Step I
The response rate for step I was 50.2% (N = 257 of N = 512 hospitals). Characteristics of the participating hospitals are summarised in Table
1. With an average of 130 inpatient beds, these hospitals served an average of about 500 patients with depressive disorders in 2011.
Table 1
Hospital characteristics
number of inpatient beds2,3 (n = 228) | 129.8 (115.0) | solely inpatient | 16.3 |
≤ 50 beds1
| 18.9 | inpatient and day clinic | 72.8 |
51 – 100 beds1
| 30.7 | solely day clinic | 10.9 |
101 – 150 beds1
| 21.0 |
hospital type (n = 255)
1
| |
≥ 151 beds1
| 29.4 | specialised hospital | 48.6 |
patients with depression treated in 20112 (n = 219) | 486.9 (457.8) | dept. general hospital | 35.7 |
≤ 150 patients1
| 24.2 | dept. university med. centre | 9.0 |
151 – 300 patients1
| 16.4 | others | 6.7 |
301 – 450 patients1
| 20.1 |
hospital orientation (n = 257)
1
| |
451 – 600 patients1
| 13.3 | psychiatric | 76.3 |
≥ 601 patients1
| 26.0 | psychosomatic | 16.3 |
number of day clinic places2,4 (n = 214) | 32.3 (22.6) | not specified | 7.4 |
Overall – during the time of the survey – 35.4% of the respondents report that PGIR were conducted as part of depression treatment in their hospitals. 51.6% of the PGIR offering hospitals offer depressive-specific PGIR, 40.7% offer PGIR combining depressive disorders with other diagnostic groups (mostly ICD-10 F2: 80.6% (N = 25); other F3 diagnoses: 61.3% (N = 19); F4: 32.3% (N = 10); F6: 32.3% (N = 10); others: 16.1% (N = 5); sum greater than 100% due to multiple response options; total N = 31) and 7.7% offer specific PGIR as well as combined PGIR. 64.6% of the respondents state that PGIR were not conducted at all as part of depression treatment in their hospitals. Reasons were mostly lack of resources (manpower, time, finances) but also lacking concepts of intervention for PGIR in depression treatment (for details, cf. Table
2). When respondents not offering PGIR in depression treatment were asked for required conditions for initiating PGIR, the most frequently stated answers were additional resources (additional staff; more time and financial resources) as well as adequate concepts of intervention (for details, cf. Table
2).
Table 2
Reasons for not conducting PGIR and required conditions for initiating PGIR
lack of manpower | 60.1 | too few patients with depression | 5.1 |
lack of time | 44.9 | PGIR considered as irrelevant | 3.2 |
financial constraints | 24.1 | PGIR not considered as hospital’s task | 2.5 |
lacking concepts of intervention | 15.2 | others* | 40.5 |
hospitalisation too short | 7.6 | *in particular: relatives are involved otherwise, catchment area too big, low acceptance of the intervention |
Required conditions for initiating PGIR
1
(n = 158)
|
additional staff | 67.1 | none, PGIR are considered as irrelevant | 4.4 |
more time | 49.4 | none, PGIR are not considered as hospital’s task | 1.3 |
adequate concepts of intervention | 25.3 | others* | 22.2 |
more financial resources | 24.1 | *in particular: bigger catchment area, higher acceptance of the intervention, bigger hospital |
Of those hospitals randomly chosen for the nonresponder-sample (N = 64), 7.8% (N = 5) gave no information or were not accessible. 16.9% (N = 10) of the hospitals which participated in the nonresponder analysis (N = 59) stated that they did offer PGIR in depression treatment.
Step II
Of the N = 91 respondents which stated that they offered PGIR in depression treatment in step I, 84.6% (N = 77) named a contact person responsible for offering PGIR. N = 45 of the step II questionnaires sent to these contact persons were returned, with the response rate for step II lying at 58.4%. Thus, detailed data about how PGIR were conducted were gathered from 49.5% of all hospitals, which stated that they offered PGIR in depression treatment in step I.
Most of the respondents in step II were psychologists (40.9%), 31.8% were physicians, 15.9% social workers and 11.4% were nurses. 91.1% of the respondents worked at a hospital with a psychiatric orientation. 42.2% were employed at a specialised hospital for mental illnesses, 33.3% at a general hospital, 20.0% at a university medical centre and 4.4% at another hospital type. All of the results presented below refer solely to hospitals participating in step II.
Of those hospitals conducting PGIR in depression treatment and responding to step II, 77.8% offered PGIR without participation of the patient and 22.2% offered PGIR in which patients and relatives took part in the same group. Overall, the respondents estimated a mean of about 18% (SD 16%; Mode 20%; Median 12.5%; Range 1% - 70%) of patients with depressive disorders whose relatives took part in PGIR in 2011. Respondents stated that a mean of about 29% (SD 16%) of the relatives taking part in PGIR discontinued their participation. Reasons for discontinuation included termination of the group sessions, lack of time and health burden of the relatives themselves.
Standardised manuals are used in more than half of the PGIR (24.4% completely manualised; 40.0% partly manualised). Of those respondents using standardised manuals (N = 29), about one half use self-developed and the other half use published manuals [
34‐
37]; therefore, published manuals are at least partly used by about one third of respondents. 75.6% of the respondents use standardised information material, in particular handouts, presentations as well as brochures (for details, cf. Table
3). The most frequently mentioned didactic methods within the PGIR are discussions and lectures (for details, cf. Table
3).
Table 3
Standardised information material and didactic methods used
utilisation of standardised material | 75.6 | | |
if standardised material is used (n = 34) | | | |
handouts | 61.8 | slides | 35.3 |
presentations | 44.1 | flip chart | 26.5 |
brochures | 41.2 | videos/DVDs | 14.7 |
Didactic methods
1
(n = 45)
|
discussion | 95.6 | role play | 20.0 |
lecture | 88.9 | behavioural training | 13.3 |
small groups | 22.2 | others | 20.0 |
Study participants were also asked how they advertised their PGIR (sums add up to more than 100% because of multiple response options). 75.6% of the respondents stated that they invite relatives indirectly through the patients; 44.4% of the hospitals invite relatives via personal contact, 26.7% invite relatives directly via written invitation, and 64.4% invite relatives upon request to participate in the PGIR. Furthermore, PGIR are announced via flyers (55.6%) and posters (53.3%), but other methods of distribution are also chosen (31.1%), in particular via the internet and advertisements in the local press.
Regarding the structure (for details, cf. Table
4), PGIR is mostly conducted in an open or continuous form (71.1%). The onset of participation in the PGIR is mostly independent of inpatient depression treatment (57.8%). 51.5% of the hospitals offer PGIR with four or fewer group sessions. Group sessions are held usually weekly (35.6%) and last one to one and a half hour (77.8%). The typical group size is six to ten relatives. The majority of participating relatives are the patients’ partners (53.5%), 28.6% are parents, 10.8% are patients’ children and 7.1% are others, in particular siblings and friends as well as in rare cases parents-in-law, grandparents or neighbours.
Table 4
Structure of the PGIR
closed | 15.6 | ≤ 60 | 6.7 |
partially closed | 13.3 | 61-90 | 77.8 |
open or continuous | 71.1 | ≥ 91 | 15.6 |
Onset of groups
1
(n = 44)
|
Frequency of sessions
1
(n = 45)
|
during inpatient treatment only | 15.6 | weekly | 35.6 |
continuation after discharge | 24.4 | bi-weekly | 17.8 |
during outpatient treatment only | 2.2 | monthly | 26.7 |
independent of inpatient treatment | 57.8 | other frequencies | 20.0 |
Number of sessions
1
(n = 33)
|
Average number of participants
1
(n = 41)
|
≤ 4 | 51.5 | ≤ 5 | 17.1 |
5-8 | 36.4 | 6-10 | 48.8 |
≥ 9 | 12.1 | 11-15 | 22.0 |
| | ≥ 16 | 12.2 |
In two thirds of the PGIR two group moderators are present (62.2%), one group moderator only is involved in 28.9% of the PGIR. A few respondents state they use three or four moderators (8.9%). 75.6% of the moderators or co-moderators are physicians, 66.7% psychologists, 42.2% nursing staff, 40.0% social workers and in rare cases also clinical pastoral staff, occupational therapists or other relatives (sums add up to more than 100% due to multiple response options). Primarily the person in charge or the responsible moderator for conducting PGIR, respectively, is a psychologist (43.9%); 26.8% are physicians, 17.1% social workers and 12.2% nursing staff.
In an open-ended question, respondents were asked about the goals they pursued within the PGIR and their responses were subsequently categorised (sums add up to more than 100% due to multiple answers). The most frequently addressed
goals within the PGIR are: to improve self-care and relief strategies in relatives (68.2%), to inform relatives about the illness, its symptoms and causes as well as its treatment (59.1%), to foster the relatives’ ability to deal adequately with the illness and support the patient (52.3%), and to create a better understanding of the illness and the patient in relatives (47.7%). Further goals are to stabilise the family climate (27.3%), to enhance communication between relatives and patients (20.5%), relapse prevention and a better compliance of the patient (11.4%), and to facilitate inter-exchange between relatives (9.1%). 6.8% stated early recognition of warning signs as being a goal of the PGIR. The most frequently addressed
information topics within the PGIR are how to deal adequately with the patient (90.9%) as well as relief strategies in order to reduce caregiver burden (86.4%). However, other behaviour-related topics (e.g. communication patterns) and illness-specific (e.g. symptoms and diagnoses) as well as treatment-related information contents (e.g. pharmacotherapy) are also addressed frequently (for details, cf. Table
5). The most frequently addressed
emotional topics within the PGIR are excessive demands (95.6%) and helplessness on the part of the relatives (91.1%) as well as suicidality of the patient (82.2%) and feelings of guilt and shame (77.8%) of the relatives (for details, cf. Table
5).
Table 5
Frequency of information and emotional topics addressed in PGIR
1 | dealing adequately with the patient | 90.9% |
2 | decompression strategies | 86.4% |
3 | symptoms and diagnosis | 75.0% |
4 | communication patterns | 61.4% |
| contingency plan | 61.4% |
5 | warning signs | 59.1% |
6 | pharmacotherapy | 54.5% |
7 | psychotherapy | 52.3% |
| risk factors | 52.3% |
8 | cause of illness | 50.0% |
9 | relapse prevention | 47.7% |
10 | sociotherapy | 40.9% |
11 | course of illness | 36.4% |
12 | problem solving | 31.8% |
13 | epidemiology | 9.1% |
Frequency of emotional topics
1
(n = 45)
|
1 | excessive demands | 95.6 |
2 | helplessness | 91.1 |
3 | suicidality | 82.2 |
4 | guilt and shame | 77.8 |
5 | partnership | 75.6 |
6 | stigmatisation | 71.1 |
7 | isolation | 60.0 |
8 | quarrel with destiny | 46.7 |
| resignation | 46.7 |
| anergy | 46.7 |
In addition to the frequency of information and emotional topics, respondents were asked about their experience regarding which topics relatives needed to discuss most during the PGIR within an open-ended question, which was subsequently categorised (sums add up to more than 100% due to multiple answers). In accordance with the information and emotional topics which were addressed most frequently, the respondents saw the highest need for discussion on the part of relatives with regard to dealing adequately with the patient and the illness (56.8%), helplessness (22.7%), excessive demands (15.9%), feelings of guilt (15.9%), own needs and relief (13.6%), suicidality (11.4%), pharmacotherapy (11.4%), partnership (9.1%) and relapse prevention (6.8%).
Regarding expressed emotion, 83.7% of the respondents stated that the offered PGIR consisted of measures to reduce criticism and 82.9% of respondents stated measures to reduce emotional overinvolvement. When asked in an open-ended question to specify these measures, respondents cited information about the illness, behavioural and communication exercises regarding dealing with the patient, measures to improve self-care as well as explaining expressed emotion.