Elsevier

Journal of Affective Disorders

Volume 187, 15 November 2015, Pages 35-44
Journal of Affective Disorders

Research report
Symptom course in inpatient and day clinic treatment of depression: Results from the INDDEP-Study

https://doi.org/10.1016/j.jad.2015.07.025Get rights and content

Highlights

  • Severely impaired patients with MDD can be treated in a day hospital setting.

  • The effectiveness of day hospital and inpatient psychotherapy is comparable.

  • In patients with co-morbid somatic illness, inpatient treatment might be preferable.

Abstract

Background

In major depression (MDD), hospital treatment is an option in more severe cases or if outpatient treatment failed. Psychosomatic hospitals in Germany provide treatment programs with multimodal psychotherapy, either in an inpatient or a day hospital setting. In the context of health care research, this study aimed (1) to compare characteristics of patients treated in psychosomatic day hospitals and inpatient units, (2) to compare the effectiveness of both treatment modalities.

Methods

A naturalistic design was chosen to achieve external validity. 604 consecutive patients were assessed at admission, discharge and a 3-month follow-up. Primary outcome was defined as a reduction of depressive symptomatology (QIDS-C), secondary outcomes comprise overall functioning and quality of life. For a comparison of effectiveness, inpatient and day hospital samples were matched according to known predictors of outcome.

Results

The few differences found between the inpatient and day hospital sample were related to severity of depression and physical impairment. Inpatients more often got antidepressant medication. Additionally, inpatients were treated significantly longer, due to a subgroup of patients with somatic co-morbidity. There were no differences when comparing effectiveness.

Limitations

When comparing treatment effectiveness, possible bias cannot be ruled out. There was no randomization or untreated control group.

Conclusions

In patients with a more severe depression and somatic co-morbidity, inpatient treatment might be preferred as compared to day hospital treatment. However, most patients can be treated in both settings.

Introduction

Major depressive disorder (MDD) is one of the most common diseases and a leading cause of disability worldwide (Jacobi et al., 2004, WHO, 2004). Most often it presents as a chronic and recurrent disorder (Biesheuvel-Leliefeld et al., 2015). Although most of the patients with MDD can be treated in an outpatient setting, there is a group with insufficient improvement (Driessen et al., 2013, Cuijpers et al., 2014) as well as a group of more severe or complex cases in which inpatient or day hospital treatment is indicated (DGPPN, 2009; NICE, 2009).

In day hospital programs, patients return home in the evening and over the weekends (Seidler et al., 2006, Marshall et al., 2001). Advantages of day hospital treatment include the daily transfer of experiences (home↔hospital) and an emphasis on self-reliance. This might allow an easier transfer of experiences into everyday life and reduce the risk for relapse (Zeeck et al., 2009c, Zeeck et al., 2009d, Mörtl and von Wietersheim, 2008). However, inpatient treatment can be considered more “safe and containing” as patients are accommodated in their own rooms and staff is available for 24 h. Inpatient treatment allows a respite from everyday life with its tasks, challenges and sometimes dysfunctional social relationships, but might invite to “give up responsibility” and support an escape from problems at home (Zeeck et al., 2009a, Zeeck et al., 2009b).

Psychosomatic inpatient and day hospital treatment programs in Germany are characterized by a strong focus on psychotherapy as the main treatment modality (Zeeck et al., 2009a, Herrmann and Huber, 2013). Like in other mental healthcare institutions, patients with a diagnosis of MDD are the largest diagnostic group, with about 40–50% of all patients treated (Liebherz and Rabung, 2014). Because of the lower costs of day hospital treatment, there is a current debate on the proportion of day hospitals and inpatient units that should be provided in mental health care in Germany. Thus, the question of differential indication has become highly important: To what extent can day hospital treatment replace inpatient treatment? What are criteria for suitability of inpatient versus day hospital admission?

A systematic review on studies comparing inpatient and day hospital treatment in mental disorders found similar effectiveness in patients, for whom both settings are suitable (Marshall et al., 2001). Most of the 10 studies included were conducted in psychiatric hospitals and reported on heterogeneous samples in terms of diagnoses. Overall, we could replicate this finding for psychosomatic hospitals (Zeeck et al., 2003, Zeeck et al., 2009a, 2009b), but found differences when focusing on single diagnostic categories like eating disorders (Zeeck et al., 2006, Zeeck et al., 2009c, Zeeck et al., 2009d). One small randomized controlled mono-center study compared the effects of psychosomatic inpatient versus day hospital treatment in depression (Dinger et al., 2014). No difference between treatment modalities was found, but the study was too small to distinguish between subgroups of patients.

The research project described subsequently can be understood in the context of health care research. We tried to overcome limitations of previous studies in focussing on one diagnostic category only (major depressive disorder, MDD) and in conducting two follow-up assessments to assess the “transfer phase” after discharge as well as more long-term outcome (one year follow up). Furthermore, we used a naturalistic design to achieve high external validity, structured interviews to assess symptomatology and included a broad range of variables known to be relevant for treatment outcome in MDD to describe and compare the patient samples (demographics, aspects of depression, overall functioning, traumatization, social support and interpersonal problems).

This first report on the INDDEP study (“Inpatient and Day Hospital Treatment for Depression”) had the following aims:

  • 1.

    To describe characteristics of patients with MDD usually treated in inpatient units and day hospitals for psychosomatic medicine (providing multimodal psychotherapy)

  • 2.

    To assess and compare symptom courses and outcome (admission→discharge→3-months follow-up) of inpatient vs. day hospital treatment

Section snippets

Methods

A naturalistic design was chosen to achieve external validity (study protocol: Zeeck et al., 2013) as we expected only a minority of patients to agree to a randomization procedure when admitted to a hospital. Furthermore, we assumed that there would be considerable resistance to such a study in non-university centers. For a comparison of inpatient and day hospital treatment, we choose to match samples according to known predictors of outcome. The study was approved by the University of Freiburg

Sample

Out of 2164 patients admitted with a main diagnosis of MDD during the recruitment period 604 were included in the study (see Fig. 1). A sample description of the whole sample (N=604) and matched samples (N=500) can be found in Table 1. Through the matching procedure the sample was reduced to 83% of the original sample (expected reduction: 20%; see study protocol).

Comparing patients admitted to inpatient units vs. day hospitals (whole sample)

There were some significant differences when comparing inpatient and day hospital samples at T0: inpatients were more impaired in

Discussion

One aim of the INDDEP-study was to characterize patients with MDD treated in psychosomatic hospitals. We further aimed to compare patients and symptom courses in two treatment modalities: inpatient and day hospital treatment. This comparison is highly relevant, as day hospital treatment is less cost intensive and may be better or less suited for subgroups of patients.

Previous studies on intense, multimodal psychotherapeutic hospital treatment in MDD were either conducted at a single center and

Role of funding source

The INDDEP study was funded by a grant from the Heidehofstiftung GmbH Stuttgart (No. 59055.02.1-4). The Heidehofstiftung had no influence neither on the study design, the collection, analysis and interpretation of the data, nor in writing or submitting this manuscript.

Contributors

A.Z. is the principal investigator of the study and was responsible for study coordination. She wrote the manuscript. Jv.W. is the co-investigator and A.H. the leading biostatistician (he conducted the data analysis). H.W. made essential contributions to development and design of the study. M.B., P.R., A.V., A.He. and A. E.-H. were coordinators for recruitment at cooperating hospitals. K.E. and J.K. were responsible for the assessments and study management in Freiburg and Ulm (coordinating

Conflict of interest

The authors have no conflicts of interest, related to this manuscript.

Acknowledgments

The authors would like to thank all participating centers and research assistants, in particular: Sabine Hermann and Elvira Bozykaya (University of Freiburg), Franziska Kunzl (University of Ulm), Anja Kidess (Robert-Bosch-Krankenhaus, Stuttgart), Johannes Becker-Pfaff (Bürgerhospital, Stuttgart), Caroline Linn (Fürst-Stirum-Klinikum Bruchsal) and Antje Haselbacher (University of Mainz).

References (50)

  • S.A. Baldwin et al.

    Analyzing multiple outcomes in clinical research using multivariate multilevel models

    J. Consult. Clin. Psychol.

    (2014)
  • M. Barkham et al.

    The IIP-32: a short version of the Inventory of Interpersonal Problems

    Br. J. Clin. Psychol.

    (1996)
  • B.J. Becker

    Synthesizing standardized mean-change measures

    Br. J. Math. Stat. Psychol.

    (1988)
  • D.P. Bernstein et al.

    Childhood Trauma Questionnaire – A Retrospective Self-report Manual

    (1998)
  • M.E. Beutel et al.

    Psychoanalytic versus cognitive-behavioral therapy for chronic depression: study protocol for a randomized controlled trial

    Trials

    (2012)
  • A.S. Bryk et al.

    Application of hierarchical linear models to assessing change

    Psychol. Bull.

    (1987)
  • J. Dekker et al.

    What is the best sequential treatment strategy in the treatment of depression? Adding pharmacotherapy to psychotherapy or vice versa?

    Psychother. Psychosom.

    (2013)
  • U. Dinger et al.

    Day-clinic and inpatient psychotherapy for depression (DIP-D): a randomized controlled pilot study in routine clinical care

    Psychother. Psychosom.

    (2014)
  • DGPPN, BÄK, KBV, AWMF, AkdÄ, BPtK, BApK, DAGSHG, DEGAM, DGPM, DGPs, DGRW, 2009. S-3 Guideline/National Treatment...
  • E. Driessen et al.

    The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial.

    Am. J. Psychiatr.

    (2013)
  • G.A. Fava et al.

    New modalities of assessment and treatment planning in depression

    CNS Drugs

    (2010)
  • M.B. First et al.

    Structured Clinical Interview for DSM-IV (SCID)

    (1997)
  • G. Franke

    Symptom-Checkliste von L.R. Derogatis-Deutsche Version

    (2002)
  • M. Franz et al.

    Effectiveness of psychodynamically oriented inpatient psychotherapy on deression associated symptom load – findings from the STOP-D study

    Ärztliche Psychother. Psychosom. Med.

    (2014)
  • T. Fydrich et al.

    Fragebogen zur sozialen Unterstützung (F-SozU): Normierung der Kurzform (K-14)

    Z. Med. Psychol.

    (2009)
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