S-52-01

Designing trials for the treatment of depression in the medically ill

F. Creed. University of Manchester, Manchester, United Kingdom

Objective: To review studies of medically ill patients and assess how depressive disorder predicts poor outcome.

Methods: The review covers medical in and out patients, in whom depression has been measured and which have a prospective cohort design.

Results: Depressive disorder leads to impaired health related quality of life and, possibly, increased healthcare costs. This effect is independent of the effect of the comorbid medical illness. Trials demonstrate that compliance with antidepressants is poor in medical patients and few studies have included sufficient patients to demonstrate the full benefits of treatment of depression in the medically ill.

Conclusion: Trials to demonstrate improved health related quality of life in medical patients following treatment of depression need to be designed with a sufficiently intensive intervention, adequate power and sufficient allowance for confounders.

S-52-02

The importance of early intervention in depression in the medically ill

V. Arolt, B. T. Baune. University of Münster Dept. of Psychiatry, Münster, Germany

Depression is very common in the medically ill. Depending on the type and severity of the somatic illness and on the extent of disability, the prevalence of depressive disorders is 20-50%, about half of these being major depression. It is known that psychosocial and pharmacotherapeutic interventions may enhance quality of life in these patients; however, there is only little evidence that, by such interventions, both the progression of disease and the timepoint of premature death can be substantially influenced. These aspects will be explicated for the case of coronary heart disease. The relatively weak influence of psychiatric treatments may be due to the fact that they are implemented too late during the time course/progression of the somatic illness. Our own findings from a large population based study not only show significant associations of depression subtypes with coronary heart disease but also demonstrate a major role for somatic eomorbidity, that has as yet been neglected. If, at all, antidepressive treatments are expected to have an influence not only on depressive symptoms, but also on the progression of a chronic and complex somatic disorder, they probably must be implemented as early and as powerful as possible.

S-52-03

Major depression in the general hospital: Critical appraisal of different strategies to improve its treatment at the University Hospital of Lausanne

A. Berney, L. Michaud, R. Voellinger, B. Burnand, F. Stiefel. Lausanne, Switzerland

Objective: Major Depressive Disorders (MDD) remains undertreated in the general hospital despite a high prevalence, major impact on health, and effective therapeutic possibilities; no consensus exists to date as to what strategies would be effective to improve this situation.

Methods: Over the past few years, several efforts targeting MDD were conducted at Lausanne University Hospital: i) a general agenda was established, identifying major difficulties in the management of MDD in the physically ill (1), ii) studies aimed at demonstrating the importance of MDD in specific clinical settings, (i.e. post-stroke depression, Parkinson disease patients) were conducted (2), iii) clinical practice guidelines for the management of MDD in the general Hospital were developed (3) and iv) implementation of guidelines in different somatic services were evaluated.

Results: Preliminary evaluation of the impact of the guideline approach shows very limited effects of a minimal implementation intervention. Focused studies conducted in the service of neurology, seem to be followed by greater changes in clinical practice, with the limit to be circumscribed to very specific settings.

Conclusion: There is a dilemma between the feasibility of large scales brief interventions and time consuming, highly adapted interventions. The minimal requirement for an intervention to improve the management of depression in the General Hospital is an unresolved issue that will be discussed-where possible-by means of scientific evidence. References: 1) Stiefel F et al. Journal of Supportive Care in Cancer (2001), pp: 477-88 2) Bemey Aet al. Neurology (2002), pp: 1427-29 3) Voellinger R et al. Gen Hospital Psychiatry (2003), pp: 185-193