Non-pharmacological treatment of psychiatrists in addition to the prescribing of an antidepressant drug

European Psychiatry 22 (2007) 419e426 http://france.elsevier.com/direct/EURPSY/

Original article

Non-pharmacological treatment of psychiatrists in addition to the prescribing of an antidepressant drug M. Linden a,b,*, W. Dierkes c, T. Munz c a

Research Group Psychosomatic Rehabilitation at the Charite´, University Medicine Berlin, Germany b Rehabilitation Centre Seehof, Teltow, Germany c Medical Department, Wyeth Pharma GmbH, Mu¨nster, Germany Received 2 January 2007; received in revised form 17 March 2007; accepted 18 March 2007 Available online 7 May 2007

Abstract Background. e Guidelines for the treatment of depression regularly emphasize that pharmacotherapy of depression should be accompanied by supportive counseling and other psychotherapeutic interventions. It is unknown which role psychiatrists in routine care give to such verbal therapies. Methods. e In a drug utilization study of venlafaxine, psychiatrists in private practice and in hospitals were asked to tell what non-pharmacological therapies they saw as an important part of the treatment of the present depressive episode. Additionally patient characteristics, treatment variables, setting characteristics and physician characteristics were assessed. Results. e Psychiatrists reported some kind of verbal therapies in 19.0% of outpatients and 36.8% of inpatients. Verbal therapies were reported more often for younger patients, who got more double diagnoses and were more severely ill. Patients with verbal therapies got more psychotropic medication. In the inpatient setting verbal therapies were related to generally more treatment overall and a higher rate of treatment response. In both treatment settings verbal therapies were related to lower rates of discontinuation of the antidepressant. Conclusion. e Verbal interactions are part of any patientephysician encounter and should be theory guided as part of the therapeutic process in the treatment of depressive disorders. Under this assumption the rate of patients for which psychiatrists reported some kind of verbal therapy as explicit part of their treatment could be higher. More research is needed on patient guidance, counseling and supportive psychotherapy in psychiatry. Ó 2007 Elsevier Masson SAS. All rights reserved. Keywords: Antidepressant drugs; Depression; Venlafaxine; Psychotherapy; Counseling; Patient guidance

1. Introduction Guidelines for the treatment of depression recommend that the prescribing of antidepressant drugs should be accompanied by psychosocial support, or psychiatric management, clinical management, psychosocial education, patient and family education, pharmacotherapy management, counseling, problem solving treatment, supportive psychotherapy * Corresponding author. Research Group Psychosomatic Rehabilitation, Rehabilitation Center Seehof, Lichterfelder Allee 55, 14513 Teltow, Germany. Tel.: þ49 03328 345678; fax: þ49 03328 345555. E-mail address: [email protected] (M. Linden). 0924-9338/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2007.03.006

[1e3,6,7,11,16,27,36,39]. It is expected that supportive counseling improves the patientephysician relationship, reduces misconceptions about the illness, increases compliance with pharmacotherapy, or helps to solve live problems which have a negative impact on the patient and on the course of treatment [1e3,20,21,37]. ‘‘Specific’’ psychotherapy, which is explicitly based on theoretical concepts such as cognitive-behavioral therapy or interpersonal therapy, for which therapists have to write an application in advance, which are specially reimbursed, and which come in weekly sessions of 50 min for a limited number of sessions, cannot be provided for every patient but are recommended for special cases, i.e. when depressive illnesses

420

M. Linden et al. / European Psychiatry 22 (2007) 419e426

take a chronic course or when psychosocial factors play a major role in the development of the illness [1e4,7,12,14, 17,19,33]. Even in countries like Germany, where there are almost as many psychotherapists in outpatient general health care as general practitioners (about one licensed therapist for every 2000 inhabitants, who is providing longterm specific psychotherapy only, not including general psychiatrists), the majority of patients with depressive disorders are nevertheless treated with antidepressants and/or short term interventions or counseling only. There is a lack of research on verbal therapies and supportive counseling in psychiatric care. Although it must be assumed that psychiatric supportive counseling is the most often used psychotherapeutic intervention in the treatment of patients with mental illness, this has received very little scientific discussion and empirical investigation. It is unknown what role psychiatrists in routine care attribute to supportive counseling and verbal interventions when prescribing an antidepressant drug and in which cases they see this as important. 2. Materials and methods In a drug utilization study on venlafaxine, conducted by Wyeth Pharma Germany, psychiatrists who worked in inpatient or outpatient settings were asked to document prospectively and in a standardized way all cases in which they routinely decided to prescribe venlafaxine. Treatment decisions were not influenced in any way by the study but fully left to the discretion of the psychiatrist. There was no limit on the number of patients that a physician could include in the study. Venlafaxine is a widely prescribed antidepressant which is effective for all types of depression and anxiety disorders [8,10,15,24]. This allows the treatment of many different patients and psychiatrists to be observed. Assessments were made at the beginning of treatment (T0), after 7e14 days (T1), after 4e6 weeks (T2) and after discontinuation of venlafaxine, or at discharge from the hospital, or after 3 months at the latest (T4). At the beginning, sociodemographic characteristics of the patient were recorded. The treatment-relevant diagnoses were documented for reasons of validity at the end of the observation period in accordance with ICD-10 classification [45]. Assessments of severity were done with the Clinical Global Impressions (CGI) severity scale [13] and in the inpatient setting also with the Montgom˚ sberg Depression Rating Scale (MADRS) [35]. Informaery A tion was recorded on the course of illness (‘‘recurrent’’, ‘‘first manifestation’’, ‘‘chronic, relatively constant’’, ‘‘aggravation of a chronic condition’’), age of first manifestation, presence of delusional symptoms, psychotropic treatment history (multiple-response list of medication classes), antidepressant therapy within 2 weeks prior to treatment with venlafaxine and discontinued at the latest with onset of venlafaxine treatment (‘‘TCA,’’ ‘‘TetraCA,’’ ‘‘SSRI/SNRI’’ and ‘‘MAO-Inhibitor’’ were classified as ‘‘major antidepressives’’). The presence of concomitant diseases was documented and classified according to the World Health Organization (WHO) body systems.

The initial dosage of venlafaxine and the frequency of application per day were documented and the initial daily dosage was computed. Changes in dosage during the study period were documented and the maximum dosage was computed. Dosage values are reported in 18.75 mg/day, which amounts to half of a tablet with the lowest strength of TrevilorÒ, the brand name of venlafaxine in Germany. The medications prescribed in addition to venlafaxine were documented at the beginning of treatment and coded into medication classes. All major antidepressive classes plus ‘‘other antidepressives’’, ‘‘lithium,’’ ‘‘neuroleptics,’’ ‘‘tranquilizers/ benzodiazepines,’’ ‘‘antiepileptics’’ and ‘‘other psychotropic medication’’ were coded as psychotropic medication. Herbal medications were not classified as psychotropic medication. Physicians were asked at the beginning of treatment (T0) ‘‘Apart from the prescribing of venlafaxine, does the patient get for the treatment of depression (a) any additional pharmacological treatment? (b) any non-pharmacological treatment?’’. Both questions had to be answered in free writing. The second question uses the ‘‘pivotal topics method’’ [30]. In contrast to multiple choice lists, which can provoke predefined and/or socially desirable answers, the pivotal topics method elicits cognitive representations on what the physicians see as an ‘‘important’’ part of their treatment, which is worth reporting. After encounters with other persons everybody can say what the topic has been and what has been important. This does not reflect the ‘‘truth’’ but the personal view of the reporting person. What is reported depends on individual attributions, goals, or judgments. Whatever a psychiatrist may have done, it is first of all his/her judgment whether he/ she thinks he/she is doing, e.g. cognitive or analytical psychotherapy. Responses of the psychiatrists mostly consisted of one- or two-word phrases. The answers were classified according to the type of intervention by content analysis, i.e. whether they indicated unspecific activation, supportive counseling, cognitive-behavioral therapy, analytic psychotherapy, couples/family therapy, group therapy, verbal therapy with a psychologist, counseling by a social worker, occupational therapy, relaxation, music/art therapy, physical therapy, sleep deprivation, or ECT. They do not refer to a single session but the treatment of this individual case. For a random sample of 300 patients the physician responses were coded by two raters. Interrater reliability was high, with a kappa of 0.952. Patients who received at the third or final examination scores on the CGI of 1, ‘‘very much improved,’’ or 2, ‘‘much improved’’, were classified as responders, as well as inpatients whose initial MADRS score was reduced by at least 50% at the third or final examination. At the last examination the physician responded to the questions, ‘‘How good was the therapy in the view of the patient?’’ and ‘‘How good has been the treatment with venlafaxine, also in comparison to other therapies?’’ For both questions, the physician was asked to choose between the answers: 1, ‘‘very good’’; 2, ‘‘good’’; 3, ‘‘moderate’’; and 4, ‘‘bad’’. Adverse drug reactions (ADR) were documented at the second, third and final examinations and classified according to the Adverse Reaction Terminology (ADT) Version 3.0 of the

M. Linden et al. / European Psychiatry 22 (2007) 419e426

World Health Organization and then grouped according to the preferred terms. The ADR used in the analyses were judged by the treating psychiatrists to have a definite, probable or possible relationship with venlafaxine treatment. Reactions which were judged to have ‘‘no’’ relationship with venlafaxine therapy were excluded. It was documented whether or not therapy with venlafaxine was terminated before the end of the 3-month observation period and reasons for termination were reported on a multiple choice list with ‘‘marked improvement,’’ ‘‘patient request,’’ insufficient improvement,’’ ‘‘adverse drug reaction’’ or ‘‘other’’. All patient and illness variables, treatment variables, setting, and physician gender were included in a logistic regression. Backwards stepwise procedure was used and there was a cutoff level of p ¼ 0.05 for inclusion in the model. The indicator variables, CGI severity of illness, MADRS (inpatients only), concomitant diseases, initial dosage, maximum dosage and dummy coded with the lowest value as the reference value. Course of disease and treatment relevant diagnosis were effect coded, because there was no logical reference value. Patient age and age of first manifestation were included as interval-scaled covariates. The remaining variables were included as dichotomous indicators. One thousand thirty-one psychiatrists participated in the study, 14.7% of all psychiatrists in Germany [9]. Of these, 82.9% worked in outpatient settings and 15.8% in hospitals, 1.2% treated patients in both settings. 66.3% of physicians were male and 33.7% were female. There was a higher proportion of female physicians in the outpatient setting (35.0%) than in the inpatient setting (26.7%). An average of 5.4 (SD 3.5) patients were documented by each physician. Treatment of 6706 patients was recorded, of which 19.8% were inpatients and 80.2% outpatients; 66.7% were female. As can be taken from Table 1, recurrent depressive episode was the most frequent diagnosis (39.0% all, 41.2% inpatients, 38.5% outpatients), followed by depressive episodes (inpatient 31.5%, outpatient 26.7%), persistent mood disorders (17.5% outpatients, 4.5% inpatients), and bipolar disorder (7.9% inpatients, 6.3% outpatients). Seventy percent of patients were rated on the CGI as markedly, severely or extremely ill. Inpatients were more severely ill than outpatients. Inpatients had an average score of 32.7 (SD 9.0) on the MADRS. 3. Results 3.1. Frequency of non-pharmacological therapies In 25.6% of patients the psychiatrists reported at least one nonpharmacological (verbal and/or non-verbal) therapy (Table 2). Non-pharmacological therapies were reported twice as frequently for inpatients (45.6%) than outpatients (20.7%). The psychiatrists reported on average 1.6 non-pharmacological therapies (inpatient 2.28, outpatient 1.18) per patient with a maximum of 7. Verbal therapies were more often reported (22.5% of all patients) than non-verbal therapies (9.3% of all patients), both in the inpatient (36.8% verbal, 33.9% non-verbal) and outpatient

421

(19.0% verbal, 3.2% non-verbal) setting. The most commonly reported verbal therapy was supportive counseling (22.1% of inpatients, 12.1% of outpatients). Specific forms of psychotherapy were rare. Most often mentioned was cognitivebehavioral therapy (3.6% of inpatients, 1.1% of outpatients). Analytic psychotherapy, marital or family therapy and psychotherapy by a psychologist were mentioned in less than 1% of cases. Group therapy was mentioned in 2.6% of all patients (9.2% of inpatients and 0.9% of outpatients). 3.2. Inpatient and outpatient care Non-verbal non-pharmacological therapies were reported ten times more often for inpatients than for outpatients (33.9% vs. 3.2%). This is due to physical therapy (17.1% inpatient, 1.8% outpatient) and occupational therapy (21.7% inpatient and 0.2% outpatient). Music, art or dance therapy and relaxation were reported in 1.2% and social work was reported in 1% of all patients. Sleep deprivation, electroconvulsive therapy (ECT) and unspecific activation were reported for less than 1% of all patients. Of the 1021 physicians who worked exclusively in the outpatient setting, 39.2% reported verbal therapies for at least one patient they included in the study. In the inpatient setting, 115 (59.0%) physicians reported verbal therapies for at least one patient. The reporting of verbal therapies was not consistent across patients of one physician. Omitting the physicians who documented only one patient for the study, 6.4% of inpatient physicians and 5.6% of outpatient physicians reported verbal therapies for all patients they included in the study. 3.3. Patient characteristics There were no gender differences between patients with or without reported verbal therapy in either treatment setting (Table 1). Patients with verbal therapy were somewhat younger, had less often recurrent depressive disorders (33.4% vs.39.7% for outpatients, 35.6% vs. 40.1% for the total sample) and more often multiple diagnoses (9.5% vs. 4.9% for outpatients, 9.7% vs. 5.3% for the total sample). Outpatients with verbal therapy were on the CGI more severely ill than those without, while there was no difference in the inpatient setting as measured by the MADRS. Inpatients with verbal therapy were more likely to have had previous treatment with major antidepressives directly before therapy with venlafaxine. Outpatients with verbal therapies also had more concomitant physical diseases. Inpatients were generally treated with higher dosages of venlafaxine than outpatients (Table 3). Patients with verbal therapy got more drugs with respect to the initial dosage of venlafaxine, maximum dosage, and concomitant psychotropic medication. 3.4. Gender of physicians In the inpatient setting verbal therapies were reported more often by female physicians (49.5% of patients treated by

422

Table 1 Patient characteristics (VT, verbal therapy; No VT, no verbal therapy, %) Inpatient

Gender (female) Age mean (SD)

Outpatient

Total

VT (N ¼ 489)

No VT (N ¼ 841)

Total

Test

VT (N ¼ 1022)

No VT (N ¼ 4354)

Total

66.9 53.4 (15.2)

70.5 56.3 (15.1)

69.2 n.s. 55.2 (15.2) t ¼ 3.3, p ¼ 0.001

64.9 48.6 (13.4)

66.4 52.4 (13.9)

Test

VT (N ¼ 1511)

No VT (N ¼ 5195)

Total

65.5 50.2 (14.2)

67.1 53.0 (14.2)

6.4 27.8 35.6

6.7 27.6 40.1

66.7 n.s. 52.4 (14.2) t ¼ 6.8, p < 0.001 c2 ¼ 44.7, p < 0.001 6.6 27.7 39.0

6.4 33.2 40.0

8.8 30.6 41.8

7.9 31.5 41.2

6.4 25.2 33.4

6.2 27.0 39.7

3.3

5.3

4.5

19.8

17.0

17.5

14.3

15.1

14.9

1.4

0.6

0.9

2.7

2.8

2.8

2.3

2.4

2.4

5.4 10.3

5.3 7.6

5.3 8.6

3.1 9.5

2.4 4.9

2.5 5.8

3.8 9.7

2.9 5.3

3.1 6.3

Recurrent First manifestation Chronic, relatively constant Aggravation of a chronic condition Multiple responses CGI severity of illness

51.9 29.0 8.4 9.9 0.8

Not at all/borderline/mildly ill Moderately ill Markedly ill Severely/extremely ill Delusional symptoms MADRS 0e19 20e29 30e39 40e49 50e60 Age of first manifestation mean (SD) Medical history of major AD Previous therapy with major AD Concomitant physical diseases

6.5 17.1 42.7 33.8 14.8

4.4 18.0 47.8 29.8 16.7

5.2 17.6 45.9 31.2 16.0

8.7 26.4 39.6 20.6 4.7 44.7 (15.9)

5.9 31.2 41.2 19.5 2.2 46.4 (16.7)

81.8 57.9

Diagnosis

None 1e2 3e4

n.s.

n.s. 56.3 24.8 7.4 10.8 0.9

54.6 26.3 7.7 10.4 0.9

43.2 24.3 16.6 13.7 2.2

48.3 23.8 15.8 10.0 2.1

47.3 23.9 16.0 10.7 2.1

4.6 22.6 50.3 22.6 5.6

4.5 28.4 51.7 15.4 6.3

4.5 27.3 51.5 16.8 6.1

6.9 29.4 40.7 19.9 3.1 45.7 (16.4) t ¼ 5.9, p < 0.001

40.1 (14.7)

43.9 (15.3)

78.7

79.8

n.s.

66.2

67.1

43.2 (15.3) t ¼ 5.9, p < 0.001 67.0 n.s.

50.9

53.5

c2 ¼ 6.1, p < 0.01

37.8

38.3

38.2

52.4 38.8 8.8

51.2 39.7 9.1

49.6 24.0 14.4 10.1 1.9

48.8 24.4 14.3 10.7 1.9

n.s.

n.s.

c2 ¼ 60.0, p < 0.001 5.2 20.8 47.8 26.3 8.6

4.5 26.6 51.1 17.8 8.0

4.7 25.3 50.3 19.7 8.1

41.6 (15.2)

44.3 (15.6)

71.3

69.0

43.7 (15.5) t ¼ 5.9, p < 0.001 69.5 n.s.

44.3

40.3

41.2

58.5 35.5 6.0

63.4 33.2 3.4

62.3 33.7 4.0

c2 ¼ 10.9, p < 0.01

n.s. 49.1 41.3 9.6

46.1 25.8 13.9 12.4 1.8 c2 ¼ 34.0, p < 0.001

n.s.

n.s. c2 ¼ 12.7, p < 0.05

c2 ¼ 10.2, p < 0.05

n.s

63.0 32.8 4.2

65.5 32.1 2.4

65.0 32.2 2.7

n.s.

c2 ¼ 7.5, p < 0.01 c2 ¼ 25.2, p < 0.001

M. Linden et al. / European Psychiatry 22 (2007) 419e426

F31 bipolar disorder F32 depressive episode F33 recurrent depressive disorder F34 persistent depressive disorder F38 other affective disorder Other disorder Multiple responses Course of disease

66.1 n.s. 51.7 (13.9) t ¼ 7.7, p < 0.001 c2 ¼ 43.3, p < 0.001 6.3 26.7 38.5

Test

M. Linden et al. / European Psychiatry 22 (2007) 419e426

423

Table 2 Patients with non-pharmacological therapies in the inpatient and outpatient setting (%, multiple responses)

Any non-pharmacological therapy Verbal therapy Supportive counseling, total Psychotherapy, total Specific psychotherapy, total Cognitive-behavioral therapy, total Analytic psychotherapy, total Couples/family therapy Verbal therapy with a psychologist Group verbal therapy Any non-verbal, non-pharmacological therapy Physical therapy Occupational therapy Relaxation Music, art, dance therapy Sleep deprivation ECT Social work Unspecific activation Not classified Both verbal and non-verbal non-pharmacological therapy a

Inpatient (N ¼ 1330)

Outpatient (N ¼ 5376)

Total (N ¼ 6706)

Descriptive test

606 489 294 233 58 48 12 7 7

1114 1022 651 388 98 57 40 9 2

1720 1511 945 621 156 105 52 16 9

c2 ¼ 345.0, p < 0.001 c2 ¼ 192.6, p < 0.001 c2 ¼ 88.0, p < 0.001 c2 ¼ 134.7, p < 0.001 c2 ¼ 30.2, p < 0.001 c2 ¼ 5.8, p < 0.05 n.s. p < 0.05a n.s.a

(45.6) (36.8) (22.1) (17.5) (4.4) (3.6) (0.9) (0.5) (0.5)

123 (9.2) 450 (33.9)

(20.7) (19.0) (12.1) (7.2) (1.8) (1.1) (0.7) (0.2) (0.0)

50 (0.9) 170 (3.2)

(25.6) (22.5) (14.1) (9.3) (2.3) (1.5) (0.8) (0.2) (0.1)

175 (2.6) 620 (9.3)

c2 ¼ 300.9, p < 0.001 c2 ¼ 1199.6, p < 0.001

227 289 43 46

(17.1) (21.7) (3.2) (3.5)

95 12 40 32

(1.8) (0.2) (0.7) (0.6)

322 301 83 78

(4.8) (4.5) (1.2) (1.2)

c2 ¼ 546.1, p < 0.001 c2 ¼ 1150.3, p < 0.001 c2 ¼ 54.0, p < 0.001 c2 ¼ 76.0, p < 0.001

32 2 58 20 15 333

(2.4) (0.2) (4.4) (1.5) (2.1) (25.0)

0 1 11 1 29 78

(0.0) (0.0) (0.2) (0.0) (0.3) (1.5)

32 3 69 21 44 411

(0.5) (0.0) (1.0) (0.3) (0.6) (6.1)

c2 ¼ 130.0, p < 0.001 n.s.a c2 ¼ 180.9, p < 0.001 p < 0.001a c2 ¼ 59.1, p < 0.001 c2 ¼ 1031.0, p < 0.001

Fischer’s exact test.

female physicians, 31.4% of patients treated by male physicians, c2 ¼ 38.7, p < 0.001). In the outpatient setting there were no effects of physician gender.

and the diagnosis of recurrent depressive disorder decreased the risk ratio of reported verbal therapy. 3.6. Verbal therapies and treatment outcome

3.5. Factors which increase the probability of verbal therapies A logistic regression was calculated to put all variables in context and to study which variables still explain which patients did or did not get verbal therapies if covariance of other variables is controlled for. Inpatients were 2.40 times more likely to have verbal therapy than outpatients. Patients with concomitant psychotropic medication were 1.38 times more likely to have verbal therapies (inpatient odds ratio 1.73, outpatient 1.24). Younger patients (odds ratio for all and outpatient 0.98, inpatient 0.99) and those younger at first manifestation of illness (outpatient and total odds ratio 0.99), patients with multiple mental (odds ratio 1.43), or more concomitant somatic diseases (odds ratio 1.84) had an increased likelihood to get verbal therapy while patients with diagnoses of bipolar disorder (odds ratio 0.70) or recurrent depressive disorders (odds ratio 0.83), patients with more severe illnesses according to the CGI (odds ratio 0.71) or with delusional symptoms (odds ratio 0.77) had a decreased odds ratio of verbal therapy. In the inpatient setting, having a female physician was the strongest predictor for verbal therapy, with an odds ratio of 2.23, followed by a higher initial venlafaxine dosage of 112.5e150 mg/day and a lower MADRS score. In the outpatient setting, multiple mental and somatic diagnoses increased

Treatment results of patients with and without verbal therapy are shown in Table 4. In the total sample, there was no difference in treatment response as measured by the CGI Severity of Illness scale. In the inpatient setting, patients with verbal therapy were more often responders according to CGI and the MADRS, and physicians and patients were more satisfied with the treatment. In outpatients, the reporting of adverse drug reactions (ADR) was higher for patients with verbal therapy (38.3%) than for patients without (33.0%). There were no differences in ADR in the inpatient setting. Significantly fewer patients discontinued treatment with venlafaxine during the 3month observation period when verbal therapy was reported (34.0% vs. 43.1%) which was true for inpatients and outpatients. In patients with verbal therapy, reasons for discontinuation (recovery, insufficient improvement, ADR, or patient request) were significantly more often insufficient improvement (32.5% verbal therapy, 27.1% without verbal therapy) and patient requests (47.9%, vs 41.4% in outpatients). 4. Discussion Additional to drug treatment, verbal interactions between patient and psychiatrist, counseling, or supportive psychotherapy are important parts of psychiatric care. Nevertheless, there is a lack of studies on theoretical concepts of

M. Linden et al. / European Psychiatry 22 (2007) 419e426

424

Table 3 Verbal therapy and pharmacological treatment characteristics Inpatient VT (N ¼ 489)

Outpatient No VT (N ¼ 841)

Total

Test

VT (N ¼ 1022)

Total No VT (N ¼ 4354)

Total

c2 ¼ 10.2, p < 0.01

Initial dosage 0e75 mg 112.5e150 mg 187.5 mg Maximum dosage

75.9 21.6 2.5

0e75 mg 112.5e150 mg 187.5e225 mg 262.5 Concomitant psychotropic medication Yes

16.6 35.8 26.6 21.1

83.1 15.0 1.9

80.4 17.5 2.1

Test

VT

No VT

Total

c2 ¼ 20.8, p < 0.001

n.s. 94.6 5.4 —

94.0 5.6 0.4

94.1 5.6 0.3

Test

88.5 10.7 0.8

92.2 7.1 0.6

91.4 7.9 0.7 c2 ¼ 59.9, p < 0.001

16.0 37.4 28.2 18.4

16.2 36.8 27.6 19.4

n.s.

53.4 39.7 5.7 1.2

54.3 39.8 4.5 1.5

54.1 39.8 4.7 1.4

c2 ¼ 14.1, p < 0.001 83.2

74.3

77.6

n.s.

41.4 38.5 12.5 7.6

48.1 39.4 8.4 4.2

46.6 39.2 9.3

c2 ¼ 11.5, p ¼ 0.001 46.7

non-pharmacological treatment of psychiatrists and a lack of empirical investigations on their role and effects under conditions of routine care. We could not find a similar study to ours. Respective publications mostly refer to general practitioners [5,34,41,43]. Our data are based on observational data from a very large sample of physicians (N ¼ 1231) and patients (N ¼ 6706), including inpatient and outpatient care and using the same methods in both settings. The participating physicians took part in a drug utilization observation study of venlafaxine, an antidepressant that is prescribed for a broad spectrum of depressive disorders, thus allowing a broad and differentiated patient sample to be studied. This is no RTC which would allow to test efficacy of predefined interventions but an observational study which can tell what is done by psychiatrists under conditions of routine care. The first important finding of this study is that verbal therapy was reported in 36.8% of inpatients and 19.0% of outpatients and specific forms of psychotherapy in 2.3%. Obviously, psychiatrists did in the majority of cases not see non-pharmacological or verbal treatment as important enough to be reported as part of their ‘‘treatment’’ of depression additional to prescribing an antidepressant. This supports findings from Michels [33] that most verbal/psychotherapeutic interventions in routine practice are rather unspecific. Verbal therapy is preferably reported in younger patients, patients with more complex illnesses (more diagnoses, greater severity), but less specific forms (bipolar or delusional depression) of depression. Verbal therapy is part of an overall more intensive treatment, as these patients also got more drug treatment. This supports findings from other studies [40,44,46]. An interesting finding is that gender, i.e. female physicians, is associated with higher rates of verbal therapy which points to a physician factor [26,31]. More important is the setting for the explanation of treatment style. As can be expected, inpatients are not only different from outpatients but also get different treatments [25,29], i.e. more verbal therapy and especially more special forms of non-pharmacological interventions such as occupational therapy, physical therapy, or

40.9

42.0

c2 ¼ 69.8, p < 0.001 58.5

46.3

49.0

art therapy. The inpatient setting can therefore be characterized by more intensive treatment, pharmacologically and psychotherapeutically alike. Although patients who get verbal therapy are rated to suffer from more complex illnesses, they nevertheless show lower drop out rates and better treatment results (74.1% vs. 65.8% responders). This also replicates findings from Judd et al. [23] who found that the addition of ‘‘focused education’’ could further improve effectiveness of venlafaxine treatment. Patients and physicians also expressed greater treatment satisfaction with the treatment. Of special interest in this context is that more ADRs are reported in patients with verbal therapy. The reporting of verbal therapy obviously is a sign of a generally better patientephysician communication, so that physicians are more aware of patient complaints. But, our data show that a better awareness of side effects does not mean more but rather less drug discontinuation. Limitations of this study are that there is no external validation of whether reported therapies actually took place or not, to what extent non-pharmacological therapies were not reported, how long ‘‘verbal therapies’’ lasted [38], or what their content has been. Also this is not a survey of a representative sample of physicians and patients but only of cases which have been treated with venlafaxine. Therefore the psychiatrists have been ‘‘drug therapists’’, so the data only tell about ‘‘nonpharmacological treatment of psychiatrists in addition to the prescribing of an antidepressant drug’’. They cannot tell how psychiatrists work who are preferring psychotherapy. The question is to what degree our findings can be generalized to other patient and physician samples. Irrespective of these limitations, the data suggest several conclusions. More research is needed to develop theoretical models and manuals for psychiatric counseling, as this undoubtedly is an important and indispensable part of psychiatric patient care. Randomized controlled outcome studies are needed to confirm the beneficial effects of counseling, as our observational study is no proof of such effects. Also, studies are needed to test the effects of psychiatric counseling in

c2 ¼ 5.6, p < 0.05 34.3 65.7 33.6 66.4

29.0 42.0 18.8 10.2 29.6 43.9 18.0 8.4 n.s.

33.0 67.0 Yes No

33.9 66.1

36.9 63.1

35.8 64.2

n.s.

38.3 61.7

29.9 41.5 20.0 8.6 c2 ¼ 14.4, p < 0.001 25.6 45.9 18.6 9.9 23.7 44.0 21.3 11.0 28.9 49.2 14.0 8.0

Non-pharmacological therapies are an important part of psychiatric routine care to which psychiatrists should give greater attention. The data raise questions which need thorough further research: Is the rate of specific psychotherapies too low? In which cases is supportive counseling sufficient? In summary, there is a need for better conceptualization of supportive psychiatric guidance and counseling, i.e. the type, form, content, and effects of non-pharmacological and especially verbal therapies [5,18,22,28,32,34,41,42]. References

34.0 66.0

30.1 41.6 18.6 9.7 30.1 41.6 18.3 10.0

28.5 36.5 16.4 18.7 28.6 36.3 16.0 19.1 27.9 37.1 18.3 16.6 25.3 38.3 17.5 18.9 22.1 48.9 16.2 12.8

24.1 42.4 17.0 16.6

5. Conclusion

36.9 63.1

28.0 36.7 16.2 19.1 26.0 41.1 17.6 15.3 n.s.

43.8 44.8 39.5 c2 ¼ 15.9, p ¼ 0.001 30.2 34.6 22.6

Yes Patient satisfaction Very good Good Moderate Poor Physician satisfaction Very good Good Moderate Poor ADR

425

comparison to specific psychotherapy. This is a prerequisite for directing patients to different treatments. Finally, all teaching courses for psychiatrists should include training sessions on psychiatric counseling.

c2 ¼ 10.4, p < 0.01

43.1 34.0

27.6 37.7 16.5 18.2

29.2 42.4 18.6 9.8

n.s.

c2 ¼ 38.3, p ¼ 0.001 41.0

c2 ¼ 38.3, p < 0.001 c2 ¼ 9.0, p < 0.01

n.s. 68.0 N/A 67.4 N/A 67.9 N/A 65.8 61.3 74.1 69.7

CGI responder MADRS responder Venlafaxin discontinued

No VT (N ¼ 841)

68.9 64.5

c2 ¼ 9.6, p < 0.01 c2 ¼ 9.2, p < 0.01 c2 ¼ 20.5, p < 0.001

67.7 N/A

67.8 N/A

n.s.

70.0 N/A

Test Total No VT (N ¼ 5195) VT (N ¼ 1511) VT (N ¼ 1022) Test VT (N ¼ 489)

Table 4 Verbal therapy and treatment outcome variables

Total

Outpatient Inpatient

No VT (N ¼ 4354)

Total

Test

Total

M. Linden et al. / European Psychiatry 22 (2007) 419e426

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