investigating the efficacy of triiodothyronine (T3,

active thyroid hormone) addition to paroxetine in the treatment of depression. Patients fulfilled

criteria for major depressive disorder according to the Structured Clinical Interview for Axis I DSM-

IV Disorders (SCID) and had a baseline score of at least 16 on the 17-item Hamilton Rating Scale for

Depression (HRSD) before treatment. The DEX/CRH test was obtained before the beginning and

after 8 weeks of treatment. Out of the 106 patients participating in the T3 addition trial, 47 persons

(44%) had responded (defined as a 50% decrease in score on the HRSD) to treatment within the 8

weeks duration of the study. Relapse was assessed by telephone interviews using the SCID section

mood disorders, carried out 8–38 months after discharge from the T3 addition trial. DEX/CRH test

results of relapsed and non-relapsed patients were compared. A Cox regression analysis was

performed to identify predictors of relapse.

Results: Forty-five out of 47 (96%) unipolar depressed patients who had responded favorably to

8 weeks of outpatient treatment with T3 or placebo in addition to paroxetine 30 mg, were available

for follow-up. The follow-up interview took place 8–38 months (mean: 22 months) after discharge

from the treatment protocol. Of these 45 remitted patients, 23 (51%) had remained without relapse

during the follow-up period, while 22 (49%) had relapsed. Thirteen patients relapsed within the first

6 months after treatment. Maximal ACTH and maximal cortisol levels, as well as delta ACTH and

delta cortisol levels in response to CRH, were significant higher among the patients who relapsed.

However, in the Cox-regression analysis neither of the DEX/CRH test parameters reached

significance to predict relapse.

Conclusion: The link between a persistent high cortisol response in patients with remitted depression

and relapse was confirmed, supporting a role for hypothalamic–pituitary–adrenocortical (HPA) axis

dysregulation in the course of major depression. However, this association lacks the strength to be of

clinical value for the prediction of relapse in the treatment of depression.


F7

Name Erkki Isometsa

Address Department of Mental Health and Alcohol Research, Mannerheimintie 166 FIN 00300, Finland


Authors Tarja K. Melartina, b, Heikki J. Rytsalaa, b, Ulla S. Leskelaa, b, Paula S. Lestela-Mielonena, b, T.

Petteri Sokeroa, b, Erkki T. Isometsaa

Affiliations aDepartment of Mental Health and Alcohol Research, National Public Health Institute, Helsinki,

Finland; bDepartment of Psychiatry, HUCH, Peijas Hospital, Health Care District of Helsinki and

Uusimaa, Vantaa, Finland

Conflict No

Abstract ID 49


Title Severity and comorbidity predict episode duration and recurrence of DSM-IV major depressive

disorder

Keywords Depression; Outcome; Comorbidity; Recurrence; Episode duration

Abstract Objectives: Information on the naturalistic outcome of major depressive disorder (MDD) is

important in developing rational clinical practices. The aim of the study was to determine the

outcome of MDD in a modern secondary-level psychiatric setting, and the influence of comorbidity

plus psychosocial factors on the outcome of MDD.

Methods: The Vantaa Depression Study (VDS) is a prospective, naturalistic cohort study of 269

secondary-level care psychiatric out-and inpatients, with a new episode of DSM-IV MDD,

interviewed with SCAN and SCID-II, collected between 1 February 1997, and 31 May, 1998, and

interviewed again at 6- and 18-months. The exact duration of the index episode and the timing of

relapses/recurrences were examined using a life chart.

Results: The median time with full MDE criteria was 1.5 (95% CI, 1.3–1.7), and to full remission

8.1 (95% CI, 5.2–11.0) months after entry. During the follow-up 38% of patients had a recurrence.

Although numerous factors predict outcome of MDD to some extent, severity of depression and

current comorbidity were the twomost important predictors of longer episode duration and recurrence.

Conclusion: The course of MDD in modern psychiatric settings remains unfavourable. Any

estimates of duration of depressive episodes and rates of recurrence are likely dependent on the

severity of depression and level of comorbidity. At least among mostly outpatients with MDD in

medium-term follow-up, severity of depression and comorbidity appear more useful predictors of

recurrence than number of prior episodes. These factors should influence clinical decision-making

regarding the need for maintenance therapy.


F8

Name Matthew Keller

Address 525 East University, Ann Arbor, MI 48109, USA


Authors Matthew C. Keller, Randolph M. Nesse

Affiliations University of Michigan

Conflict No

Abstract ID 40


Title Subtypes of low mood provide evidence for its adaptive significance

Keywords Depression; Low mood; Evolution

Abstract Objectives: A widely recognized global function of low mood is to reduce effort and to facilitate

disengagement when organisms pursue unreachable goals. While this framework has much to offer,

it also seems likely that specific kinds of fitness losses and failing pursuits recurred often enough in

the course of evolution to shape partially differentiated subtypes of low mood similar to the subtypes

of anxiety that protect against different kinds of danger. To test this hypothesis, we looked to see if

the symptoms of low mood vary depending on what precipitated the low mood, and if the variation

matched expectations of what would be specifically useful in each kind of situation.

Methods: Three hundred and thirty seven participants who experienced low mood within the last 12

months wrote accounts about what most likely caused their low mood and filled out the CES-D

depression inventory. Judges blindly coded the written accounts into one of six precipitant

categories. Seven symptom scales were derived from the CES-D.

Results: The specific symptoms of low mood varied predictably and significantly depending on the

precipitant. Those arising from social losses—death of a loved one, romantic break-ups, and social

isolation—led to higher levels of crying and pain. Failed goals, stress, and the wintertime led to

higher levels of fatigue and pessimism.

Conclusion: These results suggest that natural selection may have shaped not only a generic state of

low mood but also partially differentiated subtypes designed to cope with specific situations

associated with fitness losses among ancestors.


F9

Name Ahmed Abdel Khalek

Address Faculty of Social Sciences, Department of Psychology, Kuwait University, 71962 Kaifan, Kuwait


Authors Ahmed Abdel Khalek

Affiliations Kuwait University

Conflict Yes

Abstract ID 21


Title Prevalence of insomnia and its consequences among adolescents in Kuwait

Keywords Insomnia; Epidemiology; Prevalence; Adolescents; Kuwait

Abstract Study objectives: To examine the psychometric characteristics of a short scale to assess insomnia

complaints and its consequences; to estimate the prevalence rates of reported insomnia; and to

explore the gender differences in reported insomnia.

Methods: 5044 male and female non-clinical secondary school students in the State of Kuwait

participated. Their ages ranged from 14 to 19 years. Insomnia scale (IS) comprising 12 items was

administered in group sessions. It has acceptable test–retest and alpha reliabilities. Two factors were

disclosed: consequences of insomnia and difficulty initiating and maintaining sleep. Point prevalence

rate was computed as the summation of the percentages of responses in the two options: ‘‘Much’’

and ‘‘Very much’’ on each item during the past month.

Results: The prevalence of the 12 IS items ranged from 6.4% to 31.7% in boys, and between 6.5%

and 35.9% among girls. The highest reported insomnia complaint was from early morning

awakening, i.e. 31.7% in boys, and 35.9% in girls. It was found that 14.6% of boys and 20.3% of

girls reported difficulty initiating sleep, while 8.6% of boys and 15.7% of girls reported difficulty

maintaining sleep. Girls have higher mean scores in most of the IS items.

Conclusions: Adolescents in the present sample have reported high rates of insomnia. There is a

great need to agree upon the methodology, especially the assessment tool, on the epidemiology of

sleep disorders research.

F10

Name Christine Helena Kuehner

Address Central Institute of Mental Health, PO Box 122120, 68072 Mannheim, Germany


Authors Christine Helena Kuehner

Affiliations Central Institute of Mental Health, Mannheim, Germany

Conflict No

Abstract ID 20

Type Free-communication

Title The coping with depression course and its variants: An updated meta-analysis

Keywords Coping with Depression Course; Depression; Meta-analysis; Treatment

Abstract Objectives: The Coping with Depression Course is a psychoeducative group program for the

treatment and prevention of unipolar depression. During the last years, variants of the program for

use in different settings have been developed. The present meta-analysis summarizes existing

efficacy studies on the program.

Methods: A total of 24 studies from German- and English-speaking countries with more than 1000

clients were included. Effects are mainly presented as pre-post improvement effect sizes.

Results: With regard to symptomatic improvement, a large effect resulted for clients within the

clinical range of depressed symptomatology at pretest (ES = 1.45) while, expectedly, that for

samples from the subclinical range was lower (ES = 0.65). Less than 30% of improvement

variance was attributable to placebo effects. Among the clinically depressed samples, self-

referred clients displayed larger improvement effects than study-referred clients. Treatment effects

were stable at least over a medium-term post-intervention period.

Conclusion: Requirements for more methodologically sound studies on the program and its variants

in different settings are underscored, which should allow for further outcome criteria, comparisons

with other active treatments, and health economic aspects of such interventions.


F11

Name Ma. Asuncion Lara

Address Calzada Mexico Xochimilco, 101 San Lorenzo Huipulco Tlalpan 14370, Mexico


Authors Ma. Asuncion Claudia Navarro, Laura Navarrete

Affiliations Ramon de la Fuente, National Institute of Psychiatry

Conflict No

Abstract ID 50


Title Influence of life events and social support on a psychoeducational intervention for women with

depressive symptoms

Keywords Depression; Psychoeducational intervention; Women; Social support; Life events

Abstract Objectives: Studies reviewing the effects of preceding life events and life events that occur during

the follow-up period of treatment on depression have shown mixed results: some have found no

effect while others have found that the occurrence of negative events predict a worse outcome. The

aim of this study is to investigate the influence of social support, adverse life events and other socio-

demographic variables on depression levels, during the pre-treatment, post-treatment (15–30 days)

and follow-up (4 months) stages of a psycho-educational intervention for depression.

Methods: Two hundred and fifty-four women with depression were selected from those seeking

treatment at a primary health institution. Treatment consisted of a psychoeducational intervention

that proved effective in reducing depression symptoms in a comparative study with pre-, post- and

follow-up assessments (Lara et al., 2003 a,b). These symptoms were evaluated using the CES-D

(Radloff, 1977), while life events and social supported were evaluated on scales specifically

designed to measure these aspects (Lara, 2002). Depressive symptoms were measured on the three

occasions; life-events and social support in pre- and follow-up.

Results: Hierarchical regression analyses were carried out to test various models: (1) Effect of

variables: life events, social support and socio-demographic factors in pre-treatment depression

symptoms. The model was significant (P= 0.000) and the first two variables and age fit the model.

(2) Effect of the same predictive variables on post-treatment depression. The model was significant

(P= 0.001); with social support and life events fitting the model. (3) Effect of the same variables on

depression during follow-up. The model was significant (P= 0.000); educational attainment and

social support fit the model. (4) Effect of social support and life events on depression, all measured

during follow-up. The model was also significant (P= 0.000) and both variables fit the model. In

models 2 and 3, when pre-treatment depression was also introduced as a predictive variable, the

former was significant but the others were not.

Conclusion: The results support previous findings that show that the presence of life events and the

lack of social support reduced the possibility of improvement as a result of treatment. It seems that

the effect of pre-treatment social support and life events on post-treatment and follow-up depression

symptoms is confirmed by their high correlation with pre-treatment depression. These findings can

be translated into options for interventions in depression in the future, such as assigning more time to

focus on ways of handling life events more effectively and to secure an increase in social support.

Further research is needed to advance our understanding of the factors that determine when an event

will lead to depression.

(Lara (2002)) An intervention proposal for women at risk of depression in primary care. Doctoral

Dissertation. Health Sciences. National University of Mexico. Lara et al. (2003a). Outcome of two

levels of intervention in low-income women with depressive symptoms. American Journal of

Orthopsychiatry; 73(1): 35–43. Lara, et al. (2003b) Two levels of intervention in low-income

women with depressive symptoms. Compliance and programme assessment. International Journal of

Social Psychiatry; 49(1): 43–57.)


F12

Name Joseph Levine

Address Beersheva Mental Health Center, Hatzadick Myrusha Beersheva Mental Health Center, Hatzadick

Myrush 48611, Isreal


Authors J. Levine, R.H. Belmaker

Affiliations Ben Gurion University of the Negev, Faculty of Health

Conflict No

Abstract ID 47


Title Controlled trials of inositol in psychiatry

Keywords Myo-inositol; Major depression; Anxiety disorders

Abstract Objectives: Myo-inositol is a simple polyol precursor in the phosphatydil-inositol second messenger

system. We present here a summary of clinical studies with Myo-inositol in a variety of psychiatric

disorders.

Methods: Double blind studies of Myo-inositol (12–18 g/day) versus placebo are presented.

Results: Oral myo-inositol (12–18 g/day) has shown beneficial effect in placebo-controlled studies

of major depression, panic disorder, and obsessive-compulsive disorder, and preliminary data

suggest it also may be effective in bipolar depression and bulimia. Several mechanism of actions

were offered for inositol therapeutic effects including the correction of shortage of Myo-inositol

brain levels (Simon et al., 1997), its effects on 5-HT-2 receptors (Einat et al., 2001), its anti-

oscillatory effect on monoaminergic systems (Antelman et al., 2000) and its ability to increase brain

phosphatidylethanolamine plasmalogen levels, a phopholipid reported to enhance membrane fusion

(Pettegrew et al., 2001) among others.

Conclusion: Myo-inositol seems to be effective in affective and anxiety disorders. The fact that no

drug company can patent its use and finance further research with this orphan drug should not

discourage further exploration of its therapeutic role in psychiatric disorders.


F13

Name Rachel Maayan

Address 3 Dvora-Hanevia str., Petach-Tikva Psychobiology, FMRC, Campus Beilinson, Petach-Tikv 49427,

Israel


Authors Rachel Maayan, Oren Morad, Gal Yadid*, Pnina Dorfman, Abraham Weizman

Affiliations Biological Psychiatry, Felsenstein Medical Research Center and Sackler Faculty of Medicine, Tel

Aviv University; Rabin Medical Center, Beilinson Campus, Petah Tikva; Faculty of Life Sciences,

Bar Ilan University, Ramat Gan, Israel

Conflict No

Abstract ID 25


Title High levels of DHEAS attenuate the anti depressive effect of ECS in an animal model of depression

and ECT in depressed patients

Keywords ECT; ECS; DHEAS; Depression; Neurosteroids

Abstract Objectives: To examine whether a high basal level of dehydroepiandrosterone sulfate (DHEAS)

contributes to the resistance to electroconvulsive therapy (ECT). We have previously observed that

high basal serum DHEAS levels in depressed patients negate effects of ECT.

Methods: Flinder sensitive line (FSL) rats, a genetic animal model of depression, were pretreated

with DHEA (to increase their DHEA and DHEAS levels both in serum and brain) and then exposed

to electroconvulsive shock (ECS). DHEA, DHEAS, pregnenolone, corticosterone, adrenocortico-

tropic hormone (ACTH) levels and liver steroid sulfotransferase activity, were assessed. Depressive

behavior was measured by the length of immobility in swim test.

Results: We found that while administration of DHEA and ECS alone demonstrated an

antidepressive effect, this effect was nullified when they were combined. Furthermore, rats

pretreated with DHEA responded to ECS differently than untreated rats on all hormonal and

enzymatic parameters.

Conclusion: The lack of behavioral response to ECS noted in rats pretreated with DHEAwas similar

to our results in humans with high circulating DHEA and DHEAS levels. We conclude that basal

high levels of DHEAS may be the cause of resistance to ECT in depressed patients.


F14

Name Tariq Mahmood

Address Malham House, 25 Hyde Terrace, Leeds LS2 9LN 7 Derwent Drive, Leeds LS16 8JD LS2 9LN, UK


Authors T. Mahmood, T. Silverstone

Affiliations Universities of Leeds and Toronto

Conflict No

Abstract ID 27


Title Mood, migraine and 5-HT

Keywords Bipolar disorder; Migraine; 5-HT; Neuroendocrine; Sumatriptan

Abstract Objectives: This free communication will provide a synthesis of our work, which looks into the

association of bipolar disorder with migraine and explores the role of serotonin as a possible

underlying biological link.

Methods: We looked into the prevalence of migraine in patients registered with Dunedin Bipolar

Register by carrying out a postal survey. A neuroendocrine study using a 5-HT1D agonist,

sumatriptan, was then carried out in cases of bipolar disorder with migraine, bipolar cases, migraine

patients, and healthy controls. Growth hormone response was used as the measure of serotonergic

function.

Results: (1) Migraine was found to be five times more prevalent in male bipolars and twice more

common in female bipolars. (2) Growth hormone response was found to be blunted in cases of

bipolar disorder with migraine. (3) We were also able to examine the growth hormone response in

bipolar patients with a manic onset and those with a depressive onset. We found the GH response to

be blunted in those with manic onset.

Conclusion: Bipolar disorder associated with migraine seems to be a subtype with an underlying

abnormality of the serotonergic system/5-HT1D receptor.

F15

Name Simon Naji

Address Department of Mental Health, University of Aberdeen, Institute of Medical Sciences, AB25 2ZD

UK


Authors Simon Naji, Jennifer Gibb, John Eagles, Ross Hamilton

Affiliations Department of Mental Health, University of Aberdeen, Scotland, UK

Conflict No

Abstract ID 37


Title The role of practice nurses in the identification and management of depressed patients in primary

care: Knowledge, attitudes, current practice and educational needs

Keywords Depression; Primary care nurses; Training

Abstract Objectives: To survey practice nurses (PNs) working in Scottish general practice to determine: (a)

Their current practice with respect to the number of depressed patients they identify, how these

patients are managed thereafter, and which professionals PNs consult about depressed patients. (b)

Their attitudes to depressed patients and the management of depression. (c) Their perceptions of their

own knowledge about the detection and management of depression. (d) Their views on education

and training about depression.

Methods: National postal survey of PNs in Scotland.

Results: 442 (56%) PNs, representing 72% of sampled practices returned completed questionnaires.

85% had at least one mental health placement during their general training, but more than 40% did

not describe this as a good experience. PNs were seeing around 70 patients a week, of whom they

believed an average proportion of 5% to be depressed, with more recently qualified PNs identifying

higher proportions. Almost all reported being asked about depression by patients. Only 18% felt able

to deal effectively with depressed patients, with higher proportions among those who had

experienced good training placements. Over 90% of those who felt unable to deal with depressed

patients reported lacking knowledge and training. In response to questions derived from the Defeat

Depression Campaign, most PNs did not express particularly negative views about depression, but

their responses indicated significant gaps in their knowledge. Involvement in the assessment and

management of depressed patients was infrequent. Action taken in respect of patients suspected of

being depressed was normally to refer to a GP, although nearly 50% said they sometimes counsel

patients, and 15% said they would do nothing. There was very little contact with mental health

professionals. Since qualification, only 25% had attended any mental health training, and those that

had felt more able to deal with depressed patients. 83.5% would attend future courses under

favourable circumstances, but only 47.5% believed metal health courses to be a priority for PNs, and

it received the lowest rating among 5 training options. Responses to the depression attitude

questionnaire revealed significant professional unease about working with this patient group and

additional gaps in knowledge, but also that most PNs agree that they are seeing increasing numbers

of such patients and that they PNs could be useful in supporting such patients.

Conclusion: There are significant weaknesses in PNs’ training experiences and concomitant gaps in

their knowledge of depression and its treatment. This is associated with feeling poorly equipped to

deal with depressed patients, and significant professional unease. There is a need to develop

appropriate training interventions and to explore ways of providing incentives for PNs to acquire the

necessary knowledge and skills. If PNs are to fulfil their potential to identify and support the

management of depressed patients in primary care, nationally accredited courses should be

developed and evaluated.


F16

Name Veronica O’Keane

Address Section of Perinatal Psychiatry, Institute of Psychiatry, de Crespigny Park SE5 8AF, UK


Authors Annamaria Meaney, Veronica O’Keane

Affiliations Institute of Psychiatry, London SE5 8AF

Conflict Yes study funded by an unrestricted research grant from Eli Pharmaceuticals, UK

Abstract ID 120


Title Evidence that antipsychotic drugs cause osteoporosis in young women with schizophrenia

Keywords Schizophrenia; Prolactin; Sex hormones; Osteoporosis; Antipsychotic medication

Abstract Objectives: Schizophrenic illness is associated with high rates of osteoporosis, the aetiology of

which remains obscure, but which may be related to the prolactin-raising (PR) properties of anti-

psychotic medication. All conventional antipsychotic drugs cause hyperprolactinaemia, secondary

to dopamine-2 receptor blockade; whereas a limited number of newer atypical antipsychotic

agents do not. Possible relationships between antipsychotic medication, endocrine variables and

bone mineral density (BMD) were examined in this study.

Methods: Premenopausal women with a diagnosis of schizophrenia who had received exclusively

either PR antipsychotics (n= 26), or olanzapine (prolactin-sparing: n= 12), participated in the study.

Half of the subjects in the PR group were being treated with conventional, and half with atypical,

antipsychotic drugs. Lumbar spine and hip BMD were measured using a DEXA scan. Among the

endocrine variables assessed were prolactin and sex hormone axis measures.

Results: Prolactin levels and rates of osteoporosis and osteopenia were significantly higher in the PR

group, compared to the olanzapine group, and were correlated with measures of hypogonadism.

Within the PR group, those taking atypical medication had higher levels of prolactin, lower levels of

sex steroid hormones and more severe bone loss; than the group taking conventional antipsychotic

medication.

Conclusion: These findings suggest that the high rates of osteoporosis associated with schizophrenia

may result from hypogonadism secondary to antipsychotic-induced hyperprolactinaemia: a process

that is more pronounced in those taking atypical PR antipsychotics. These findings suggest that PR

properties of the different atypical antipsychotic drugs should be taken into account in the risk

balance equation when considering the choice of antipsychotic medication.


F17

Name Veronica O’Keane

Address Section of Perinatal Psychiatry, Institute of Psychiatry, de Crespigny Park SE5 8AF, UK


Authors Veronica O’Keane

Affiliations Institute of Psychiatry, London SE5 8AF

Conflict Yes study funded by an unrestricted research grant from Cyberonics, Europe

Abstract ID 121


Title Changes in hypothalamic–pituitary–adrenal axis measures following 3 months treatment with

vagus nerve stimulation therapy

Keywords Vagal nerve stimulation therapy; Depression; HPA axis; CRH challenge

Abstract Objectives: Vagus nerve stimulation (VNS) is a novel physical therapy for resistant depression. HPA

axis abnormalities are common in major depressive disorder (MDD), some of which have been

found to normalise following treatment. This study compared ACTH and cortisol responses to CRH

challenge in a group of patients with resistant depression prior to and following 3 months of VNS

therapy, and a group of healthy control subjects. Cerebrospinal fluid (CSF) levels of CRH and

5HIAA and were compared at the two time points in the test group only.

Methods: The study used an intra-group, repeated measure design. Subjects were eligible for

inclusion if they were currently suffering from DSM-IV-defined MDD, and had either a history of a

current episode lasting for at least 2 years, and were unresponsive to at least two classes of

antidepressant medications; or if they had suffered from at least three episodes in the last 2 years.

Eleven subjects underwent a CRH challenge test using ovine CRH (100 Ag) in the 2 weeks

preceeding surgical implantation of the VNS device. CSF was removed following lumbar puncture

prior to anaesthetic. Both procedures were repeated 12 weeks following active VNS therapy. Among

the clinical measures used to assess depression at both time points were the Hamilton depression

rating scale (HAMD) and the MADRAS.

Results: There were significant reductions in depression scores over the study period. ACTH

responses to CRH in the depressed group prior to implantation did not differ from the healthy group,

but decreased significantly from both measures following VNS treatment. There were no differences

in cortisol responses between the depressed pre-implant, the control or post-treatment groups. CSF

measures of CRH increased from pre-to post-implant time points.

Conclusion: These results suggest that short-term treatment with VNS therapy, associated with

modest clinical improvement, is accompanied by increased central CRH secretion and a consequent

reduction in ACTH responses to CRH.


F18

Name Albertine J. Oldehinkel

Address Department of Psychiatry, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The

Netherlands


Authors A.J. Oldehinkela,b, A.F. de Wintera, F.C. Verhulstb, J. Ormela

Affiliations aDepartment of Psychiatry, University of Groningen, The Netherlands; Department of Child and

Adolescent Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands

Conflict No

Abstract ID 57


Title Consequences of environmental adversity for psychobiological vulnerability for internalizing

disorders in a Dutch sample of preadolescents

Keywords Internalizing disorders; Life events; Self-esteem; Temperament; Cortisol; Preadolescence

Abstract Objectives: Many studies have reported that adverse circumstances in childhood are predictive of

anxiety or depressive disorders later in life. However, it is not well understood through which

mechanisms early adversity exerts its influence. Whereas many adverse experiences trigger transient

psychological reactions at the most, others have long-term consequences for mental health and

adaptation (Van Os and Jones 1999; Veijola et al., 1998; Weiss et al., 1999). The effects of adverse

experiences may be carried forward to later phases of development via two mechanisms: (1) change

of environmental risk; i.e. the adversity marks the onset of a chain of psychosocial stressors, which

mediate the association with later mental health problems (Clarke and Clarke, 2000); and (2) change

of individual vulnerability, i.e. the adversity induces lasting psychological or biological change

(Francis et al., 1999; Hart et al., 1996; Heim and Nemeroff, 1999; Hyman, 1998; Luecken, 1998;

Weiss et al., 1999). The presentation will address the question to what extent a history of stressful

life events is associated with present adversity and, through this or directly, with preadolescents’

psychobiological vulnerability for internalizing disorders in a normal-population sample of

preadolescents.

Methods: Data come from the first assessment wave of TRAILS (TRacking Adolescents’ Individual

Lives Survey), a large prospective population study of 2230 10–12-year-olds, living in the North of

the Netherlands, who will be measured biennially at least until they are 25-years-old. TRAILS

(response rate 76%) involves multiple-informant data on a wide range of psychological, biological,

and social factors. Stressful life events (e.g. parental death, illness or divorce) and present adversity

(e.g. low family income) were assessed by interviews with the children’s parents (usually mothers),

self-esteem (child-rated) by the Perceived Competence Scale for Children (Harter, 1982),

temperament (parent- and child-rated) by the Early Adolescent Temperament Questionnaire (Ellis,

2002), and cortisol levels by saliva samples, collected in the morning and in the evening.

Results: Preliminary analyses suggest that a history of stressful life events is strongly associated with

present adversity and affects, both directly and indirectly, psychological vulnerability factors (low

self-esteem, temperamental fear and frustration) for internalizing disorders. Evidence is weaker for

salivary cortisol levels.

Conclusion: Change agents of individual vulnerability factors are important because they bring

about stable alterations in risk of psychopathology. A history of adverse experiences may, directly or

through accumulation of environmental risk, increase psychobiological vulnerability for internal-

izing disorders.


F19

Name Aysegul Ozerdem

Address Department of Psychiatry, Dokuz Eylul University Medical School, Narlidere, Izmir 35340, Turkey


Authors Aysegul Ozerdema, Olcay Yazicib, E. Timucin Oralc, Zeliha Tuncaa, Simavi Vahipd, Erhan Kurtc, and

the Mood Disorders Study Group of Psychiatric Association of Turkeye

Affiliations aDepartment of Psychiatry, Medical School, Dokuz Eylul University, Izmir, Turkey; bDepartment of

Psychiatry, Medical School, Istanbul University, Istanbul, Turkey; cBakirkoy State Neuropsychiatry

Hospital, Mood Disorders Outpatient Unit

Conflict No

Abstract ID 114


Title Establishment of a registry program for bipolar illness in Turkey

Keywords Bipolar illness; Registry program

Abstract Objectives: The aim of this project was to establish a patient registration form for bipolar illness to be

used in a large scale bipolar registration program which will cover a number of mood disorder clinics

throughout Turkey. Four major needs were determined while designing the form: (1) ability to cover

information on demographics, medical and family history of the patient and course of illness; (2)

capability for active follow up; (3) a dynamic format which would allow the clinician to break it into

pieces and still get meaningful cross-sectional data; (4) ability to educate residents on bipolar illness.

Methods: Two major investigators had worked on establishing the forms. A series of forms from

inside and outside the country had been reviewed. Discussions on drafts took place during several

workshops of the mood disorders study group of the Psychiatric Association of Turkey and revised

in accordance with the feedbacks. The pilot application period took place in two experienced clinics

and the last corrections were made according to their feedback.

Results: The final form has two features in a modular format. It allows both for computerized

registration and free style entry of the data and includes four major modules. The first module is the

general information form which includes patient’s demographic data, family history, a detailed

personal medical history, co morbid conditions in SCID-I format as well as course of the illness. The

second module is for the first visit which includes today’s complaints with a brief background,

questions for core DSM-IV symptoms for depression and mania and all the DSM-IV symptoms for a

mood episode present for the last week. It uses DSM-IV severity rating scale for the symptoms (0–

3) and syndrome (0–4). It defines state of the illness and screens for related symptoms and the

subsyndromal complaints. It questions duration of the present state. Role achievement of the patient

in four different areas (partnership, parentship, occupational and sexual activity) is rated and

occupational status is specified. It contains a detailed psychiatric and physical examination,

HAM-D-21, YMRS, UKU, GAF scores and a table for the most recent laboratory work and

the list ofmedication he/she is taking. A five axis DSM-IV diagnosis and the treatment plan are

added to the end. The third module is the follow-up form which is similar to the second module

except that it is completely structured. It questions similar properties for the last 2 weeks as well as

since last visit. The last module contains the life chart of the patient with a flow chart of all the

treatment modalities that the he received up to date. A user’s guide which includes all definitions

required to be able to use the forms has also been written. A computer program has been prepared for

entry and evaluation of data.

Conclusion: We found the forms useful in accordance with the aims stated above. It will allow a

detailed database for defining different features of bipolar illness in a large scale epidemiological

study.


F20

Name Frenk Peeters

Address Department of Psychiatry, University Hospital Maastricht, PO Box 5800, Maastricht, The

Netherlands


Authors Frenk Peeters, Nancy Nicolson, Johannes Berkhof

Affiliations Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands

Conflict No

Abstract ID 36


Title Dynamics of cortisol in major depression; a study in daily life

Keywords Depression; Salivary cortisol; Daily life; Stress; Variability; Responses

Abstract Objectives: Dysfunction of the hypothalamic–pituitary–adrenal (HPA) axis is an important feature

of major depressive disorder (MDD), but little information about naturally occurring patterns of

cortisol secretion throughout the day and cortisol responses to daily hassles in depressed outpatients

in their everyday environment is available.

Methods: Experience sampling methodology (self-reports of mood and daily events, with

simultaneous saliva samples, 10 times each day for 6 consecutive days) and multilevel regression

analysis were used to examine the effects of MDD on (1) cortisol levels and intraindividual

variability, and (2) the relationship between events in daily life and salivary cortisol levels in 47

medication-free outpatients with MDD and 39 healthy controls.

Results: We found no clear evidence for hypercortisolaemia in MDD outpatients. MDD was

characterized by a more erratic pattern of basal cortisol secretion, especially in patients with more

severe or recurrent episodes. In contrast to healthy participants, depressed participants showed no

increase in cortisol following negative events. Responses were even more blunted in depressed

participants with a family history of mood disorders. Although the effects of negative events on

cortisol responses appeared to be mediated by changes in mood, negative affect tended to be less

closely associated with cortisol levels in depressed participants. Depressed women showed larger

cortisol responses to negative events than depressed men. Positive events had no effect on cortisol

levels in either group.


F21

Name Martin Preisig

Address Department of Adult Psychiatry, Site de Cery, Prilly-Lausanne 1008, Switzerland


Authors Martin Preisig, Olivier Chouchena, O. Halfon, F. Ferrero

Affiliations Department of Adult Psychiatry, Lausanne

Conflict No

Abstract ID 109


Title Offspring of parents with mood disorders

Keywords Bipolar disorder; Major depressive disorder; High-risk study

Abstract Objectives: Research on the offspring of affected parents allows to prospectively study premorbid

risk and protective factors, early signs, and consequences of psychiatric disorders. The goal of the

present paper was to assess early psychiatric disorders in adolescent offspring of parents suffering

from bipolar and major depressive disorder.

Methods: As part of a family study on mood and substance disorders, we have collected extensive

clinical information on 55 probands with bipolar, 54 probands with major depressive disorder

(MDD) as well as 45 medical controls with children in the age range from 7 to 17 years. Parents and

offspring were interviewed face to face using the DIGS for adults and the K-SADS for children. The

diagnostic assessment according to a best estimate procedure was based on the direct interview,

family history information and medical records. Proportional hazard models were applied to

determine the association between parent and offspring disorders.

Results: Among offspring younger than 12 years, children of bipolars showed increased rates of

oppositional defiant disorders as compared to those of control and MDD probands. Among offspring

between 12 and 17 years, children of probands with unipolar or bipolar mood disorders had more than

four times increased lifetime prevalence rates of MDD. Moreover, offspring of MDD probands were

more than three times as likely to suffer from separation anxiety disorder than offspring of controls.

Similarly, offspring of mood disorder parents were socially more disabled than children of controls.

Conclusion: The results of our study confirm that offspring of mood disorder parents are a high-risk

group for MDD in adolescence. In addition, the children of bipolar probands may present early

behavioral problems more frequently, whereas those of MDD probands seem to be at a higher risk

for childhood anxiety disorders. The follow-up of children and adolescents to adulthood will be

necessary to study the association between early manifestations of psychopathology and adult

disorders including bipolar and substance use disorders. Such follow-up data will also help to

understand the interplay between familial vulnerability, early psychopathology and identified

environmental and individual risk factors.


F22

Name Henricus Gerardus Ruhe

Address Program for Mood Disorders A3-255.1, Department of Psychiatry AMC/De Meren, P.O. Box 22660

1100 DD, The Netherlands


Authors H.G. Ruhe, J. Huyser, J.A. Swinkels, A.H. Schene

Affiliations Academic Medical Center, Department of Psychiatry AMC/De Meren, Amsterdam, The Netherlands

Conflict No

Abstract ID 97


Title Failure to respond to the first SSRI in major depressive disorder: An evidence-based guideline for

timing of treatment changes, increasing the dose and switching.

Keywords Guidelines; Evidence-based; Selective serotonin reuptake inhibitors; Depressive disorder;

Systematic review

Abstract Objectives: Major depressive disorder is an illness associated with high burden and costs. Forty to fifty

percent of patients treated with antidepressants do not respond to the first treatment, which currently

most often is a selective serotonin reuptake inhibitor (SSRI). A systematic review of the literature and

the formulation of evidence-based recommendations for the pharmacological treatment of adult

patients with depression, when a standard dosage of a first SSRI is unsuccessful, is unavailable.

Methods: Clinicians and patient representatives in a guideline panel chose three important major

clinical questions by giving these highest priority: when to change, effectiveness of increasing the

dose and switching (in this process, augmentation strategies were rated at a much lower priority).

Searches were performed in MEDLINE, EMBASE, CINAHL, PsycInfo, DARE, and Cochrane

Collaboration databases (last in June 2003) for all indexed years. Sensitive queries were used to

improve identification of relevant studies. Additional cross-references were retreived, animal studies

were excluded and no language restrictions were applied. Two independent reviewers screened the

retreived references for eligibility. One reviewer critically appraised all selected studies, using

standard appraisal forms. A random subset of 12 articles was appraised by other reviewers to validate

the appraisal process. If possible, likelihood ratio’s for diagnostic studies and numbers needed to treat

for therapeutic studies were calculated, precision was expressed as 95% confidence intervals.

Results: Of approximately 5000 articles retrieved, 57 studies, mostly clinical trials, met previously

specified inclusion and exclusion criteria based upon the clinical questions. These 57 studies were

categorized into 14 sub-questions. Qualitative summaries were presented to the guideline panel.

Fourteen recommendations were formulated by panel discussion leading to consensus. Additional

concerns influencing the recommendations within these discussions were clearly documented.

Recommendations were graded according to the level of evidence supporting them.

Conclusion: In the bottom-up guideline development process three clinical questions of highest

priority were studied with systematic reviews. Clinical recommendations were formulated based

upon the reviews and consensus within the guideline panel. The minimal duration of a first

antidepressant trial should be 4 weeks for non-responders (grade 2), 6 weeks for partial responders

(grade 2) and 8 weeks in chronic depression (grade 3). The effectiveness of increasing the dose for

SSRIs is unclear and requires deliberation with the patient about this strategy (grade 2). The choices

for switching to another antidepressant after the first SSRI are essentially identical to the available

options at the moment a first antidepressant is chosen (grade 2). Large gaps of evidence were

identifies during the preparation of this guideline. These gaps concern the dose–response

relationship for SSRIs, and relative efficacy of switching to different antidepressant classes if there is

insufficient response to a first SSRI.


F23

Name Ayal Schaffer

Address Sunnybrook and Women’s College, Health Sciences Centre, 2075 Bayview Avenue, Room FG 46

Toronto, Ontario M4N 3M5 Canada


Authors Ayal Schaffer, Muhammad Mamdani, Anthony Levitt, Nathan Herrmann

Affiliations University of Toronto

Conflict No

Abstract ID 41


Title Effect of antidepressant use on admissions to hospital among elderly bipolar patients

Keywords Bipolar disorder; Antidepressants; Elderly

Abstract Objectives: There has been little study of the use of antidepressant medications in elderly bipolar

patients. The goal of this study was to evaluate the effect of antidepressant use on hospitalization

rates for depression and mania among elderly bipolar patients.

Methods: Population-based retrospective cohort design using linked administrative healthcare

databases. Eligible patients were all residents of the Province of Ontario who were greater than 65-

years-old and had a past admission for mania or bipolar depression. The cohort was comprised of

eligible subjects who received a prescription for an antidepressant between 1994 and 2001 and

exposure continued as long as repeat prescriptions were filled within 90 days. Control subjects were

eligible patients who did not receive an antidepressant between 1994 and 2001.

Results: The cohort included 1072 subjects, and the control group included 3000 subjects. Rates of

admission to hospital for mania were significantly lower among subjects who received an

antidepressant (adjusted rate ratio 0.5 (95% CI = 0.3–0.8)). Rates of admission to hospital for

depression were also lower among subjects who received an antidepressant (adjusted rate ratio 0.7

(95% CI = 0.2–2.2)).

Conclusion: Elderly bipolar subjects who were treated with an antidepressant had a decreased rate of

hospitalization for both mania and depression as compared to elderly bipolar subjects not receiving

an antidepressant. The results of this study may have major implications for the treatment of elderly

bipolar patients, however, interpretation is limited by the retrospective design.

F24
Name Tyge Schelde
Address Department of Psychiatry, Frederiksberg Hospital, Nordre Fasanvej 57 DK, 2000 Frederiksberg,

Denmark


Authors Tyge Schelde

Affiliations Department of Psychiatry, Frederiksberg Hospital

Conflict No

Abstract ID 56


Title Behavioural manifestations of depressives, schizophrenics, and nonpsychiatric, medical patients on

the ward

Keywords Behaviour; Ethology; Depression; Schizophrenia; Medical controls

Abstract Objectives: The objective of this investigation was to carry out behavioural (ethological) studies of

depressed, schizophrenic, and nonpsychiatric, medical patients on the ward to provide psychiatry

with new theoretical and practical knowledge.

Methods: Eleven depressed, 11 schizophrenic, and 11 nonpsychiatric, medical control patients were

observed by an ethological observation method. The observations were carried out systematically

and quantitatively according to an observation sheet including 166 detailed behaviours. Data were

treated by nonparametric statistics. The results below all show significant differences.

Results: The results of the investigation are derived from three studies. The first study singled out

depression markers and improvement markers. In depressives, 12 depression markers with higher

frequencies in the first hospital week than in the last week were: nonspecific gaze, social withdrawal,

and 10 behaviours that indicated a substantial decrease of social interaction. Eighteen markers

showed higher frequencies in the last week compared with first week. The most characteristic of

these markers were: socially interested, verbal-social-initiative, talk, nod, smile, laugh, gesticulate,

and help. The depression markers and the improvement markers can be useful to doctors and staff.

The second study documented a substantial difference between depressed and control patients in the

first hospital week (expressed by 49 detailed behaviours and six parameters). The parameter

differences included higher frequencies of Introvert-Eye-Fixation in depressives than in controls. On

the contrary, controls showed higher frequencies than depressives of the following parameters:

diversity (the number of different behaviours per week), activity, receive-social-behaviour, send-

verbal-communication, and send-nonverbal-communication. Moreover, this study showed that

controls reduced the parameter send-verbal-communication from the first to the last hospital week,

which may be interpreted as an adaptation to the hospital environment. Finally, it appeared that

remitted depressives showed an increased frequency of send-verbal-communication in the last week

compared with its frequency in the first week, but it was still lower than that of the controls. This

indicates that remitted depressives are not fully recovered at discharge. In addition, the increased

frequency of remitted depressives from first to last week compared with the reduced frequency of

this parameter in controls shows that the increased frequency of remitted depressives cannot be

perceived as an adaptation to the hospital environment, but rather as a consequence of a favourable

treatment. The third study dealt with the behaviour of schizophrenics. It showed a considerable

difference from controls in the first hospital week (48 detailed behaviours and seven parameters).

Moreover, the behavioural pattern of the schizophrenics was characterised by several bizarre

behaviours, e.g. talk to himself/herself (P < 0.05). Some of these behaviours still occur in discharged

schizophrenics. Thus, these patients easily become isolated in common society.

Conclusion: Based on the above findings, it is estimated that this ethological-psychiatric

investigation has provided psychiatry with new knowledge, which may be important theoretically

as well as clinically.


F25

Name Aart Schene

Address Program for Mood Disorders, Department of Psychiatry, Academic Medical Center, PO Box 22660,

Amsterdam, The Netherlands


Authors A.H. Schene, M.J. Kikkert, J.A. Swinkels, M.W.J. Koeter

Affiliations Academic Medical Center, Department of Psychiatry AMC/De Meren, Amsterdam, Netherlands

Conflict No

Abstract ID 105


Title The effectiveness of adjuvant occupational therapy for work-related major depression: A randomized

controlled trial including economic evaluation

Keywords Depression; Work; Disability; Costs; Coping

Abstract Objectives: Major depression has far-reaching consequences like personal suffering, impairment in

work functioning (work cutback days) and absenteeism (work loss days). Depression related

impairment seems to be similar to or even exceeding that of common chronic physical illnesses as

diabetes and heart disease. Until recently employment status and the capacity to work was a sorely

neglected topic in depression literature. Mostly depression is treated by medication and clinical

management. However, in more severe depression the recovery of disabilities seems to lack behind

symptom remission, and sometimes fails, contributing to chronicity. From clinical experience we

know that for those patients for whom depression is related to impairment in occupational

functioning, recovery may stagnate if ‘work’ is not part of the treatment plan. We determined—as far

as we know for the first time—the effectiveness of the addition of occupational therapy to care as

usual on recovery from depression, work resume, occupational functioning and costs.

Methods: Design and setting: randomized controlled trial conducted at the Program for Mood

Disorders of an academic medical center. Participants: 62 adults (n = 32 women; mean age: 45.9

(7.4)), with major depression and mean absenteeism of 242 days. The estimated contribution of work

to the onset and/or continuation of depression was >50%. All patients gave written informed

consent. Interventions: patients were randomly assigned to care as usual (CAU: outpatient

psychiatric treatment) and care as usual plus occupational therapy (OT: including a three session

diagnostic phase with occupational history and work reintegration plan, and a therapeutic phase with

12 individual sessions and 24 thematized group sessions with a total duration of 6 months). Main

outcome measures: assessments at baseline, 3, 6 and 12 months. Outcome domains: depression,

depression symptoms, work resume, work stress, coping and costs.

Results: The addition of OT to CAU did not improve depression outcome. However, it resulted in a

significant reduction of work loss days, in particular during the second 6 months of the trial

(P= 0.05). Time between start of the RCT and the moment of any work resume also showed a

significant difference in favor of the experimental condition (P= 0.01). Although occupational

therapy increased total mental health care costs, a median total economic gain of $2.902 was found

caused by greater productivity in the experimental condition. We will also present follow-up data

over 36 months.

Conclusion: Results of this study suggest that the addition of occupational therapy to good outpatient

clinical practice reduces absenteeism but not depression. It might also improve work performance.

The experimental condition reduces total costs substantially.


F26
Name Aart Schene
Address Program for Mood Disorders, Department of Psychiatry AMC/De Meren, Academic M PO Box

22660, 1100 DD, Amsterdam, The Netherlands


Authors C.L.H. Bockting, A.H. Schene, Ph. Spinhoven, M.W.J. Koeter, L.F. Wouters, J. Huyser


Conflict No

Abstract ID 106


Title Preventing new episodes in recurrent depression by an eight session cognitive group therapy:

A randomized controlled trial

Keywords Depression; Cognitive therapy; Prevention; Recurrence; Relapse; Age of onset

Abstract Objectives: There is encouraging evidence that beside the continued use of antidepressants,

psychological interventions might be helpful in preventing new major depressive episodes. Others

already showed the preventive effect of (1) cognitive therapy during the acute phase of depression,

(2) the continuation of cognitive therapy for patients recovered on acute phase cognitive therapy,

and (3) the addition of cognitive interventions for patients recovered on acute phase antidepressant

treatment. We developed a low cost eight sessions group cognitive therapy and studied outcome for

patients with recurrent depression recovered on different types of treatment (antidepressants and/or

psychological therapy or no treatment).

Methods: Outpatients (n = 187) with recurrent depression (two or more major depressive episodes in

the last 5 years), in remission for 10–104 weeks, with a HRSD score < 10, recruited from primary

care, psychiatric or mental health care centres and by media. They were randomized to Treatment As

Usual (TAU) or eight weekly 2 h sessions of group cognitive therapy (CT). CT was given by trained

cognitive behavior therapists using a treatment manual. New depressive episodes were assessed with

SCID-I by blind raters over a 2 year follow-up period. Audiotaped interviews were evaluated by two

independent experienced psychiatrists, also blind to treatment condition.

Results: Cox regression analyses with number of previous episodes as covariate revealed a

significant interaction effect of treatment condition and previous episodes (Wald (1) = 6.523,

P= 0.011, Hazard ratio 0.568, 95% CI: 0.368–0.877). The number of episodes needed to benefit

significantly from CTwas five or more. Over the total study period of 24 months the cumulative rate

of new episodes for TAU patients with five or more previous episodes at baseline rose to 80% (95%

CI: 61–92%) compared to 53% (95% CI: 35–71%) for CT patients. For those with less than five

episodes these figures were TAU: 64% (95% CI: 48–77%) and CT: 69% (95% CI: 54–82%). No

significant differences were found between the two treatment groups for proportion of use of

antidepressants, of mean dosages of milligrams of fluoxetine daily dose equivalents and of

psychological treatments. Patients with five or more episodes differed from those with less than five

episodes: they had an earlier age of onset (P= 0.000), had more family members with psychiatric

illness (P < 0.05), had a more avoidant coping style (P= 0.006) and a shorter duration of remission

since the last episode (P>0.05).

Conclusion: This study showed that adding brief group CT to treatment as usual for high risk patients

who experienced five or more previous episodes (41% of the sample) had a significantly protective

effect. Different explanations as the negative effect of the number of episodes on cognitive processes,

the avoiding coping style, the early age of onset and possible genetic influence will be discussed.

Brief psychological interventions can be useful in the prevention of new episodes in recurrent

depression. These interventions can be given to groups and so will have low costs. We so far found

that group cognitive therapy given to recovered patients is effective for a sub group of patients

suffering from recurrent depression. The exact characteristics of this group need further study.


F27

Name Aart Schene

Address Program for Mood Disorders, Department of Psychiatry AMC/De Meren, Academic M PO Box

22660, 1100 DD, Amsterdam, The Netherlands


Authors A.H. Schene, B. van Wijngaarden, M.W.J. Koeter


Conflict No

Abstract ID 107


Title Caregiver consequences in depression and schizophrenia

Keywords Depression; Caregiving; Family members; Schizophrenia; Children

Abstract Objectives: Psychiatric patients’ caregivers (parents, partners, children, friends) bear considerable

burdens. The consequences of psychiatric illness for those caregivers have almost exclusively been

studied in samples of caregivers of patients with schizophrenia. Instruments to measure these

burdens have also mostly been developed in relation to psychosis. Research questions addressed for

this study were: (1) What are the differences in caregiver consequences between caregivers of

patients with depression and those of patients with schizophrenia? (2) Is it possible to specify distinct

groups of caregivers according to their level of caregiving consequences? (3) Are these

consequences related to diagnosis, illness phase, duration and severity of the illness and patient

and/or caregiver sociodemographic characteristics?

Methods: Sample: We studied 260 caregivers of patients with depression and 151 caregivers of

patients with schizophrenia. Measures: To measure caregiver consequences we used an instrument

developed and validated for use in depression as well as schizophrenia: the Involvement Evaluation

Questionnaire (IEQ), a 31 item self report questionnaire with four distinct sub scales (tension,

supervision, worrying and urging) and a 27 item overall consequences score. Psychopathology of the

patient was measured with the Zung Selfrating Depression Scale in case of depression and the Brief

Psychiatric Rating Scale in case of schizophrenia.

Results: Caregiving in depression generally takes place in the household by a partner, while in

schizophrenia it is the ongoing parental care for an adult ‘child’. The mean number of days in the

same house per month were 21.7 for depression and 9.7 for schizophrenia. On the item level of the

IEQ we found some significant differences: caregivers of schizophrenia patients were significantly

more active in urging and encouraging while the interpersonal stressed atmosphere was higher in

depression. When all caregivers were divided in low, medium and high level consequences both

samples did not differ. When the depression sample was divided in inpatient, acute outpatient and

non-acute outpatient the inpatient sample gave significant more consequences on most items. A

stepwise multiple regression analysis showed that the level of overall burden was predicted by a

relationship that changed over time, by a lack of social support, a non effective coping style

(daydreaming), a limited duration of the illness and by being an acute outpatient (R2 = 44). Finally

we found the consequences for children of depressed patients to be high, in particular in the non

acute outpatient sample.

Conclusion: This study has shown that the consequences for caregivers have a pattern which is to a

great extent comparable for those related to patients with depression and schizophrenia. And

although the overall severity of burden did not differ between both disorders, we found some

differences: depression caregiving has more interpersonal consequences while schizophrenia

caregiving is more related to lower levels of functioning which need care and encouragement. In

depression the overall level of burden was more related to a change of the long term relationship,

social support and coping than to the severity of the current psychopathology.


F28
Name Leon Sloman
Address Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada


Authors Leon Sloman, Peter Farvolden

Affiliations Department of Psychiatry, University of Toronto. Centre for Addiction and Mental Health, Toronto

Conflict No

Abstract ID 99


Title Depression, anxiety and the maintenance of hierarchies

Keywords Depression; Anxiety; Co-morbidity; Evolution; Involuntary defeat strategy

Abstract Objectives: We aim to provide a context for explaining the high co-morbidity between depression

and anxiety.

Methods: We discuss the evolutionary functions of depression and anxiety and show how they may

complement each other so that a triggering of depression can in certain circumstances trigger anxiety

and vice versa.

Results: Price (1967) proposed that the evolutionary function of depression is to neutralize the loser’s

determination to continue the struggle. The recognition by one protagonist that defeat is inevitable

triggers the ‘‘Involuntary Defeat Strategy’’ (IDS), characterized by feelings of helplessness,

hopelessness, inferiority, inadequacy and tiredness. It is exquisitely geared to inhibit combativeness

in agonistic (hierarchical) competition. The IDS can save both combatants from unnecessary injury

or death and may serve to reconcile the loser to his inferior social position. The IDS is normally of

relatively short duration and mild intensity. However, when the IDS are more powerful and

sustained, it may manifest as clinical depression. It should be noted that failure in agonistic

competition is only one subset of a larger number of arenas where failure can trigger the IDS.

Anxiety: To survive in this dangerous world an organism has to be alert to environmental changes

and prepared to meet whatever emergencies may arise. Vigilance shifts into anxiety when a possible

threat or danger has been perceived. In the environment of evolutionary adaptedness, vigilance and

anxiety were crucial to survival. Price’s (2003) novel perspective of the evolutionary aspects of

anxiety is derived from observations on chimpanzees. His premise is that, in the early evolutionary

environment, humans demonstrated similar mechanisms to present day monkeys and apes in the

wild, where rewards are dependant on social rank. When the animal challenges the animal above him

in the hierarchy and the latter resists, a ritualized fight ensues. When one or the other gives up, the

two undergo what de Waal has called a ‘‘conditional reconciliation’’. However, as depression (IDS)

does not help the loser reconcile with the winner, this function, according to Price, is served by

anxiety. It should be noted that agonistic threat is only one subset of a larger number of arenas where

threat can trigger anxiety.

Conclusion: Whereas the IDS reduces motivation to compete, anxiety stimulates submission. Thus

the IDS and anxiety act synergistically to facilitate the resolution of conflict and maintain the

stability of the hierarchy. It should be noted that submission and acceptance of defeat by the loser

and reconciliation between the two competitors generally leads to a termination of the loser’s anxiety

and depression (IDS). In some circumstances, this resolution fails to occur so that depression and/or

anxiety persist and even escalate. Because both depression and anxiety play pivotal roles in conflict

resolution of agonistic interactions, one would expect them to often coexist. Therefore, when one

person has a strong expectation of defeat, but cannot give up the fight, one would expect to observe

an escalation of both his/her depression and anxiety.


F29

Name Kirsi Suominen

Address Ryytimaa 6, 02940 Espoo Jorvi Hospital, Department of Psychiatry, Turuntie 02940 Espoo, Finland


Authors Suominen Kirsi, Isometsa Erkki, Suokas Jaana, Haukka Jari, Achte Kalle, Lonnqvist Jouko

Affiliations Department of Mental Health and Alcohol Research; Jorvi Hospital, Department of Psychiatry

Conflict No

Abstract ID 51


Title Completed suicide after a suicide attempt: A 37-year follow-up study

Keywords Suicide; Attempted suicide; Outcome; Follow-up

Abstract Objectives: Attempted suicide is the strongest known predictor of completed suicide. However,

suicide risk is highest during the first months after the attempt and declines thereafter. It is unclear

how long the suicide risk persists. Risk estimates are mainly based on studies of less than 10 years of

follow-up. The aim of the present study was to determine the rate of suicide after attempted suicide

over a follow-up period of almost four decades during the era of modern psychiatric treatment.

Methods: We followed a cohort of 100 consecutive self-poisoning patients in Helsinki in 1963, for

whom forensically classified causes of death during the following 37 years were investigated.

Results: By the end of follow-up 55% of the suicide attempters had died; 13% had committed

suicide. Two thirds of the suicides occurred at least 15 years after the suicide attempt. Suicide

mortality was significantly higher among males v2 = 7.2, df = 1, P= 0.007.Conclusion: In the present study, suicides continued to accumulate almost four decades after the

index suicide attempt. A history of a suicide attempt by self-poisoning indicates suicide risk over the

whole adult lifetime.


F30

Name Reidar Tyssen

Address aDepartment of Behavioural Sciences in M

Health C N-0317 Oslo, Norway


Authors Reidar Tyssena, Per Vagluma, Jan Ole Røvika

Affiliations Department of Behavioural Sciences in Med

Conflict No

Abstract ID 100


Title Prevalence and predictors of depressive sy

longitudinal study

Keywords Depression; Cohort studies; Epidemiology; N

Abstract Objectives: We lack representative and long-

Physicians have a raised risk of committing

high level of depressive symptoms in the very

gender differences are discrepant. This study a

symptoms beyond the first postgraduate years

compare the prevalence with general populat

Methods: Prospective survey of a nationwide

1993 and 1994 (time 1); they were approache

year (time 2), in their third/fourth postgraduat

ninth/tenth postgraduate year (time 4). A sli

83%. We compared the depressive symptom

sample of the same age and socio-economic g

Study). The outcome variables included depre

ideation, GHQ-28-severe depression). Predict

medical school variables, negative life even

places at the postgraduate levels. Predictors w

edicine; bDepartment of Public Health and Primary

, Ingvar Bjellandb, Nina T. Grønvolda, Øivind Ekeberg

icine, Faculty of Medicine, University of Oslo,

mptoms among Norwegian physicians: A 10-year

orwegian; Nationwide

time prospective studies on predictors of depression.

suicide and pervious studies have shown a relatively

first postgraduate years. The findings with respect to

ims to identify prevalence and predictors of depressive

in a nationwide cohort of medical doctors, and also to

ion data.

cohort (N = 631) of medical students that graduated in

d again at the end of the first postgraduate (internship)

e year (time 3), and finally in 2003 when being in their

ght majority were women. Response rates were 58–

prevalence at time 4 with a data from a representative

roup of the Norwegian general population (The HUNT

ssive symptoms (HADS-Depression subscale, suicidal

or variables included personality traits, social support,

ts and measures about working conditions and work

ere studied by means of multiple regression models.

Results: The prevalence of clinically relevant depressive symptoms (HADS-D, cut-off 7/8) was 11%

among the men and 7% among the women doctors at time 4. The prevalence among men doctors

was higher than among men in the general population. Further longitudinal data on depressive

symptoms and preliminary results of individual and contextual predictors among the doctors will be

presented at the conference.

Conclusion: The higher level of depressive symptoms among men physicians than among other men

calls for attention, in particular since there is an elevated risk for suicide in this occupational group.


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