Matthias Backenstrass

Background: Studies show that subthreshold depression is highly prevalent in primary care, has impact on the quality of life and causes immense health care costs. Although this points to the clinical relevance of subthreshold depression, contradictory results exist regarding the often self-remitting course of this state. However, first steps towards quality improvement in the care of subthreshold depressive patients are being undertaken. This makes it important to gather information from both a GPs' and a patients' point of view concerning the clinical relevance as well as the status quo of diagnosis and treatment in order to appraise the need for quality improvement research. Method: We conducted qualitative, semi-structured interviews for the questioning of 20 GPs and 20 patients with subthreshold depression on aspects of clinical relevance and on the status quo of diagnosis and treatment. Interviews were transcribed and analyzed on a content analytical theoretical background using Atlas.ti software. Results: Most of the GPs found subthreshold depression to be clinically significant. Although some problems in diagnosis and treatment were mentioned, the GPs had sensible diagnostic and treatment strategies at hand which resulted from the long and trustful relationship with the patients and which corresponded to the patients' expectations. The patients rather expected their GP to listen to them than to take specific actions towards symptom relief and, in the main, were satisfied with the GPs' care. Conclusion: The study shows that subthreshold depression is a clinically relevant issue for GPs but raises the possibility that quality improvement might not be as necessary as past studies showed. Further quantitative research using larger random samples is needed to determine the effectiveness of the strategies used by the GPs, patients' satisfaction with these strategies and the course of these patients' symptoms in primary care.

Background: A number of studies have shown that marital interaction plays an important role regarding etiology, maintenance, and course of depression. The Kategoriensystem für Partnerschaftliche Interaktion (KPI; ‘Coding System for Marital/Family Interaction’) and the Structural Analysis of Social Behavior (SASB) are both widely used to describe and quantify the interactional behavior of patients and their relatives. To evaluate the validity of extrapolating research findings from one system to another, especially in the field of depressive disorders, the two coding systems were compared in an empirical analysis. Sampling and Methods: Videotaped marital problem-solving interaction tasks of 29 married couples with a depressed spouse were coded by means of both systems by separate teams of observers. Results: Between-system comparisons revealed that convergent validity on the level of SASB clusters and KPI verbal categories were moderate and differentiated between the behavior of patients and that of spouses. The KPI nonverbal positive and negative categories were not simply correlated with the SASB affiliation dimension. Conclusion: The results underline the importance of undertaking validation studies with different samples.

Background: Osteoarthritis (OA) is highly prevalent and has substantial impact on quality of life as well as on healthcare costs. The general practitioner (GP) often is the first care provider for patients with this chronic disease. The aim of this study was to identify health care needs of patients with OA and to reveal possible obstacles for improvements in primary care management of OA patients. Methods: We performed semi-structured interviews with a stratified sample of 20 patients, 20 GPs and 20 practice nurses. Results: Diagnosing OA posed no major problem, but during the course of OA, GPs found it difficult to distinguish between complaints resulting from the affection of the joints and complaints related to a concomitant depression. Patients felt to be well informed about the degenerative nature of the disease and possible side effects of medications, but they lacked information on individual consequences of the disease. Therefore, the most important concerns of many patients were pain and fear of disability which they felt to be addressed by GPs only marginally. Regarding pain treatment, physicians and patients had an ambivalent attitude towards NSAIDs and opiates. Therefore, pain treatment was not performed according to prevailing guidelines. GPs felt frustrated about the impact of counselling regarding life style changes but on the other hand admitted to have no systematic approach to it. Patients stated to be aware of the impact of life style on OA but lacked detailed information e.g. on how to exercise. Several suggestions were made concerning improvement. Conclusion: GPs should focus more on disability and pain and on giving information about treatment since these topics are inadequately addressed. Advanced approaches are needed to increase GPs impact on patients' life style. Being aware of the problem of labelling patients as chronically ill, a more proactive, patient-centred care is needed.

Since the efficacy of cognitive–behavioral therapy for depression has been shown, questions arise concerning possible factors that moderate and mediate therapy outcome. For cognitive variables such as automatic thoughts or dysfunctional attitudes, the mediational function for therapeutic changes could be substantiated. Only few studies, however, concern locus of control, self-efficacy, and negative mood regulation (NMR) expectancies, even though they seem to be relevant for the etiology of depression. Therefore, the authors investigated the extent to which these variables are moderators or mediators of therapeutic changes in treatment of depression. Fifty-one depressive patients in a cognitive–behavioral group program were studied using a pre–post design. Therapy outcome could not be predicted by any of the investigated variables. However, changes in NMR expectancies correlated with changes in depression during time of treatment. Moreover, NMR expectancies could predict further changes in the follow-up interval. The interpretation of NMR expectancies as a mediator of therapy-induced changes is discussed critically based on specific and common factors of effectiveness. Die Effektivität der kognitiven Verhaltenstherapie der Depression kann als nachgewiesen gelten. Forschungsfragen beziehen sich deshalb zunehmend auf Faktoren, die als Moderator- oder Mediatorvariablen für Therapieerfolg gelten können. Für kognitive Variablen wie z.B. automatische Gedanken oder dysfunktionale Einstellungen konnte bereits die Mediator-Funktion für therapeutische Veränderungen aufgezeigt werden. Für Konstrukte wie Locus of Control (LOC), Selbstwirksamkeitserwartungen (SE) und Erwartungen, negative Stimmungen beeinflussen zu können (NMR-Erwartungen), liegen bisher nur vereinzelt Studien vor, obwohl diese von großer Bedeutung hinsichtlich der Ätiologie depressiver Störungen zu sein scheinen. Es wurde deshalb untersucht, inwieweit die genannten Variablen (LOC, SE und NMR) als Moderatoren oder Mediatoren therapeutischer Veränderungen in der Depressionsbehandlung gelten können. N = 51 depressive Patienten, die eine kognitiv-verhaltenstherapeutische Gruppentherapie in Anspruch nahmen, wurden im Rahmen eines Prä-Post-Designs genauer untersucht. Es zeigte sich, dass der Therapieerfolg durch keine der Variablen vorausgesagt werden konnte. NMR-Erwartungen korrelierten jedoch mit Veränderungen der Depressivität im Behandlungsintervall. Darüber hinaus konnten mit Hilfe der NMR-Erwartungen weitere positive Veränderungen im Follow-up vorausgesagt werden. Die Interpretation von NMR-Erwartungen als ein Mediator-Effekt therapieinduzierter Veränderung wird vor dem Hintergrund der Diskussion um spezifische und allgemeine Wirkfaktoren erörtert. L'efficacité de la thérapie cognitivo-comportementale ayant été démontrée, les questions surgissent au sujet de facteurs possibles qui fonctionnent comme modérateurs ou médiateurs du résultat. Pour des variables cognitives comme les pensées automatiques ou les attitudes dysfonctionnelles, la fonction de médiation pour le changement thérapeutique a pu être établie. Mais peu d’études seulement concernent le lieu de contrôle, l'auto-efficacité et les attentes de régulation de l'humeur négative (NMR) alors qu'ils apparaissent comme importants pour l’étiologie de la dépression. C'est pourquoi les auteurs ont investigué dans quelle mesure ces variables ont un rôle modérateur ou médiateur de changements thérapeutiques dans le traitement de la dépression. 51 patients dépressifs dans un programme de groupe cognitivo-comportemental ont été étudiés sur la base d'un design pré-post. Aucune des variables investiguées pouvait prédire le résultat du traitement. Cependant, des changements des attentes NMR corrélaient avec des changements de la dépression en cours de traitement. En plus, les attentes NMR pouvaient prédire des changements supplémentaires dans l'intervalle catamnestique. L'interprétation des attentes NMR comme des médiateurs de changements induits par la thérapie est discutée, de façon critique, sur la base des facteurs communs et spécifiques de l'efficacité. Desde que se ha demostrado la eficacia de la terapia cognitivo-comportamental para la depresión, surgen preguntas acerca de los posibles factores que moderan y median los resultados de la terapia. Pueden substanciarse la función mediadora de los cambios terapéuticos en el caso de variables cognitivas tales como los pensamientos automáticos o las actitudes disfuncionales. Pocos estudios, sin embargo, se dedican al locus de control, la auto-eficacia y la regulación de las expectativas del humor negativo (NMR), no obstante resultar relevantes en la etiología de la depresión. Por lo tanto, los autores investigaron hasta dónde estas variables son moderadoras o mediadoras de los cambios terapéuticos en el tratamiento de la depresión. Se estudiaron cincuenta y un pacientes depresivos que estaban en un programa grupal cognitivo-comportamental, utilizando un diseño pre-post. El resultado de la terapia no pudo predecirse por medio de ninguna de las variables investigadas. Sin embargo, los cambios en las expectativas NMR correlacionaron con cambios en la depresión durante el tiempo de tratamiento. Más aún, las expectativas NMR pudieron predecir cambios posteriors durante el seguimiento. La interpretación de las expectativas NMR como mediadoras de los cambios inducidos por la terapia se discutieron críticamente basándose en factores específicos y comunes de la efectividad. Da quando è stata mostrata l'efficacia della terapia cognitivo-comportamentale per la depressione emergono domande relative ai possibili fattori che moderano e mediano l'esito della terapia. Per le variabili cognitive come i pensieri automatici o gli atteggiamenti disfunzionali, la funzione mediatrice per i cambiamenti terapeutici potrebbe essere provata. Solo pochi studi, comunque, riguardano il locus of control, l'autoefficacia e le aspettative di regolazione dell'umore negativo (NMR), perfino il pensiero sembra essere rilevante per l'eziologia della depressione. Pertanto gli autori hanno indagato l'ampiezza entro la quale queste variabili risultano moderatori o mediatori di cambiamenti terapeutici nel trattamento della depressione. Usando un pre-post disegno, sono stati studiati cinquantuno pazienti depressi in un programma cognitivo-comportamentale di gruppo. L'esito della terapia potrebbe non essere predetto da alcune delle variabili investigate. Comunque i cambiamenti nelle aspettative di NMR ha correlato con i cambiamenti nella depressione durante il trattamento. Inoltre le aspettative di NMR potrebbero predire futuri cambiamenti nell'intervallo di follow-up. L'interpretazione delle aspettative di NMR come mediatore di cambiamenti indotti in terapia è criticamente discusso basandosi su specifici e comuni fattori di efficacia. Desde que a eficácia da terapia comportamental -cognitiva foi demonstrada, têm-se levantado quest[otilde]es acerca dos possíveis factores mediadores ou moderadores dos resultados terapêuticos. Podemos substanciar a função mediadora de variáveis cognitivas como pensamentos automáticos ou atitudes disfuncionais. No entanto, existem apenas alguns estudos relativos ao locus de controlo, auto-eficácia e regulação do humor negativo (RHN), embora estes processos pareçam ser relevantes na etiologia da depressão. Por isso, os autores investigaram em que medida estas variáveis são mediadoras ou moderadoras das mudanças terapêuticas na terapia da depressão. Cinquenta e um pacientes deprimidos em tratamento de grupo cognitivo-comportamental foram estudados utilizando um desenho pré-teste pós-teste. O resultado da terapia não pode ser previsto por nenhuma das varáveis investigadas. No entanto, mudanças nas expectativas de RHN correlacionaram-se com mudanças na depressão durante o tratamento. Além disso, expectativas de RHN conseguiam predizer mudanças adicionais no período de seguimento (follow-up). A interpretação das expectativas de RHN como uma variável mediadora de mudanças induzidas pela terapia é discutida criticamente com base em factores de factores comuns e específicos de eficiência.