Does depression require hospitalization?
A study published in the current issue of Psychotherapy and Psychosomatics has analyzed the difference between day hospital and inpatient stay in depression. Depending on the severity of depression, patients may be treated at different levels of care with psychotherapy and/or antidepressant medication. While several previous studies compared the efficacy of different levels of care for psychotherapy of personality disorders, sufficient data is lacking for the comparison of day-clinic and inpatient psychotherapy for depression. The current pilot study evaluates the feasibility of randomization in a routine hospital setting and compares preliminary efficacy for day-clinic and inpatient psychotherapy for depression.
Of 144 incoming patients who met inclusion criteria, 44 patients agreed to participate. Of these, 97.7% had a major depressive episode, 1 patient was primarily diagnosed with dysthymia. Comorbid diagnoses included anxiety (45.5%), somatoform (13.6%), obsessive-compulsive (6.8%), and personality disorder (33.3%).
After the initial assessment, patients were randomized to either the day-clinic or inpatient setting and treated for 8 weeks with multimodal psychotherapy. The therapy unit combines inpatient and day-clinic treatment, therapeutic staff is the same for both treatment arms. Both groups received equal amounts of psychotherapeutic interventions. The psychopharmacological antidepressant treatment followed the German national treatment guidelines for depression. In order to be representative for routine clinical practice, no further specifications with regard to psychopharmacological medications were made for the study.
At admission, 22 patients (50%) were taking antidepressant medication. Within the completer sample, 11 patients (31.4%) had a change in antidepressant medication during treatment. Antidepressants were reduced or terminated for 6 patients (17.2%) and increased or started for 4 patients (11.4%). One patient had a change of drug class. At termination, 51.4% of completer patients were taking antidepressant medication. There were no differences between groups for change during therapy or medication at termination. Change of medication was not related to initial depression severity and beginning or increasing medication was not significantly related to symptom reduction.
Depression severity decreased from baseline to the 4-week follow-up. There were no differences between day-clinic and inpatient psychotherapy concerning change over time. In addition, response and remission rates are reported descriptively. Eight inpatients (50% of completers) and 6 day-clinic patients (35.3% of completers) were classified as responders. In both groups, 3 patients (16.7% of inpatients, 17.7% of day-clinic completers) reached remission.
These results may encourage the incorporation of a scientific evaluation in routine clinical settings. Also, the findings suggest that it may be beneficial to consider different levels of care for the treatment of severe depression. Finally, the results call for further research in larger samples in order to test for moderator effects. As inpatient psychotherapy is more expensive than day treatments, it will be crucial to find out who benefits more in each setting.