1987 - Early Subjective Reactions Predicting The Outcome Of Hospital Treatment In Depressive Patients

Acla psychiatr.scand.1987:76:134-138 Key words: depres,oni Fychralnc lheGpy oulcome p.ed'c

Early subjectivereactionspredictingthe outcome

patients oI nosDltaltreatmentln depressive Oepanment ot Psychialry 66ad: Proaeser ol Be.lin,W€slBenin, H. Heiochen),FreeUniv€rsity

AASTR,\CT Earl) nrremeos b\ 1l ddpressivcInparens abour a subjeclve changeLn rhcr $ndnion ind abour rheir atnude ro proposedrreatmenrqcfe e\anined. Ihese naremena. mlde on rhe da! aiter admission,*ere found lo co(elare {irh rhe ourcomeol !he rrearmenr li *as iound rhar early subjec'ive reacrionscan Indicarero tome.rrenr- not onlv rhe rciult ot hospnalrrearmenrior depre$tre rr_mproin. bur rllo rhe ourcomeme.rured b! obje.lvc and subjeclve crnena, afier ! I ro I monrh ioLlowup. Re.etwdJanuorr !6. l93i: urceptedfar prbtnatian Februatr I, 1987

The aim oi this study was ro resr whelher the t n f y i n g r o i m p r o r ed e d s i o nas b o u lt h et l p e a n d q u e s ! i o n p \ ! c h i a r i . I r e c t n e n r s r, h e odrcomeof such a cornpler proces as hospnal c o u r s eo l p 3 r i e r l j . a d r _ r e a c l i o n s r a nt r e e r n e n r( N i r h a l l i t s ! a r i o u s t h e r a p e u r racp a r o s e r sr o h o { l r r r h e p f e d i c r b e s e e nI o r h c c \ e n r u a lo u r . o n e o l e proachet, could .ho be predicredby looking .rl p a r i e n r se ! r 1 ys u b l e c r i vrec a c t i o n s . I I h e r a p e u lm i cc r h o d h , \ h ! s b e e ne \ a d j n e dN i r h i n ! a r i o u sr h e r a p e u racp p r o ! c h e \E a . l - v . e a c r o n s a n d o u r c o n e th . \ e . l s a \ s b e e tr e l a r e dr o a p a l r i c u l i r m c r h o do l r . e e r m e n(rh. i . h m a ! b e a p s r _ Method symproms i ce l n All paliens wirh subjecrivedepressive chorhe.rpeuro i . r r s o m a l o r h e r a p e uor n b o r h i n d i \ i d u a l p \ t . h o r h e r a p v( l ) a n d l a m i l t (Von Zensendepresion scalesDS + DS' > 24. Ds{core ol 12) , h r c h. a n i r ea s s e s c d u L a . . o r d i n c ! o a t h e ' a p v( l ) , ! a . i a b l e sw i n e o r a n c r ! h . l , 6 t s e s \ i o i .h a ! eb e e ni o u n dr o a d n i t r e di D I l / : m o n r h s i n I 9 6 5* e r e e x a n r n e d . , olaa r f f e c t i v ea,n d i n d j c a r er.o ! o d e e \ t e n r .r h e p r o e r c sosf I h e p a - P a t i e n rws i r hs c h i z o p h r e n bi ci p r i e n ra n d I h e d i r c c u o no r t c r t m e n l L u b o n k ye r organic disorden Nere excludedbecauseol rhe a l - ( l ) s h o \ r e d( h a (p a r i e n !\\ h o l i r u n dr h ee \ p e . i - dificrent concepc of illne$ io. thesediso.ders. c n c co f r h . r a p vi n d r h e . i p s rh e l p f u la n e r e a r l y A p a . r f t o m r h r s e \ c l u \ r o . , t h e r ew a s n o o l h e t .esrncrion.Depresilc 5ymprodssere selecledas s e s \ i o n3sr em o r cl i } i c l rr o b e n c l i e r \ e n r u a l lf' r o n p s \ c h o p h a n n a c o l p s t c h o r h e r a p \S i n i l a r l r . n r a c ' i r e . i o nf o r i n c l u s i o na n d e v a l u a l i o nb, e c a u s c di5or o g r . a ! g n i i i . a n r . o r e l . r i o n * a i f o u n db e t t r c c n c \ e . i n c a s crsh a ta r en o t p r i m a r yd c p r e $ i v e ( . 1 be regarded as symprons can 6 ) . dc6, depresile s u b l e c r n e' n j r i a L. e 5 p o n \ ersn d o u r . o n e ' ' S u b j e d n e i n i t i a l i e s p o n s e "m e a n s p a t i e . l s e s p c c i a l lrte l e ! a n tr o r h e p a t i e n t ' s ! f f e r i n sa n d i n d i r e . r l yI o h i s a d D i 5 s i o t. o h o s p i t a l . {aremen6 madc shodlv afrer the begrnningol T h e e a r l i s u b j e d i v cr e a c l i o nw a s a s s e $ e di n r r e a r m e n rq h c r h e rr h e r l c l t J i f l e r e n r l ta i t e rr h e .t l i ' s r u r o f d r u e \ . r n d s h e r h e r h . r r h o u g h r h e ! r h e r f t c r n o o n o i r h e d a ) a l r e r a d m i s s i o nB * o u l d . e . f l \ e r h e f i s h rm c d i . a r i o n r h . n . r h e . e g d l . f i r r e n s ' ! ep 5 r . c h i a r rei cx a m i n a

PFEDICT'NG OUTCOMEIN HOSPITALIZED DEPFIESSIVES B 5 rheir presenrcondition eirher b]' lelephoneor by

Termtr,a'ionol B.Binn'ngot

Characteristics of the sampleand psychiatric treatments the

The rypeand couAeof r.eatmen!.and outcomeof 4 l p a r i e n r {, . 1 0t e m a l e .l l m d l e l* e r " . \ r m i n e Then ?ses ransed from :l to 8l (mean = 50) years.For 2l parien$rbis was rhe iAst adnission Ob5d5rnccompukNe ftu.oes 1o a psycbialrichospiral.Thifly'rvo patientshad p r e ! r o u ' l rr e c . r r e dp \ ) c h o r r o p rm c edicdnoa nnd ( o m e r o ' r of p\ychorherap, n i n eh a d u n d e r g o n e b e f o r e . f h e d i s r ' i b u ' i o no f p I m a r y p ' y c h i a r n . diagnosesa! lerminadonand the bes'nninsof u e a r m e n ra c . o r d i n Sr o I C D - Qc i a $ i f i c a l o n ( q ' are shown in Table l. The diasnosticjudgemenr c h a n e e df o r o n l ) r h r e e p a , i e 1 ! ' d u r i n g r h . r e a r m e n r I. n t i v ep a r i e n r .t.h e\ e c o n d a rdy i a s n o sis was drug abuseor dep€ndence. I o n b \ ' h < p * c r r " r r . i . h 3 J ' , r e " d rr J l e n p l d c c . lor ,he *hole,ample rhem(cn \o-e on rhe V - , l i ( : i r n h - , 1 n o ' J e r . r , r ' . 1 r o r ! n \ p i f i e n r H d m , l r o n5 . d l r w r ' ' l q a r r h e b e g ' n n i n s , r J n s e : _ o , a n d b r r r h ee n do t r h e r r e a r m e n l An inrervrewcr,who sas nor n'ohed in .ny wav b 4 0 , . 6 . 0 r .O n v o n Z c t s c n D e p t c . s i r h r h e r r e a r m e nLr a r eo. n . $ k e d r h e p a r ' e n r s ( r " n ! e 0 2 8 . ' l'or'r1 .ll s i o n S c a l e (sD S * D S ' ) , t b e n e a n s c o r ew a s 5 1 , nd2?(range P o . , b ( " n . q e r r e r c : o c . i r r - n . L n . h J r s e d . ( r a n g e2: , 18 0 , s = l i l . 8 ) i n i t i a l l y a ' r ( ' r = , . l e d . 1 15, s 1 8 . 8 )b e i o r ed i s c h a . g eT. h e F a t i e n r i or sor e ,hJnber T r( . 1 . , / r r h ( r r ( r ' h r r D r l r r ' c Jr l e \ \ . i db e e . e i \ ' r dh . srayedin hospital fo. berween3 and 223 day5 r g n f i e - t n . r ' o r b l F . t q ( r ' * e r e v ( . (nean = 58, s = 36). They werelrearedo. iive r n d e . i d e d- n . l n O r ' h . , e , n o o n, l e h c .lifferent wards by 12 psychia$is6. Dudne rhis anridepresives,l2 receiv' d J , o ' r d m r - , o a . d o n n ( " r ( e ' n o o r b e f o r e time,l2 pati€ntsreceived r r e d r ! o r d r . c h - r s e .r l ' ( P ' r r e n r . d e p t e - i \ r €d neuroleptics,four receivedbenzodiazepines, t m p r o m . $ e r e J . . e . \ e d b ' i e p . r . h r a l n . l ' and rhreereceivedlithium- Six palientsdid nol re' u s i n gr h e H . m i i r o n D e p . e 5 ! o nS . a l e ( i ) , a n d ceive any medication.On an average.2.1 dii5 e l lr a r e do n r h e \ o n Z e n s e . D e p r e s i o nS c a l e s lerenrpsychorropicdruss per pat,enlwere8iven. 1 8 ) . F i n a l l y , b e i o r e d i s c h x ' _ ! ep. a r r e n r sw e r e Tuo parienKreceivedelectroconvuhiveIh€rapy. a s k e d .$ h e l h e . ( h e r r e a r m e nar 5 a s h o l e h a d Besidesrhe ord'na.y p.ogramde on lbe ward, b e e nm o r e .e q u a l l \ .o r l e $ j u c c s s f u tr h a nI h e r specialoccupalional!herapyrook place with l: pallenrs.The typeand amount o I psychotherapeuh a d e r p e c l e d' n r h e b e g r n n , n s H o \ c v c r - i ! s e e m e du n ! 3 r i r f a c r o rIyo d e r e r tic acri!ities dependedvery much on rhe narure psychorherapeuric n i n e r h e s u c c e so t h o s p ' I a:l r e a r m e nb! ) e x c l u - and errenrol !he psychiarrjsrs' !!.1) usns lariabl- rvhirh ae.e asesed durins r r a , n i n sa n do n r h ew a r d ' sa t n o s p h e r ae l d s t a f f . ( h e k e 3 r d e n ri r s e l f :p a r r i c u l a r llvn c e t . e : l m e n t The rherapcuticacti!ilies itcluded parrly group . u s r ci h e r a p y onll ended when rhe pariers were iii io be t h e r a p ya n d ,w i r h o n e p a t i e n t m . r d r s e h a r g e dT.h . r e , o r e ,c h e . r j $ e r e m a d e I n o n r h s a , r e . p a o c i 6 w e r e l j s c h a r , q e dr o- s e e Flesults s h e r h e rr h e v h a d b e e nr c a d m r r r e1do r p \ ! . h ' ' palients, aric hospnal in rhe meinhne. Those Asked how rhey fel! after rhe ii6I pslchiarric who had dot beenreadmitred.wereaskedabout e\aminarion, l5 patienrs said rhcy ielt belte.

136

S. PFiIEBE

'i'-:::l:llli.lij." sa,er(Ds- DS) md!'m'konD're!srcn,::i:-i: lX:; :".., ., ".. ,.",.. "."res'on

'* '^" "'

Condn'on and r'dl eiamrnafon

(henn' rhe feltnenl had beencompared\virh the r i a l e x p e c l a t i o n sl i, p a l i e n ! sl h o u g b t ! h a I equall\ 1: llearnenl hid beenmore luccc$iul { r c c e $ f u l .a n d l l l e s ss u c c . s s l ut lh a n I n e ! n a o erpectedlt (he b€sinnine The\eanssersshoved a moden. bu! sisnlii.lnt polrile correlatlon Nherher w i r h r h e P a l i e n r s ' c a r l r(_a t e m e n 6 o n r he flPnl f e c e i ! r n g b e " o u l d r h e vb e [ e \ e dr h e v < 0 05) P + 0 l e . I a u r . e a r m e n l(K c n d r l l trearedcor !atienl! who iniliallr_.{pecred1o be rhe judee afierwards to orien more recrlr rended s u ' c e $ ru' m o r e b e e n h a r i n s a 5 w h o l er l e a r m e n t l h e * p e c t m l $ h o d i d P a l i e n l s . r h a ne \ p e c r e d oeen risht rieatmenr,tendedto iudgert as navrne lhan erPecleo even le$ successul pro l n o r d e r! o e v a l u a t teh e p a l i e n r sf'u r t h e r * ere p a o e n G e r e s . l r o t m o n r h sa n . r d i ! ' h a r g e * h e r e lne g r o u P d i v i d e di n t o r N o g r o u p s ro n e or more as regarded hospnellrearment.ould be lr'at where group' le$ succesfui, and anolher a d e n r . o u l d b e l a k e n3 5 h a \ i n gf a i l e d a p p l v ' n g j u b j e c t i v e c n r e r i a' a n d of objc.ri\e conbrnarion htrle 'o iudsed Parienrs$ho!e resultsare summanzed been failed Nere thoseNho had rn Ihe mesnr'me succe$ful ho$ Belore discharge when ssked

was un than before, l9 said their condnron lhan rcise Ms n said seven ard chaneed. tne! {herhef queslion second On the beiore. treaL believedlbey {ould be receivinglhe ilghl case mem, l7 pali€ntsbelievedthat ihrs was lhe {ourd thev Is *ere undecided,and sii rhoughr no! be receivingrhe rieht tr.arment Tbe answ€rs ro rhe two quesrionsdid not show significant c o d e l a t i o n( K e n d a l l st a u = 0 0 2 n s l for neirherot lhe lwo questionsdid lbe rhree or nesariveearlr sroups wilh posirive,teurral, i! 'eacdonsdiflei sisnificanrll" rhe scoresol rhe Hamilton Scaleor rhe von Ze6sen Depresion Scaleat lhe beginning.Regardinsihe neverrhe' 'n less appar€nl dilterences,one should bear oav rhe on rilted wete scores ftind that lhose after admission,!o thev could have been inilu enced by chansesin accordancewnh the earl! reactions.Yet at the end there were Indr'alloni r h d rp J t r e n rs: r r h P o n r i v .E r h e l o $ e : r \ c o r e . ,r n d p J s e r r ' s i l h r n e g r i r \ ( r e . p o n . er h e h r e n e ' (s c o r F l l I J b l e l ' h c \ e

DEPRESSIVES I3'7 PBEDICTING OUTCOMEIN HOSPITALIZED

companion or.!rly subj.c'ive.. by obja'te and subie.ivc fn.i

co^dnion rl@ t^t

.nnudor

co.drnn

Nninara,

chri -

rhe righr < 0.05):

ar.t t6t

3. df = I, P < 0001

r e a d m r r e dr o a p s l c n i a u i cL 1 o ' p i ' J(l f i \ e p a r i e n h ) ;a n d t h o \ e .w h o d i d n o r * o r l \ r r r h ee n . of rbe follow up pe.iod, alrhooghrheyhad been wo.kins when admitred ro hospital (iour Pa tients).A subjecrivecrirer'onoi Iailureqas when palientssaid their condition was the sameG.!en patienls)or even*orse (two palientslthan aI the time of admission.Becauseon. patient fuliill"d rhe two criteriaof nor working (despnethe ablf i1y ro work when adnitred) and oi ltelins the sarneas at rhe rjme of admissjon,lr parr.n6 were eventuallya$e$ed as failures.TheseI*o sroups Guccesesand failures) Nere.ompa.ed (usjngrhet e.rrlyslaremenls)reeardinsI .hinle e\am in rheir conditionafte. rhe firn psYcirrarnc inarion. A difierence was mrde onlt belNeen patienrswho ielt berreraiter the iirn pr!chratnc inie.view, aod !hose who srated(herr .ondnron w a s u n c h a n g e do, . w o ( e l h a n b e ' o r e .w h ' . h s h o i h o N e da p o s r lhe palrent$ m e a n sb e t w e e n rjve earl! subjeclivereacr'onald rhoje \eho did n o t . T h e d i s l r i b u t i o nc a i n e db \ I h r t c o m p a n s o n i s s h o * n i n T a b l e3 . A p o s l i v ee a r l yr e a c o o ni n l h e d e l i n n i o nu \ e d hereis, with one exceptlon,1nno .rse 3ssoc'ared with a failure asesed rter rhe follotr_uppenod: w h e r e aw s n h n e u l r s lo r n e g a t N e a n \ . e a c r o n s rhe opposiletendencyappears

a n , m p r | | a n '- o n . l l r o n . n o t o n l v f o r t h e r e d u c r , o ao d e p r e s . r \'ey m p r o m \a c h i e \ e dd u , i n gt h ( rrearmedl.bur evenmore clearlyfor lhe outcooe afier rhe follow-up period, which clinicallyseems . i n c er h e r eb n o c l e J r r o b e o i g e t r e _r e i e \ ] n c eS causefor rhe early sErements,tbeyshouldnot be . a . l e r ' e ) p o n . e ' .D e . a u ' eu n l i t e i n p r l c h o p h . nacoiogy, ibr example, it is very doubtfrl to whar it could be a response.Therefore,the word '..eacrion"is prefered herein o.de. 10descr'bea behaviou.in a specialsituation-Paden6' gen.ral J , n r u d ersn d e \ p e c r a r i o ndr ,d a n e r ; r i n g $ i i l i n s ' nessto accepra treatmetrtmay plav a role. B , r b a . r c r r . \ ' h e r e J c r i o n .r e f l e c t r p h e ' nomeoon wbich can only be s€en*irhin all the inreractionsin rhe conplex social snuation oi I h e l d ( l o ' - o r e l d t o n b e l w e e n t h$eo q u e \ uoa' u,ed In r..ecmenr of rhe earl, leacrion' and lhe differenr correlatio.s found ior $e r*o q u e s r i o ni )n d i . a t el h a t t h es t a r e m e nar sb o u re a r l ' chance in condnion and about the agreemenr * r t n h e r r ' e , e d r r e a r m e nrre p , e ' e n td i i ' e t . n l aspecrsof lhe posible early reaclions;ver whar u n r l e a r 'S i n i l d t l \ .hb Ireren.e 'rek J p . , . . , h c . l L . j , o n o r w h , c hc o n d i r ' o n ' . u o J < J ' + h elh ' n e ( J r l \ ! e ' e J c r r o l d n d , rof 'h' ( \ ( n b \ ho\. h(\ .ou.d oe nnu(nceJ c , or r h er f e u l p . \ . r r u r f r su. o ' . h e i o n . t r u c r i o n

Conclusions

l J r r n ! r r . o ( . o u n l I ' r ( h e r e r o g e n ( i r \o I l h ( rJo,eo .,mple rnd he !J|rn.e oi he pu*blc in e - ion, JrInP ho'pirJi rea{m.n'. he co,re l " , o 1 . u J , d . , r h a r d b b e , e d u c e dr o h c i n n u ' rr.e or ..ngle ld. of. or 'ertrin lhe!1pru i. m( hod I noe_ldndrng .he .'ulr. rn J pur.l\ J e . . r p r ' \ e + " \ r h e p r ' r e n r ' -p o g t e ' \ d u a n e +en a rerqJrd. .eem' n be.nri .ated ve.-v early on wirhin the rela(ivelv conss ''dme$o x ol I p \chialrn ho' en|nt rurioncr 'rrEn ro T h e r e s u l t ss h o $ t h a r t h e e a r l ! i u b j e c t t r er e a c p , r . l e r l | r s f h , . J n n o r o e c $ ' a , i i \ b r mrJn hJr rulnP he *hole rt"Jrmenl merhod tions can predict ro someertent rhe outcomeof hospital featnenr, ar leas1in rhs sample eien are generally or even in .letail, of Inrie or no 'n "n\ .r./. oo iri\reJ!l\ 'Jbre!rr\e when the melbods of assesrngthose re3clIons I n t J l " . - c . p a l ' e n t s rea.rions can iusrify oprimism for fu.ther pro a r c a s s i m p l ea s i d i h i s s r u d \ T h e gres p . r m r t resardins the ourconc oi 5 r a t e n e n tIs d a y . i l l e r a d m j s s o nr l r e 3 d \

Discussion

I]8

5. PFIEBE

ment, whereasa deutral or negalive reaction ma,r lead !o a reconsid€ralionof the whole rherapeulicsirualon.

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