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This paper presents preliminary results of analyzes of the indoor environmental quality (IEQ) in a full scale rotatable 1:1 mockup of a patient room. As initial part of the planning of the indoor environment at a new mental hospital, the project seeks to uncover the natural differences and limitations of the building, caused by the geographical orientation. Examining the outdoor diurnal variations and their effect on the indoor environment, in order to create a balance between on the one hand, daylight and artificial lighting and on the other hand the demand for passive cooling, using natural ventilation. The analysis discuss potential health aspects of daylight and fresh air and proposes a new strategy for dynamic artificial lighting, including natural ventilation to supplement mechanical ventilation. In this article we uncover daylight conditions based on two main parameters; 1) the geographic orientation (N, S, E and W) and 2) the season (summer and winter). Based on the preliminary data and the regional daylight conditions, the article proposes a new way to plan the indoor environmental quality called Lattitude and Orientation Compensated Architectural Lighting (LOCAL).

Abstract Background Bipolar disorder is associated with circadian disruption and a high risk of suicidal behavior. In a previous exploratory study of patients with bipolar I disorder, we found that a history of suicide attempts was associated with differences between winter and summer levels of solar insolation. The purpose of this study was to confirm this finding using international data from 42% more collection sites and 25% more countries. Methods Data analyzed were from 71 prior and new collection sites in 40 countries at a wide range of latitudes. The analysis included 4876 patients with bipolar I disorder, 45% more data than previously analyzed. Of the patients, 1496 (30.7%) had a history of suicide attempt. Solar insolation data, the amount of the sun’s electromagnetic energy striking the surface of the earth, was obtained for each onset location (479 locations in 64 countries). Results This analysis confirmed the results of the exploratory study with the same best model and slightly better statistical significance. There was a significant inverse association between a history of suicide attempts and the ratio of mean winter insolation to mean summer insolation (mean winter insolation/mean summer insolation). This ratio is largest near the equator which has little change in solar insolation over the year, and smallest near the poles where the winter insolation is very small compared to the summer insolation. Other variables in the model associated with an increased risk of suicide attempts were a history of alcohol or substance abuse, female gender, and younger birth cohort. The winter/summer insolation ratio was also replaced with the ratio of minimum mean monthly insolation to the maximum mean monthly insolation to accommodate insolation patterns in the tropics, a

Light is necessary for vision; it enables us to sense and perceive our surroundings and in many direct and indirect ways, via eye and skin, affects our physiological and psychological health. The use of light in built environments has comfort, behavioural, economic and environmental consequences. Daylight has many particular benefits including excellent visual performance, permitting good eyesight, effective entrainment of the circadian system as well as a number of acute non-image forming effects and the important role of vitamin D production. Some human responses to daylight seem to be well defined whilst others require more research to be adequately understood. This paper presents an overview of current knowledge on how the characteristics of daylight play a role in fulfilling these and other functions often better than electric lighting as conventionally delivered.

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Objective: To examine the efficacy of using wake and light therapy as a supplement to standard treatment of hospitalized patients with depression. Method: In this randomized, controlled study, 64 patients with moderate-to-severe depression were allocated to standard treatment or to the intervention, which additionally consisted of three wake therapy sessions in one week, 30-min daily light treatment and sleep time stabilization over the entire nine-week study period. Results: Patients in the wake therapy group had a significant decrease in depressive symptoms in week one as measured by HAM-D17, 17.39 (CI 15.6–19.2) vs. 20.19 (CI 18.3–22.09) (P = 0.04), whereas no statistically significant differences were found between the groups in weeks two to nine. At week nine, the wake therapy group had a significantly larger increase in general self-efficacy (P = 0.001), and waking up during nights was a significantly less frequent problem (1.9 times vs. 3.2) (P = 0.0008). In most weeks, significantly fewer patients in the wake therapy group slept during the daytime, and if they slept, their naps were shorter (week three: 66 min vs. 117 min P = 0.02). Conclusion: The antidepressant effect initially achieved could not be maintained during the nine-week study period. However, sleep and general self-efficacy improved.

BACKGROUND: The Major Depression Inventory (MDI) was developed to cover the universe of depressive symptoms in DSM-IV major depression as well as in ICD-10 mild, moderate, and severe depression. The objective of this study was to evaluate the standardization of the MDI as a depression severity scale using the Visual Analogue Scale (VAS) as index of external validity in accordance with the LEAD approach (Longitudinal Expert Assessment of All Data).METHODS: We used data from two previously published studies in which the patients had a MINI Neuropsychiatric Interview verified diagnosis of DSM-IV major depression. The conventional VAS scores for no, mild, moderate, and severe depression were used for the standardization of the MDI.RESULTS: The inter-correlation for the MDI with the clinician ratings (VAS, MES, HAM-D17 and HAM-D6) increased over the rating weeks in terms of Pearson coefficients. After nine weeks of therapy the coefficient ranged from 0.74 to 0.83. Using the clinician-rated VAS depression severity scale, the conventional MDI cut-off scores for no or doubtful depression, and for mild, moderate and severe depression were confirmed.CONCLUSIONS: Using the VAS as index of external, clinical validity, the standardization of the MDI as a measure of depression severity was accepted, with an MDI cut-off score of 21 for mild depression, 26 for moderate depression severity, and 31 for severe depression.TRIAL REGISTRATION: Martiny et al. Acta Psychiatr Scand 112:117-25, 2005: None - due to trial commencement date. Straaso et al. Acta Neuropsychiatr 26:272-9; 2014: ClinicalTrials.gov ID NCT01353092 .

OBJECTIVE: To investigate the long-term antidepressant effect of a chronotherapeutic intervention.METHOD: In this randomized controlled trial 75 patients with major depression were allocated to fixed duloxetine and either a chronotherapeutic intervention (wake group) with three initial wake therapies, daily bright light therapy, and sleep time stabilization or to a group using daily exercise. Patients were followed 29 weeks. We report the last 20 weeks, a follow-up phase, where medication could be altered. Patients were assessed every 4 weeks. Remission rates were primary outcome.RESULTS: Patients in the wake group had a statistically significant higher remission rate of 61.9% vs. 37.9% in the exercise group at week 29 (OR = 2.6, CL = 1.3-5.6, P = 0.01). This indicated continued improvement compared with the 9 weeks of treatment response (44.8% vs. 23.4%) with maintenance of the large difference between groups. HAM-D17 endpoint scores were statistically lower in the wake group with endpoint scores of 7.5 (SE = 0.9) vs. 10.1 (SE = 0.9) in the exercise group (difference 2.7, CL = 0.5-4.8, P = 0.02).CONCLUSION: In this clinical study patients continued to improve in the follow-up phase and obtained very high remission rates. This is the first study to show adjunct short-term wake therapy and long-term bright light therapy as an effective and feasible method to attain and maintain remission.

INTRODUCTION: Electroconvulsive treatment (ECT) is an effective treatment for severe depression but carries a risk of relapse in the following months.METHODS: Major depressive disorder patients in a current episode attaining remission from ECT (17-item Hamilton Depression Rating Scale (HAM-D17) score≤9) received randomly escitalopram 10 mg, 20 mg, 30 mg or nortriptyline 100 mg as monotherapies and were followed for 6 months in a multicentre double-blind set-up. Primary endpoint was relapse (HAM-D17≥16).RESULTS: As inclusion rate was low the study was prematurely stopped with only 47 patients randomised (20% of the planned sample size). No statistically significant between-group differences could be detected. When all patients receiving escitalopram were compared with those receiving nortriptyline, a marginal superiority of nortriptyline was found (p=0.08). One third of patients relapsed during the study period, and one third completed.DISCUSSION: Due to small sample size, no valid efficacy inferences could be made. The outcome was poor, probably due to tapering off of non-study psychotropic drugs after randomisation; this has implications for future study designs. ClinicalTrials.gov Identifier: NCT00660062.

Background. Our T-PEMF trial has been revisited with focus on the pharmacopsychometric triangle in which effect size is used when comparing wanted versus unwanted clinical effects and quality of life as outcomes. In this analysis, we have especially focused on the self-reported HAM-D(6). Methods. The antidepressive medication which the patients were resistant to was kept unchanged during the five weeks of active versus sham T-PEMF. Results. In total 21, patients received active T-PEMF, and 19 patients received sham T-PEMF. The effect size was 1.02 and 0.90, respectively, on HAM-D(6) and HAM-D(6)-S. Concerning side effects, the active T-PEMF reduced the baseline score on concentration problems with an effect size of 0.44 while inducing more autonomic symptoms than sham T-PEMF with an effect size of -0.41. The advantage of active over sham T-PEMF obtained an effect size of 0.48. Conclusion. Active T-PEMF was found superior to sham T-PEMF within the pharmacopsychometric triangle with a clinically significant effect size level above 0.40.

INTRODUCTION: Attempts to identify the factor structure in patients with treatment-resistant depression have been very limited. METHODS: Principal component analysis was performed using the baseline datasets from 3 add-on studies [2 with repetitive transcranial magnetic stimulation and one with transcranial pulsed electromagnetic fields (T-PEMF)], in which the relative effect as percentage of improvement during the treatment period was analysed. RESULTS: We identified 2 major factors, the first of which was a general factor. The second was a dual factor consisting of a depression subscale comprising the negatively loaded items (covering the pure depression items) and a treatment resistant subscale comprising the positively loaded items (covering lassitude, concentration difficulties and sleep problems). These 2 dual subscales were used as outcome measures. Improvement on the treatment resistant subscale was 40% in the active treatment group compared to 17-30% improvement in the sham treatments. DISCUSSION: It is possible to describe patients with therapy-resistant depression by a factor structure. Both rTMS and T-PEMF had a clinical effect on the factor-derived scales when compared to sham treatment.

Objective: The aim of the study was to analyze treatments and outcome in depressed patients. Method: Patients with recurrent depressive disorder (n = 289), recruited for a prophylaxis study, were followed up in hospital settings for 6 months with diagnostic and depression ratings at baseline and monthly depression ratings. Data on psychotropic drugs were retrieved from hospital case records. Independent associations between baseline, treatment and outcome variables were examined by logistic regression models. Results: Depressive symptoms subsided gradually. After 6 months, 21% had dropped out, 43% were rated as remitted (HAM-D-17 < 8) and 8% had not responded (HAM-D-17 > 15). Patients once remitted rarely relapsed (< 5%). All patients received antidepressant drugs, half of them more than one (2-4) as well as other psychotropic drugs. Patients responding poorly received more frequently multiple antidepressants, tricyclic antidepressants, hypnosedatives, lithium and/or antipsychotics. Conclusions: The 6-month outcome was generally poor. Choice of treatment appeared at least partly to be determined by the therapeutic outcome Udgivelsesdato: 2008/8

Objective: We have tested the relapse-preventive effect of citalopram when compared with placebo in 282 patients with Seasonal Affective Disorder (SAD) responding to 1 week of light therapy. Method: The response rate to 1-week light therapy and relapse during the continuation phase of 15 weeks were assessed by use of the Hamilton Depression Rating Scale (HAM-D17), the six-item subscale (HAM-D6), the Melancholia Scale (MES), and the combined HAM-D/ SIGH-SAD. Results: The response rate to light therapy was 62.5% on the HAM-D17 and the HAM-D6, 56.1% on the HAM-D/SIGH-SAD, 52.8% on the MES. In the continuation phase, citalopram was found superior to placebo on all scales, but the difference was only of statistical significance on the HAM-D6 and the MES. Mean citalopram dose was 26.3 mg. Conclusion: Light therapy was found to have and early onset of action. On the HAM-D6 and the MES citalopram significantly reduced the relapse rate in the continuation phase.

Background. We have developed the Major Depression Inventory (MDI),consisting of 10 items, covering the DSM-IV as well as the ICD-10 symptoms of depressive illness. We aimed to evaluate this as a scale measuring severity of depressive states with reference to both internal and external validity. Method. Patients representing the score range from no depression to marked depression on the Hamilton Depression Scale (HAM-D) completed the MDI. Both classical and modern psychometric methods were applied for the evaluation of validity, including the Rasch analysis. Results. In total, 91 patients were included. The results showed that the MDI had an adequate internal validity in being a unidimensional scale (the total score an appropriate or sufficient statistic). The external validity of the MDI was also confirmed as the total score of the MDI correlated significantly with the HAM-D (Pearson's coefficient 0.86, P≤0.01, Spearman 0.80, P≤0.01). Conclusion. When used in a sample of patients with different states of depression the MDI has an adequate internal and external validity.

Background. An increasing diversity of public, voluntary sector and private providers offer services for the mentally ill in the ongoing process of psychiatric reform. Good service description is one important prerequisite for mental health service research. Aims 1) To describe service provision for the mentally ill in five European centres using the European Service Mapping Schedule (ESMS); and 2) to discuss the use of the instrument in describing service provision. Methods. All services providing care for people with severe mental illness in five European catchment areas (in Amsterdam, the Netherlands; Copenhagen, Denmark; London, UK; Santander, Spain; Verona, Italy) were identified through various sources. The identified services were classified, and service provision was quantified in accordance with the ESMS manual. Descriptive information was obtained. Results. We identified from 10 to 45 different services for catchment areas of between 50,000 (Copenhagen) and 560,000 (Santander) population run by three to 16 providers. They varied in aims, staffing and functioning. Hospital and non-hospital residential services, community-based services, and social support agencies were available in all sites. There was substantial variation across centres in the range, number and activities of services. Collecting comparable data sets on all service types, particularly for day and structured activity services and outpatient and community services required substantial effort. Conclusion. Operationalised description of mental health services across Europe is possible but requires further refinement.

Die EPSILON-Studie zur Versorgung von Patienten mit Schizophrenie in fünf europäischen Zentren (Amsterdam, Kopenhagen, London, Santander, Verona) wird vorgestellt. In einem ersten Schritt wurden Instrumente zur Ermittlung von Hilfebedarf (Camberwell Assesssment of Need), zur Ermittlung von Inanspruchnahme und Kosten psychiatrischer Dienste (Client Sociodemographic and Service Receipt Inventory), zur Lebensqualität (Lancashire Quality of Life Profile), zur Behandlungszufriedenheit (Verona Service Satisfaction Scale) und zur Angehörigenbelastungfür den Gebrauch in fünf Sprachen (und Versorgungssystemen) adaptiert (mittels Ubersetzung, Rückübersetzungund Fokusgruppen). Diese Instrumente wurden in einer querschnittlichen Erhebung bei insgesamt 404 Patienten mit der ICD-10 Diagnose einer schizophrenen Störung (SCAN, Item Group Checklist) eingesetzt. Die Instrumentenadaptation führte zu Instrumenten mit unterschiedlich guter, moderater bis substantieller psychometrischer Performanz. Es fanden sich deutliche Unterschiede der psychiatrischen Versorgungssysteme, die für Unterschiede bei befriedigtem und unbefriedigtem Hilfebedarf Inanspruchnahme und Behandlungskosten wesentlich sein dürften. Variationen von Hilfebedarf und Kosten sowie die Limitationen der Studie werden diskutiert., The EPSILON study on care for people with schizophrenia in five European centres (Amsterdam, Copenhagen, London, Santander, Verona) is presented. In a first step instruments to assess needs for care (Camberwell Assessment of Need), to record and calculate service utilisation and costs (Client Sociodemographic and Service Receipt Inventory), on quality of life (Lancashire Quality of Life Profile), satisfaction with services (Verona Service Satisfaction Scale), and carer burden (Involvement Evaluation Questionnaire) were adapted for use in five European languages using translation, back translation and focus groups. The instruments were used in a sample of 404 subjects with a SCAN (Item Group Checklist) ICD-10 diagnosis of schizophrenia across sites. Instrument psychometric properties were assessed following the adaptation process, and performance was varied but acceptable to good. There were substantial differences in care systems for people with schizophrenia some of which are likely to have contributed to substantial differences in the pattern of met and unmet needs, service use and costs. Variations in needs and service costs as well as limitations of the study are discussed.