Where to Go with Depression? – Influence of Various Treatment Settings on Therapeutic Success

Depression is no longer on the fringes; it is a widespread disease. According to the Federal Ministry of Health, about 4 million people in Germany and 350 million worldwide suffer from a depressive disorder. A team of psychologists and medical experts at the University of Potsdam wants to find out how “various treatment settings influence therapeutic success”. The study hopes to offer insight into how and especially where people suffering from depression should be treated.

Increasing number of cases of depression

Nearly one in five Germans suffers from a depressive episode in their lifetime. Depression has long been a challenge for society in general and the health system in particular. Sick days due to depressive diseases are increasing; the number of early retirements doubled between 2000 and 2009. While many people – 25-40% – suffer from a depressive disease only once, others experience several phases of the disease, and 10-15% experience chronic depression. For these chronic sufferers, depression is often the reason for early retirement. For Prof. Michael Rapp of the University of Potsdam, an expert in social and preventive medicine, this finding is as unsatisfying as it is inexplicable. “It is difficult to understand. Depression is actually the disease that psychiatrists and psychotherapists are best able to treat. The ‘success rate’ is 80%.” In fact, many who apply for early retirement have often not had treatment for years and think that their diseases are untreatable. “This, however, is not true – and it will start getting very expensive in the case of early retirement.”

There are no simple explanations why the number of depressive diseases is increasing. The problem is too complex. On the one hand, destigmatization of depressive disorders is likely to have led to more and more affected people seeking treatment. Many lack sufficient medical coverage to get adequate treatment. It often happens that insufficient capacity leads to patients “only” receiving medication rather than psychological therapy, or they are seen by their general practitioner instead of a specialist physician. On the other hand, it may be that we are exposed to more stress-inducing stimuli – so-called stressors – that promote depressive diseases. What makes them difficult to adequately treat is the – apparently – increasing number of interrelated factors. Each patient needs an individual and adequate form of treatment. “For many diseases, you would intuitively assume that if you have been suffering from it for a long time, it is best to go to a rehabilitation hospital and not to use outpatient treatment,” says Rapp. “The same cannot be said for depressive diseases.”

The art of the right therapy

This is the starting point of the Potsdam researchers’ study. “We want to find out which forms of therapy are most suitable for which patients – and, thus, take a first step towards a treatment approach that is individually tailored from the very beginning,” explains health sociologist Prof. Pia-Maria Wippert, who heads the project with Rapp. The researchers are specifically interested in the influence of various treatment settings on the course of therapy. “Whether inpatient in a rehab clinic or outpatient in a specialized outpatient department or a physician’s office, for example, the place of treatment essentially influences therapeutic measures and their application.” The Potsdam study "DepReha" will show whether these differences also ultimately affect the course and success of therapy. The researchers are collaborating with the Rehabilitation Clinic Neu Fahrland, the outpatient department of Freie Universität Berlin and with a neurologist’s office. For the researchers, this proximity to practice is something special and appealing about this study, emphasizes Andreas Häusler, who looks after patients in the outpatient departments. “The project is not being conducted isolated in a laboratory but very close to reality. We meet the participants in the facilities and accompany them for a while. So we have the chance to approach the care of depressed patients from two perspectives – scientifically and practically.”

Hair makes stress “perceivable”

About 200 subjects will be examined in a longitudinal study over two years – both physiologically and psychologically. “A testing battery with a wide measurement scale is being used. Its statistical evaluation will help to understand the complex relations and to draw conclusions,” explains Rapp.

The three facilities invite newly admitted or treated patients eligible to participate in the study. “We present the project and answer questions in an information meeting,” Andrea Block, a member of Wippert’s team, explains the approach in the rehabilitation clinic Neu Fahrland. During the clinical routine, blood samples to examine the stress markers are then taken from patients willing to participate who also meet the inclusion criteria. On the next day, a hair sample is taken as well. “The blood and hair samples provide insight into the subjects’ stress level,” says Wippert. “Not only at the time of measurement. The hair sample indicates the stress development over the past three months, because the stress hormone cortisol is deposited in the hair.”

The psychological survey is done using questionnaires that capture data, for example, on depressiveness, symptoms of mental disorders, and positive and negative affective conditions but also the so-called ‘work ability index’ and stress. There is also a health questionnaire. Relevant sociodemographic data are recorded as well.

This examination is repeated immediately after the treatment and after five and eight months in order to obtain comparative values. “We longitudinally examine whether the treatment setting influences therapeutic success. Could stress be reduced? How are the depression symptoms developing? Were they able to return to work?” says Block. Evaluating the information on the first measure has already provided valuable insight, namely on medical service coverage, Block explains. “Performing a cross-sectional analysis allows us to investigate which patients have which medical conditions, to what degree of severity, and in what treatment setting. In other words: Where do people with particular depressive illnesses go for treatment?”

Risk profiles could help find the right treatment setting

Such findings are important for the overall goal of the study. Ideally, DepReha will enable physicians and therapists to recommend the appropriate treatment setting for patients. “We hope to identify specific risk profiles,” says Häusler. "This could help optimize the success of treatment for specific patient groups. It is quite possible that, for example, patients with a high stress load are best treated in one of the three settings.”

The data are still being collected – and this is as complex as the problem itself. It demands, not least of all, constant coordination of the teams conducting the examinations in the participating medical institutions. “Every two weeks we get together to discuss issues and problems, seek solutions, and distribute tasks,” says Block.

The first reliable results will be available in mid-2017, when the other measuring points will be passed, and they can start evaluating them. “You learn to be patient,” says Rapp. "It does not help to prematurely evaluate incomplete data and draw conclusions that cannot be confirmed later.” The researchers need exactly this patience, particularly for a long-term study like this. Patients will be asked to accurately assess possible long-term effects of various treatment methods up to five years after the two-year main study. The researchers never lose sight of their long-term goal. “Our studies should ultimately help improve the existing medical service networks and individual therapy offerings for reintegrating those with depression,” says Wippert. “Even the setting turns out to not affect the course of treatment, it would be an important result that helps patient and health professionals,” Rapp adds.


The Project

DepReha – Influence of Various Treatment Settings on Therapeutic Success
Principal Investigators: Prof. Michael Rapp, Prof. Pia-Maria Wippert (both University of Potsdam) Participating at the University of Potsdam i.a: Andrea Block and Andreas Häusler; Heinrich-Heine-Klinik in Neu Fahrland, Hochschulambulanz der Freien Universität Berlin, Psychiatrische Praxis Dr. Bohlken Berlin-Spandau
Funding: DRV Berlin-Brandenburg
Duration: 2015–2017  



The Researchers

Prof. Pia-Maria Wippert has been Professor of Sport and Health Sociology at the University of Potsdam since 2010. She specializes in risk stratification of stress-associated diseases and intervention development.

Universität Potsdam
Department Sport- und Gesundheitswissenschaften
Am Neuen Palais 10, 14469 Potsdam
Email: <link to pia-maria>pia-maria.wippert@uni-potsdam.de

Prof. Dr. med. Dr. phil. Michael A. Rapp is a psychiatrist and psychotherapist and Professor of Social and Preventive Medicine at the University of Potsdam. For many years, he has been dealing with the predictors and conditions for life-long mental health.
Email: <link to michael>michael.rapp@uni-potsdam.de

Andrea Block studied psychology at the University of Potsdam. Since 2016, she has been a research assistant at the Chair of Sport and Health Sociology.
Email: <link to andrea>andrea.block@uni-potsdam.de

Andreas Häusler studied psychology at the Technische Universität Berlin. He is a research assistant at the Chair of Social and Preventive Medicine.
Email: <link to andreas>andreas.haeusler@uni-potsdam.de

Text: Matthias Zimmermann
Translation: Susanne Voigt
Published by: Daniela Großmann
Contact Us: <link to online>onlineredaktion@uni-potsdam.de