A randomised cross-over study assessing the "blue pyjama syndrome" in major depressive episode

Abstract

This paper introduces a "blue pyjama syndrome" (whereby wearing hospital pyjamas results in an exaggerated impression of severity). We performed a 5-day, prospective, randomized, cross-over study in a French mood disorder unit for inpatients. At Day 1 (D1) and Day 5 (D5), two 5-minute video interviews were recorded with patients in pyjamas or in day clothes (the sequence was randomly allocated). Psychiatrists unaware of the study objective assessed the videos and scored their clinical global impressions (CGI, with scores ranging from 1 to 7). Of 30 participants with major depressive episode selected for inclusion, 26 participants (69% women) provided useable data for an evaluation by 10 psychiatrists. Pyjamas significantly increased the psychiatrists' CGI ratings of disease severity by 0·65 [0·27; 1·02] points. The psychiatrists' global impressions also rated patients as significantly less severe at D5 in comparison with D1 by -0·66 [-1·03; -0·29] points. The "blue pyjama syndrome" is in the same order of magnitude as the difference observed after a week of hospitalisation. This potentially calls into question the reliability and validity of observer ratings of depression.

Conflict of interest statement

All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) No authors have support from any company for the submitted work; (2) HD has relationships (Travel/accommodations expenses covered/reimbursed) with Astrazeneca who might have an interest in the work submitted in the previous 3 years; JMB has relationships (Travel/accommodations expenses covered/reimbursed) with Otsuka, Lundbeck, Janssen, and Lilly who might have an interest in the work submitted in the previous 3 years; BF has been a consultant for E. Lilly, BMS, Servier, SANOFI, GSK, HRA, Roche, Boeringer Ingelheim, Bayer, Almirall, Allergan, Stallergene, Genzyme, Pierre Fabre, Astrazeneca, Novartis, Janssen, Astellas, Biotronik, Daiichi-Sankyo, Gilead, MSD, Lundbeck, Stallergene, Actelion, UCB, Otsuka, Grunenthal, ViiV; GR has relationships (Travel/accommodations expenses covered/reimbursed) with Lundbeck, Otsuka and Janseen who might have an interest in the work submitted in the previous 3 years; MR has relationships (Travel/accommodations expenses covered/reimbursed) with Astrazeneca, Orphan Europe and Janssen who might have an interest in the work submitted in the previous 3 years; J.S. and S.B. have no relationship with any company that might have an interest in the work submitted in the previous 3 years; DD has relationships (board membership or consultancy or travel/accommodation expenses covered/reimbursed) with Servier, Lilly, Janssen-Cilag, Otsuka, Lundbeck, Astra Zeneca who might have an interest in the work submitted in the previous 3 years; NF has relationships (Travel/accommodations expenses covered/reimbursed) with Servier, BMS, Lundbeck and Janssen who might have an interest in the work submitted in the previous 3 years; (3) No author’s spouse, partner, or children have any financial relationships that could be relevant to the submitted work; and (4) none of the authors has any non-financial interests that could be relevant to the submitted work.

Figures

Figure 1

Four members of the team in pyjamas and in day clothes.

Figure 2

Study flowchart.

Figure 3

Pyjama and hospitalization effects on Clinical Global Impressions (CGI). Panel A: Distribution of CGI scores in the day clothes and pyjama conditions. Data are presented for descriptive purpose only. The dots represent each value for each patient (a given patient has 2 values in each condition). Panel B: Distribution of CGI scores at Day 1 and Day 5. Data are presented for descriptive purposes only. The dots represent each value for each patient (a given patient has 2 values in each condition). Panel C: CGI analysis; Forest plot of coefficients and their 95% confidence interval observed with the mixed model (mixed model performed with the “patient” and the “psychiatrist” factors specified as random effects).

Figure 4

Pyjama and hospitalization effects on the Beck Depression Inventory (BDI). Panel A: Distribution of BDI scores in the day clothes and pyjama conditions. Panel B: Distribution of BDI scores at Day 1 and Day 5. Panel C: BDI analysis; forest plot of coefficients and their 95% confidence interval observed with a mixed model (mixed model performed with the “patient” factors specified as random effect).

Figure 5

Pyjama and hospitalization effects and interaction on Clinical Global Impressions (CGI). Panel A: Distribution of CGI scores at Day 1 (D1) and Day 5 (D5) in the day clothes and pyjama conditions. Data are presented for descriptive purposes only. The dots represent each value for each patient (a given patient has 2 values in each condition). Panel B: CGI analysis; Forest plot of coefficients and their 95% confidence interval observed with the mixed model including an interaction (mixed model performed with the “patient” and the “psychiatrist” factors specified as random effects). Negative values for the interaction term (Clothes/days) means that the positive effect perceived after 5 days of hospitalization is more marked when patients are in day clothes than in pyjamas.