Psychosomatic-psychotherapeutic treatment in an evening clinic: a qualitative examination of patients' expectations and experiences.

BACKGROUND: Over a course of 10 weeks the psychosomatic-psychotherapeutic evening clinic at the University of Heidelberg offers an intensive and multimodal 3-h treatment program on three evenings a week. The clinic aims at accommodating patients who on the one hand do not fit the criteria of partial or full-time inpatient therapy, but on the other hand requires a more intensified therapy dose than the usual German outpatient settings can cater for. In the presented monocentric, qualitative study, we wanted to examine this treatment concept with regard to the patients' specific concerns, expectations, and individual experiences. By contrasting differences in intensity of outpatient and inpatient treatment, we aimed to identify those characteristics of the evening clinic setting that were perceived as especially helpful. METHOD: Each of the 25 patients was interviewed twice, using semi-structured interviews. The interviews took place before (T0) and after (T1) the 10-week treatment interval. A qualitative content analysis of the transcribed interviews was performed using the software "MaxQDA". RESULTS: We identified a total of 1609 separate codes and grouped them into 33 topics and 5 overarching categories. Here, we found some aspects independent of the therapeutic setting, and others concerning the patients' specific expectations and experiences resulting from the particularities of the evening clinic as an outpatient setting including certain inpatient characteristics. This included the possibility of patients continuing to work and being able to fulfil social obligations, i.e. childcare or caring for relatives, while at the same time undergoing intensive psychotherapeutic treatment. CONCLUSIONS: Our results show that the evening clinic concept is particularly suitable for patients with mental and psychosomatic disorders who require intensified multimodal therapy while continuing to meet their obligations in their private and working lives. However, in comparison to other therapeutic methods, this concept generated greater stress and time challenges. Patients should therefore have a reasonably good standard of functioning in everyday life and sufficient coping resources. This is especially important for patients who continue working in their jobs while undergoing treatment. So far, there is a lack of quantitative data which would be needed to evaluate the effectiveness of this novel setting.

[Psychotherapy of depressive disorders : Procedures, evidence and perspectives]. / Psychotherapie depressiver Störungen : Verfahren, Evidenz und Perspektiven.

BACKGROUND: Depressive disorders are associated with a high burden of suffering and significantly reduce the well-being and the self-esteem of affected patients. Psychotherapy is one of the main treatment options for depressive disorders. OBJECTIVE: The aim of this article is to present the current evidence for antidepressive psychotherapeutic treatments. MATERIAL AND METHODS: During the revision of the German S3- and National Disease Management Guideline (NDMG) on unipolar depression in 2015, a comprehensive and systematic evidence search was conducted. The results of this search along with a systematic update are summarized. RESULTS: The most intensively investigated psychotherapeutic method is cognitive behavioral therapy (CBT), which proved to be effective in many trials. Evidence also exists for psychodynamic psychotherapy and interpersonal therapy (IPT), followed by systemic therapy and client-centered psychotherapy; however, the evidence is less robust. CONCLUSION: Psychotherapy alone or in combination with pharmacotherapy was shown to be an effective treatment option. Psychotherapy represents a key element in the treatment of depressive disorders.

[Psychotherapy of depressive disorders: Evidence in chronic depression and comorbidities]. / Psychotherapie depressiver Störungen: Evidenz bei chronischer Depression und bei Komorbidität.

BACKGROUND: Psychotherapy has been shown to be an effective treatment option for depressive disorders; however, its effectiveness varies depending on patient and therapist characteristics and the individual form of the depressive disorder. OBJECTIVES: The aim of this article is to present the current evidence for psychotherapeutic antidepressive treatments for patients with chronic and treatment-resistant depression as well as for patients with mental and somatic comorbidities. MATERIAL AND METHODS: During the revision of the currently valid German S3- and National Disease Management Guideline (NDMG) on unipolar depression published in 2015, a comprehensive and systematic evidence search including psychotherapy for specific patient groups was conducted. The results of this search along with a systematic update are summarized. RESULTS: Psychotherapy has been shown to be effective in reducing depressive symptoms in patients suffering from chronic and treatment-resistant depression and in patients with mental and somatic comorbidities. The evidence is insufficient particularly for patients with mental comorbidities. CONCLUSION: Based on the current evidence and clinical expertise the NDMG recommends psychotherapy alone or in combination with pharmacotherapy to treat most of these depressive patient groups. Evidence gaps were identified, which highlight the need for further research.

[Evidence-based therapy of depression: S3 guidelines on unipolar depression]. / Evidenzbasierte Therapie der Depression: Die S3-Leitlinie unipolare Depression.

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

The social phobia psychotherapy research network. The first multicenter randomized controlled trial of psychotherapy for social phobia: rationale, methods and patient characteristics.

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

Public knowledge and attitudes on organ donation do not differ in Germany and Spain.

BACKGROUND: The background of this study was the inadequate supply of donor organs in Germany. In Spain, by contrast, a strong increase of organ donors over the past years has created a satisfactory supply situation. Because both countries have similar legal situations, the causes for the drastic differences in organ donation rates remain unclear. The main issue of our study was to investigate the intellectual attitudes toward various aspects of postmortem donations in the populations of both countries as a causative factor for the observed differences. METHODS: We studied 726 persons by questionnaire. Probands, matched for age and gender, were recruited among medical students, in a public library and in a general medical practice in both Germany and Spain. RESULTS: We found no differences in the attitudes toward postmortem organ donation between the two countries. Differences among the social groups within the countries were apparent in the expected direction. CONCLUSION: A higher level of knowledge or a difference in attitudes toward organ donation is probably not the reason for the higher donation rate in Spain. The cause appears to be rather at the organizational level.

[Course of symptom severity and prediction of outcome in inpatient psychotherapy]. / Verlauf der Symptombelastung und Vorhersage des Behandlungserfolges in der stationären Psychotherapie.

OBJECTIVES: The study looks for typical curves of symptom development in inpatients and investigates the influence of initial remoralisation and terminal improvement on the global therapy outcome. METHODS: 71 psychotherapy inpatients (affective, anxiety, eating and personality disorders; average treatment duration 11.9 weeks) gave weekly self-reports on symptom severity (BSI, Derogatis, 1983) and had a complete outcome evaluation. Regression parameters of the symptom curves were taken for correlational and path analytic calculations. RESULTS: Initial symptom alleviation is able to predict better global outcome. However there is a relevant subgroup of patients which has a good outcome despite an initial deterioration. CONCLUSIONS: Initial remoralisation predicts better outcome but is not a necessary condition. The results partly call into question the group statistical "dose-response-curves". Further studies should test the influence of other process parameters (group cohesion, therapeutic alliance etc.) on the course of treatment.

Who shall be allowed to give? Living organ donors and the concept of autonomy.

UNLABELLED: Free and informed consent is generally acknowledged as the legal and ethical basis for living organ donation, but assessments of living donors are not always an easy matter. Sometimes it is necessary to involve psychosomatics or ethics consultation to evaluate a prospective donor to make certain that the requirements for a voluntary and autonomous decision are met. The paper focuses on the conceptual questions underlying this evaluation process. In order to illustrate how different views of autonomy influence the decision if a donor's offer is ethically acceptable, three cases are presented--from Germany, the United States, and India. Each case features a person with questionable decision-making capacity who offered to donate a kidney for a sibling with severe renal insufficiency. Although the normative framework is similar in the three countries, different or sometimes even contrary arguments for and against accepting the offer were brought forward. The subsequent analysis offers two explanations for the differences in argumentation and outcome in spite of the shared reference to autonomy as the guiding principle: (1) Decisions on the acceptability of a living donor cannot simply be deducted from the principle of autonomy but need to integrate contextual information; (2) understandings of the way autonomy should be contextualized have an important influence on the evaluation of individual cases. CONCLUSION: Analyzing the conceptual assumptions about autonomy and its relationship to contextual factors can help in working towards more transparent and better justified decisions in the assessment of living organ donors.

It's only love? Some pitfalls in emotionally related organ donation.

Transplanting organs from emotionally related donors has become a fairly routine procedure in many countries. However, donors have to be chosen carefully in order to avoid not just medically, but also morally, questionable outcomes. This paper draws attention to vulnerabilities that may affect the voluntariness of the donor's decision. Suggestions are made as to how to approach the evaluation and selection of potential donors.

The influence of interpersonal problems and symptom severity on the duration and outcome of short-term psychodynamic psychotherapy.

This naturalistic outcome study investigated validity aspects of the Inventory of Interpersonal Problems (IIP [Horowitz, Strauß, & Kordy, 1995]). The sample consisted of 180 patients who received short-term psychodynamic psychotherapy for an average number of 7.8 sessions and an average duration of 3.4 months. Small changes in pre-post-measures imply that the IIP is not to be recommended as an instrument for outcome evaluation in short-term psychotherapy, due to the traitlike character of its items. However, we showed by path analyses that a higher score on the affiliative dimension of the interpersonal circumplex goes along with a better treatment outcome. The influence of the dominance dimension is gender specific: male patients (who generally showed more dismissive and introverted behavior in this sample) received, if dismissive and introverted, a longer introductory therapy, whereafter they - in cases of high symptom load - were often referred to long-term treatment. Dominant male patients and, in general, female patients with high symptom scores, were referred faster, after only a few sessions. Results are discussed under aspects of adaptive therapist behavior.

State-of-the-art in the measurement of volatile organic compounds emitted from building products: results of European interlaboratory comparison.

Eighteen laboratories from 10 European countries participated in a comparison organized as part of the VOCEM project, a 2.5-year research collaboration among 4 research institutes and 4 industrial companies. The scope of the project was to improve the procedure used to measure volatile organic compounds (VOC) emitted from building materials and products in small test chambers. The interlaboratory comparison included the GC-MS determination of 5 target compounds from carpet, 8 from polyvinyl chloride (PVC) cushion vinyl and 2 from paint; for the first time, chamber recovery (sinks), homogeneity of solid materials and possible contamination during transport were tested. The results show that the intralaboratory variance (random errors) is much smaller than the interlaboratory variance (systematic errors). Causes of the largest interlaboratory discrepancies were: (i) analytical errors; (ii) losses of the heaviest compounds due to sorption on the chamber walls; and (iii) non homogeneity of the materials. The output of this work concerns both the objective of labelling materials with regard to their VOC emissions and the pre-standard drafted by the European Commitee for Standardization (CEN) for this type of determination.

Measuring psychotherapeutic change with the symptom checklist SCL 90 R.

BACKGROUND: Despite a long tradition of discussions on the evaluation of psychotherapy, there is still a lack of agreement for measuring change after psychological treatment. In this paper we describe the concept of statistical and clinical significance of change. We use the Symptom Checklist 90 R as a commonly administered instrument to propose conventions and cutoff points for psychological symptoms and their change after therapy. METHOD: A German norm population and several psychotherapy samples have been aggregated to calculate cutoffs and confidence intervals (reliable change indices) for statistically and clinically significant changes after psychotherapy. RESULTS: The cutoff point between a 'functional' and a 'dysfunctional' population was calculated as C = 0.57 (Global Severity Index, GSI). Patients above this score need a change of at least RCI = 0.43 (GSI difference) for a statististically significant change. Below this score the RCI = 0.16. The use of multiple clinical groups (e.g. inpatients and outpatients) for a more realistic determination of a 'stepwise' clinically significant change, as proposed by Tingey et al. in the USA, is not possible in the German samples collected so far. Initial SCL 90-R scores in these groups do not show enough differences to call a move from one group to the other a clinically significant change. CONCLUSION: In the German samples investigated the move from a 'functional' to a 'dysfunctional' population and vice versa has to be taken as the criterion for a clinically significant change up to now.

[Psychological health, locus of control and personality of medical students of a traditional and an alternative study program]. / Psychische Befindlichkeit, Kontrollüberzeugungen und Persönlichkeit von Medizinstudierenden eines traditionellen und eines Reformstudienganges.

Traditional medical curricula are widely criticised. Medical students show a higher prevalence of psychological distress. New problem-based curricula are said to promote higher satisfaction with medical schools and lower psychological distress. This goes together with achievement comparable to traditional curricula. A study with preclinical medical students in a traditional (Göttingen, n = 126) and an alternative (Witten/Herdecke, n = 25) medical curriculum was carried through, concerning subjective wellbeing (depression/anxiety), locus of control and primary personality traits. Students in the problem-oriented curriculum show lower prevalence of psychological distress and less experience of powerlessness and fatalism (external locus of control). There is no striking difference in the primary personality traits. Results are discussed with respect to long-term evaluation of future alternative curricula in Germany.

[SEB--an instrument for the assessment of therapeutic processes in inpatient psychotherapy]. / SEB--Ein Fragebogen zur Erfassung des Verlaufs stationärer Psychotherapie.

The Stationserfahrungsbogen (Record Sheet and Questionnaire on the experience of the inpatient therapeutic process--SEB) is an instrument to assess process aspects during inpatient psychotherapy. Weekly presentation and completion of the sheet shows changes in selected aspects of patient experience. 38 items cover the following aspects (scales): relations with the therapeutic team, relations with the individual therapist, group climate (cohesion), attention from fellow patients, intensity of treatment, therapeutic rules, self-efficacy. The questionnaire can be applied in clinical and research areas and is also useful for quality management of therapeutic institutions. Single-case studies using SEB facilitate clinical discussion and understanding of therapeutic processes. In psychotherapy research the instrument can be used to assess common and specific factors of therapeutic effects. By comparison with norm scores and SEB can also be used for the evaluation of process and outcome quality. The questionnaire can be applied economically and with good patient compliance. It is objective and has clinical validity and is of great informative value. Internal consistency of the individual scales is good to satisfactory.

[The Symptom Checklist-90-R (SCL-90-R) for presenting statistically and clinically significant psychotherapy outcome]. / Die Symptom Checklist-90-R (SCL-90-R) zur Darstellung, von statistisch und klinischsignifikanten Psychotherapieergebnissen.

After a long period of discussions on the efficacy of psychotherapy, there is still a lack of conventions for measuring change after psychological treatment. This paper first describes the concept of statistical and clinical significance of change. Using the SCL-90-R as a commonly administered instrument we then propose conventions and cut-off points for its global severity score (GSI) and change after therapy. A German standard population and several psychotherapy samples were aggregated to determine cut-off points and confidence intervals (reliable change indices) for statistically and clinically significant changes. Tingey et al. (1996) proposed the use of multiple clinical groups (inpatients and outpatients) aiming at a more realistic determination of "stepwise" changes. We examined this procedure with our data. Results show that it is not applicable in the German samples collected so far. Initial SCL-90-R scores in these groups did not differentiate sufficiently between inpatients and outpatients. Therefore, according to Jacobson and Truax (1991), moving from a "functional" to a "dysfunctional" population is still the criterion for a clinically significant change.

[Operationalized Psychodynamic Diagnosis in a trial--results of multicenter acceptability and practicability study]. / Operationalisierte psychodynamische Diagnostik (OPD) in der Erprobung--Ergebnisse einer multizentrischen Anwendungs- und Praktikabilitätsstudie.

During a multicentric field trial involving 134 diagnosticans from 16 centres in a first phase and 38 diagnosticans from 5 centres in a second phase a preliminary version of the manual "Operational Psychodynamic Diagnosis (OPD)" was tested. Focussing on feasibility, practicability and interrater-reliability the different axes of the new system were assessed as comparatively easy to use. The goodness of fit for diagnostic categories and the confidence in the diagnostic process showed a sufficient acceptance of the system. The percentage and chance-corrected inter-rater-reliability coefficients were acceptable for the most axes. It could be demonstrated that interrater-reliability depends on the degree of experiences with the OPD approach. Therefore a systematic training is necessary to use the system.

[Diagnosis of interpersonal problems in depressive disorders]. / Diagnostik interpersonaler Probleme bei depressiven Störungen.

Questionnaires assessing interpersonal problems may be of relevance in the field of psychotherapy not only to determine therapeutic goals but also for predicting the quality of the therapeutic alliance. Our study on the clinical validity of the Inventory of Interpersonal Problems-IIP (Horowitz) focussed on patients with affective disorders. According to the literature we hypothesized two subgroups with different areas of problems: one with high interpersonal dependency, one with an overly autonomous stance. Our sample comprises 169 patients of a psychotherapeutic outpatient clinic for students with the diagnosis of an affective disorder according to ICD 10 and a partly (age, sex, subject) comparison group of 119 students. The IIP was able to replicate the aforementioned groups. The instrument therefore may be applied to measure change in depressive psychopathology. It also might offer help for differential indication in psychotherapy.