Primary care patients' experiences of video consultations for depression and anxiety: a qualitative interview study embedded in a randomized feasibility trial.

BACKGROUND: Integrated mental health care models that provide rapid access to video consultations with mental health specialists for primary care patients are a promising short-term, low-threshold treatment option and may reduce waiting times for specialist care. This qualitative study, nested within a randomized feasibility trial, aimed to explore participants' views on this type of care model, its influence on the lived experience of patients, and barriers and facilitators for its delivery. METHODS: In five primary care practices, 50 adults with depression and/or anxiety were randomly assigned to either an integrated care model (maximum of five video consultations with a mental health specialist) or usual care (primary care or another treatment option). Prior to obtaining the trial results, interviews were held with participants who had received video consultations. Interviews were transcribed and analysed thematically. RESULTS: Twenty of the 23 patients who received video consultations participated in the interviews. Patients engaged well with the care model and reported positive effects on their most pressing needs, while denying safety concerns. Generally, they perceived the usability of video consultations as high, and temporary connectivity failures were not considered a substantial barrier. We identified two key mechanisms of impacts on the patients' lived experience: fast access to specialist mental healthcare and the emerging rapport with the specialist. In particular, patients with no prior mental healthcare experience indicated that familiarity with the primary practice and their physician as a gatekeeper were important facilitators of proactive treatment. CONCLUSIONS: From the patients' perspective, mental health care models integrating video consultations with mental health specialists into primary care are linked to positive lived experiences. Our findings imply that primary care physicians should promote their role as gatekeepers to (1) actively engage patients, (2) apply integrated care models to provide a familiar and safe environment for conducting mental health care video consultations, and (3) be able to regularly assess whether certain patients need in-person services. Scaling up such models may be worthwhile in real-world service settings, where primary care physicians are faced with high workloads and limited specialist services. TRIAL REGISTRATION: DRKS00015812.

[Integrated Care for Patients with Somatic Symptom Disorder in Primary Care - A Qualitative Participatory Evaluation of a Randomised Feasibility Trial]. / Integrierte Behandlung von Patient*innen mit somatischer Belastungsstörung in Hausarztpraxen ­ Eine qualitative, patient*innenbeteiligende Evaluation einer randomisierten Machbarkeitsstudie.

OBJECTIVE: The VISION intervention is a manualized short-term treatment for people with somatic symptom disorder, integrated into the primary care and delivered by psychotherapists via video consultations. As an innovative technology-based approach, the intervention was most recently piloted in a randomized feasibility trial. During the qualitative accompanying study presented here, the intervention was evaluated and optimised from the user perspective of patients who participated in the feasibility study. METHODS: We interviewed a total of N=10 patients included in the intervention group in three semi structured focus group discussions focusing on how they (1) assess the intervention in terms of acceptance and individual benefit and (2) which adjustments are necessary from the user perspective for further optimization of the intervention. We performed a qualitative content analysis using MAXQDA Plus 2022. RESULTS: Respondents reported initial reservations on their part regarding care via video consultation. After a brief period of habituation, the intervention was universally accepted. Main suggestions for improvement included a stronger focus on supporting patients find follow-up psychotherapy (if indicated) more flexible settings (e. g., location of video consultation), and a stronger integration of treatment into primary care. DISCUSSION AND CONCLUSION: The study provides systematically elaborated comprehensive findings on participants' practical experiences with the intervention. The model is appropriate for treating people with somatic symptom disorder. Before implementation, important suggestions for improvement should be thoroughly considered with continued patient and public involvement.

Health policy experts' perspectives on implementing mental health specialist video consultations in routine primary care - a qualitative interview study.

BACKGROUND: Many patients with mental disorders are treated by their general practitioner (GP). Innovative technology-based integrated care models (e.g., mental health specialist video consultations) have been proposed to facilitate access to specialist services in primary care settings. While perspectives of patients and providers have been examined, there is little insight into the perspectives of health policy experts on such models. The purpose of this study was to examine the perspectives of health policy experts on (1) current challenges for continuity of care, (2) anticipated benefits and barriers for implementation of mental health specialist video consultations along with (3) practical and regulative preconditions for sustained implementation in primary care. METHODS: In a cross-sectional qualitative study, we conducted 15 semi-structured interviews with health policy experts representing various stakeholders in the German health care system: health insurances, governmental bodies, clinicians' professional associations, and patient representatives. Following a critical realism approach, we applied a qualitative inductive content analysis to derive key themes from the material. RESULTS: Health policy experts saw long waiting times for patients and a lack of collaboration between in- and outpatient mental health services as well as mental health specialists and GPs as main barriers for current continuity of care. Health policy experts also felt that video consultations bear great potential to foster coordinated care between GPs and specialists and ensure timely referral for severely burdened patients. Increased workload for the general practice staff to facilitate video consultations and difficulties in establishing reliable therapeutic alliances between patients and specialists via remote treatment were considered as major barriers. Health policy experts varied significantly in their level of knowledge concerning legal frameworks and regulations pertaining to video consultations. However, the implementation of appropriate reimbursement schemes and sufficient data protection were regarded as the major regulative challenges. CONCLUSIONS: Health policy experts mostly consider mental health specialist video consultations as a promising way to overcome current challenges for the management of patients with mental disorders at the interface between primary and specialist care. To ensure sustained implementation, a multi-stakeholder approach accounting for the perspective of health policy experts, patients, and providers should be followed. TRIAL REGISTRATION: German Clinical Trials Register DRKS00012487.

[Psychotherapeutic Video Consultations in Primary Care - Concept of the PROVIDE Intervention and Results on the Intent to Adopt in Psychotherapists]. / Videokonsultationen durch Psychotherapeuten in der Hausarztpraxis.

Mental health conditions represent a significant burden to the individual as well as the society. Within the health care system, the general practitioner is the first and, in most cases, the only provider. Timely referral of patients to specialized care is often difficult due to several barriers, particularly in rural areas. These barriers comprise long waiting times, the rising prevalence of psychosomatic and somatopsychic comorbidity, immobility in the elderly and stigmatisation related to mental health conditions. Following the Integrated Health Care approach, diagnosis and therapy of mental health conditions by psychotherapists directly within the general practice constitute an effective care model. We present a care model that is based on a telemental treatment approach for depression and anxiety disorders. Central is the piloting of psychotherapeutic video consultations in the general practice. The following article provides an overview of the care model and provides results concerning the intent to adopt the model in office-based psychotherapists.

An integrated mental health video consultations model for patients with somatic symptom disorder in primary care: The randomized VISION pilot trial.

OBJECTIVE: Symptoms of somatic symptom disorder (SSD) are one of the most common reasons for consultations in primary care. However, specialized psychological services are mostly unavailable. This pilot trial aimed to determine the feasibility, acceptability, and safety of the integrated mental health video consultations VISION model for patients with SSD in primary care. METHODS: We conducted a parallel group, randomized controlled pilot trial involving fifty-one patients with SSD from ten primary care practices in Germany, who we randomized to the VISION model or enhanced treatment-as-usual (eTAU). The VISION model comprised five video consultations which featured diagnostic clarification, psychoeducation (acknowledging and legitimizing of symptoms), and brief psychological therapy. eTAU included training primary care practice teams on the DSM-5 concept of SSD and on current guideline recommendations for its treatment in primary care. We assessed feasibility as the primary outcome at 6-months, measuring efficiency of recruitment, intervention acceptability, and safety. RESULTS: Recruitment was efficient reflected in an overall recruitment yield (number randomized per number screened) of 55% (51/92) and a consent rate (number randomized per number eligible) of 94% (51/54). Acceptability of the intervention was high with 98% (123/125) of the video consultations conducted as planned. No serious adverse events were reported in either group. CONCLUSION: An integrated mental health video consultations VISION model for patients with SSD presenting to primary care is feasible, acceptable, and safe. Potential clinical effectiveness of the model should be evaluated in confirmatory trial implementing the multifaceted approach tailored to the individual patient with SSD directly into primary care practice. TRIAL REGISTRATION: The trial protocol was registered at German Clinical Trials Register (number: DRKS00026075, https://www.drks.de).

Model of integrated mental health video consultations for people with depression or anxiety in primary care (PROVIDE-C): assessor masked, multicentre, randomised controlled trial.

OBJECTIVE: To evaluate whether an integrated mental health video consultation approach (PROVIDE model) can improve symptoms compared with usual care in adults with depression and anxiety disorders attending primary care. DESIGN: Assessor masked, multicentre, randomised controlled trial (PROVIDE-C). SETTING: In 29 primary care practices in Germany, working remotely online from one trial hub. PARTICIPANTS: 376 adults (18-81 years) who presented to their general practitioner (GP) with depression or anxiety, or both. INTERVENTION: Participants were randomised (1:1) to receive the PROVIDE model (n=187) or usual care (n=189). Usual care was provided by GPs through interventions such as brief counselling and psychotropic medication prescriptions and may or may not have included referrals to mental health specialists. The PROVIDE model comprised transdiagnostic treatment provided through five real-time video sessions between the patient at the primary care practice and a mental health specialist at an offsite location. MAIN OUTCOME MEASURES: The primary outcome was the absolute change in the mean severity of depressive and anxiety symptoms measured using the patient health questionnaire anxiety and depression scale (PHQ-ADS) at six months, in the intention-to-treat population. Secondary outcomes, measured at six and 12 months, included PHQ-ADS subscores, psychological distress related to somatic symptoms, recovery, health related quality of life, quality and patient centredness of chronic illness care, and adverse events. RESULTS: Between 24 March 2020 and 23 November 2021, 376 patients were randomised into treatment groups. Mean age was 45 years (standard deviation (SD) 14), 63% of the participants were female, and mean PHQ-ADS-score was 26 points (SD 7.6). Compared with usual care, the PROVIDE intervention led to improvements in severity of depressive and anxiety symptom (adjusted mean change difference in the PHQ-ADS score -2.4 points (95% confidence interval -4.5 to -0.4), P=0.02) at six months. The effects were sustained at 12 months (-2.9 (-5.0 to -0.7), P<0.01). No serious adverse events were reported in either group. CONCLUSIONS: Through relatively low intensity treatment, the PROVIDE model led to a decrease in depressive and anxiety symptoms with small effects in the short and long term. Depression and anxiety disorders are prevalent and therefore the small effect might cumulatively impact on population health in this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT04316572.

The Inventory of Complicated Grief-A Systematic Psychometric Review and Conceptual Replication Study of the Structural Validity.

The Inventory of Complicated Grief (ICG) is a commonly used self-report measure in psycho-oncology, best supportive care, and palliative medicine. However, existing validation studies yielded conflicting results regarding the structural validity. This study provides a psychometric review and conceptual replication of the ICG latent structure to test the hypothesis that existing studies overfit unreliable sources of variance, which overshadow the unidimensionality of the ICG. All proposed latent models identified in the psychometric review were tested in a series of confirmatory and exploratory structural equation models. Specifically, at least five to six latent intercorrelated factors were necessary to reach acceptable model fit. However, a general CG factor accounted for most variance and ICG sum scores showed predictable associations with anxiety and depressive symptoms, which suggests that the ICG is essentially unidimensional. There are indications that other measures of pathological grief show similar inconsistencies. Overall, potentially emerging subfacets of the ICG should not be interpreted as distinct "symptom clusters." If time constraints are an issue as is often the case in clinical research, complicated grief may just be measured by a reduced item set without a significant loss of information or complexity.

From inpatient to outpatient mental health care: Protocol for a randomised feasibility trial of a care transition intervention for patients with depression and anxiety (the AMBITION-trial).

INTRODUCTION: Despite guideline recommendations, inpatients with mental health disorders often do not receive appropriate treatment after discharge. This leads to high readmission rates, problems with medication adherence, increased risk of chronicity and suicide, and exclusion from the labour market accompanied by high individual and social costs. The causes are both system-related, such as limited treatment availability, and patient-related, such as ambivalent motivation to continue treatment and lack of information about available treatment options. The aim of this trial is to assess the feasibility of a Care Transition Intervention (CTI) which supports patients in the psychosocial follow-up treatment process after discharge from a psychotherapy ward. METHODS AND ANALYSIS: Fifty patients with depression and/or anxiety who are treated as inpatients at a psychotherapy ward will be included and randomised into two groups with a 1:1 ratio. In the intervention group, patients will receive five CTI sessions with a Care Transition Navigator before and after discharge. The sessions will focus on individual patient support including a) identification and tackling of barriers to initiate follow-up treatment, b) reflection on the inpatient stay and individual progress, with focus on the helpful aspects and c) motivation of patients to organise and take up outpatient treatment. Patients in the control group will receive treatment-as-usual during discharge. We will evaluate the following outcomes: effectiveness of recruitment strategies, patient acceptance of randomisation, practicability of implemented workflows, feasibility of data collection, and clinical outcomes.

Negotiating decisions on aggressive cancer care at end-of-life between patients, family members, and physicians - A qualitative interview study.

Background: Patients with advanced cancer do receive increasingly aggressive end-of-life care, despite it does often not prolong survival time but entails decreased quality of life for patients. This qualitative study explores the unfolding of aggressive end-of-life care in clinical practice focusing on the decision-making process and the quality of end-of-life care from family members' perspective. Materials and methods: We conducted semi-structured interviews with 16 family members (six of cancer patients with and ten without aggressive end-of-life care) at the National Center for Tumor Diseases Heidelberg, Germany. We conducted a content analysis applying a theoretical framework to differentiate between 'decision-making' (process of deciding for one choice among many options) and 'decision-taking' (acting upon this choice). Results: While patients of the aggressive care group tended to make and take decisions with their family members and physicians, patients of the other group took the decision against more aggressive treatment alone. Main reason for the decision in favor of aggressive care was the wish to spend more time with loved ones. Patients took decisions against aggressive care given the rapid decline in physical health and to spare relatives difficult decisions and arising feelings of guilt and self-reproach. Conclusion: Treatment decisions at end-of-life are always individual. Nevertheless, treatment courses with aggressive end-of-life care and those without differ markedly. To account for a longitudinal perspective on the interplay between patients, family members, and physicians, cohort studies are needed. Meanwhile, clinicians should validate patients and family members considering refraining from aggressive end-of-life care and explore their motives. Clinical trial registration: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022837, identifier DRKS00022837.

Mental health specialist video consultations for patients with somatic symptom disorder in primary care: protocol for a randomised feasibility trial (the VISION trial).

INTRODUCTION: General practitioners (GP) report increasing difficulties in referring patients with somatic symptom disorder (SSD) in specialised psychosocial care. Barriers are structural conditions of the respective healthcare system and patients' reservations against receiving specialised psychosocial care. As patients with SSD often predominantly assume somatic influencing factors for the development and maintenance of their somatic complaints, close collaboration between the GP and mental health specialist (MHS) seems particularly important. Integrating internet-based video consultations by remotely located MHS and primary care can improve effective treatment of patients with SSD by overcoming structural barriers and provide low-threshold and timely care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing MHS video consultations in primary care practices. METHODS AND ANALYSIS: Fifty primary care patients with SSD will be individually randomised in two groups receiving either enhanced treatment as usual as provided by their GP (control group) or two versus five video consultations conducted by an MHS additionally to enhanced treatment as usual. The video consultations focus on (a) diagnostic clarification, (b) the development of a biopsychosocial disorder model, and (c) development of a treatment plan against the background of a stepped-care algorithm based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters. ETHICS AND DISSEMINATION: This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-620/2021). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial. TRIAL REGISTRATION NUMBER: DRKS00026075.

Aggressiveness of Care at the End-of-Life in Cancer Patients and Its Association With Psychosocial Functioning in Bereaved Caregivers.

STUDY REGISTRATION: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022837,DRKS00022837. BACKGROUND: Intensified oncological treatment for advanced cancer patients at the end-of-life has been specified as aggressiveness of care (AOC) and increased over the past decades. The aims of this study were to 1) determine the frequency of AOC in Central Europe, and 2) investigate differences in mental health outcomes in bereaved caregivers depending on whether the decedent had experienced AOC or not. MATERIALS AND METHODS: We conducted a cross-sectional study in a large tertiary comprehensive cancer care center in Germany. Bereaved caregivers provided information about (a) treatment within the last month of life of the deceased cancer patient and (b) their own mental health status, i.e., decision regret, complicated grief, depression, and anxiety. After multiple imputation of missing data, differences in mental health outcomes between AOC-caregivers and non-AOC-caregivers were analyzed in a multivariate analysis of variances. RESULTS: We enrolled 298 bereaved caregivers of deceased cancer patients. AOC occurred in 30.9% of all patients. In their last month of life, 20.0% of all patients started a new chemotherapy regimen, and 13.8% received ICU-treatment. We found differences in mental health outcomes between bereaved AOC- and non-AOC-caregivers. Bereaved AOC caregivers experienced significantly more decision regret compared to non-AOC caregivers (Cohen's d = 0.49, 95% CI [0.23, 0.76]). CONCLUSION: AOC occurs frequently in European health care and is associated with poorer mental health outcomes in bereaved caregivers. Future cohort studies should substantiate these findings and explore specific trajectories related to AOC. Notwithstanding, shared-decision making at end-of-life should increasingly account for both patients' and caregivers' preferences.

Mental health specialist video consultations versus treatment as usual in patients with depression or anxiety disorders in primary care: study protocol for an individually randomised superiority trial (the PROVIDE-C trial).

BACKGROUND: Most people with mental disorders, including those with severe and chronic disorders, are treated solely by their general practitioner (GP). Nevertheless, specialised mental health care may be required for specific patients. Notably, the accessibility of mental health specialist care is mainly complicated by (a) long waiting times for an appointment with specialists, (b) long travel distances to specialists, particularly in rural and remote areas, and (c) patients' reservations about mental health specialist care (including fear of being stigmatised by seeking such care). To mitigate those barriers, technology-based integrated care models have been proposed. The purpose of this study is to examine the effectiveness and cost-effectiveness of a mental health specialist video consultations model versus treatment as usual in patients with depression or anxiety disorders in primary care. METHODS: In an individually randomised, prospective, two-arm superiority trial with parallel group design, N = 320 patients with anxiety and/or depressive disorder will be recruited in general practices in Germany. The intervention includes a newly developed treatment model based on video consultations with focus on diagnostics, treatment planning, and short-term intervention by mental health specialists. We will systematically compare the effectiveness, cost-effectiveness, and adverse effects of this new model with usual care by the GP: the primary outcome is the absolute change in the mean depressive and anxiety symptom severity measured on the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) from baseline to 6 months after baseline assessment. Follow-up in both groups will be conducted by blinded outcome assessors at 6 months and 12 months after baseline. The main analysis will be based on the intention-to-treat principle. We will optimise the likelihood of treatment effectiveness by strict inclusion criteria for patients, enhanced intervention integrity, and conducting a process evaluation. DISCUSSION: To the best of our knowledge, this is the first confirmatory study on a video-based, integrated care model for the treatment of anxiety and depressive disorders in GP patients in Germany. TRIAL REGISTRATION: ClinicalTrials.gov, United States National Institutes of Health NCT04316572 . Prospectively registered on 20 March 2020.

Mental Health Specialist Video Consultations Versus Treatment-as-Usual for Patients With Depression or Anxiety Disorders in Primary Care: Randomized Controlled Feasibility Trial.

BACKGROUND: Most people affected by depression or anxiety disorders are treated solely by their primary care physician. Access to specialized mental health care is impeded by patients' comorbidity and immobility in aging societies and long waiting times at the providers' end. Video-based integrated care models may leverage limited resources more efficiently and provide timely specialized care in primary care settings. OBJECTIVE: The study aims to evaluate the feasibility of mental health specialist video consultations with primary care patients with depression or anxiety disorders. METHODS: Participants were recruited by their primary care physicians during regular practice visits. Patients who had experienced at least moderate symptoms of depression and/or anxiety disorders were considered eligible for the study. Patients were randomized into 2 groups receiving either treatment-as-usual as provided by their general practitioner or up to 5 video consultations conducted by a mental health specialist. Video consultations focused on systematic diagnosis and proactive monitoring using validated clinical rating scales, the establishment of an effective working alliance, and a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. Feasibility outcomes were recruitment, rate of loss to follow-up, acceptability of treatment, and attendance at sessions. Effectiveness outcomes included depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), burden of specific somatic complaints (Somatic Symptom Disorder-B Criteria Scale-12), recovery (Recovery Assessment Scale-German [RAS-G]), and perception of chronic illness care (Patient Assessment of Chronic Illness Care), which were measured at baseline and 16 weeks postallocation by assessors blinded to the group allocation. RESULTS: A total of 50 patients with depression and/or anxiety disorders were randomized, 23 in the intervention group and 27 in the treatment-as-usual group. The recruitment yield (number randomized per number screened) and the consent rate (number randomized per number eligible) were 69% (50/73) and 86% (50/58), respectively. Regarding acceptability, 87% (20/23) of the participants in the intervention group completed the intervention. Of the 108 planned video consultations, 102 (94.4%) were delivered. Follow-up rates were 96% (22/23) and 85% (23/27) for the intervention and control groups, respectively. The change from baseline scores at postmeasurement for the No Domination by Symptoms domain of recovery (RAS-G) was somewhat higher in the intervention group than in the control group (Mann-Whitney U test: rank-biserial r=0.19; 95% CI -0.09 to 0.46; P=.18). We did not detect any notable differences between the intervention and control groups in terms of other effectiveness outcomes. We did not observe any serious adverse events related to the trial. CONCLUSIONS: The intervention and study procedures were found to be feasible for patients, primary care practice staff, and mental health specialists. A sufficiently powered pragmatic trial on mental health specialist video consultations should be conducted to investigate their effectiveness in routine care. TRIAL REGISTRATION: German Clinical Trials Register DRKS00015812; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015812.

Health providers' experiences with mental health specialist video consultations in primary care: a qualitative study nested within a randomised feasibility trial.

OBJECTIVE: Despite available effective treatments for mental health disorders, few patients in need receive even the most basic care. Integrated telepsychiatry services may be a viable option to increase access to mental healthcare. The aim of this qualitative process evaluation embedded in a randomised controlled feasibility trial was to explore health providers' experiences with a mental healthcare model integrating mental health specialist video consultations (MHSVC) and primary care. METHODS: A qualitative process evaluation focusing on MHSVC in primary care was conducted. In 13 semistructured interviews, we assessed the experience of all mental health specialists, primary care physicians and medical assistants who participated in the trial. A thematic analysis, focusing on the implementation, mechanisms of impact and context, was applied to investigate the data. RESULTS: Considering (1) the implementation, participants evaluated the consultations as feasible, easy to use and time saving. Concerning (2) the mechanisms of impact, the consultations were regarded as effective for patients. Providers attributed the patients' improvements to two key aspects: the familiarity of the primary care practice and the fast access to specialist mental healthcare. Mental health specialists observed trustful therapeutic alliances emerging and described their experience as comparable to same-room care. However, compared with same-room care, specialists perceived the video consultations as more challenging and sometimes more exhausting due to the additional effort required for establishing therapeutic alliances. Regarding (3) the intervention's context, shorter travel distances for patients positively affected the implementation, while technical failures, that is, poor Internet connectivity, emerged as the main barrier. CONCLUSIONS: MHSVCs in primary care are feasible and successful in improving access to mental healthcare for patients. To optimise engagement and comfort of both patients and health providers, future work should focus on empirical determinants for establishing robust therapeutic alliances with patients receiving MHSVC (eg, leveraging non-verbal cues for therapeutic purposes). TRIAL REGISTRATION NUMBER: DRKS00015812; Results.

[Realtime video consultations by psychotherapists in times of the COVID-19 pandemic]. / Videokonsultationen durch Psychotherapeuten in Zeiten der COVID-19-Pandemie: Wirksamkeit, Gestaltung des Settings und erste Erfahrungen aus einer Machbarkeitsstudie sowie mit dem Routineangebot im Krankenhaus.

Due to the pandemic caused by the coronavirus disease 2019 (COVID-19) and the resulting constraints on personal (i.e. face to face) treatment, video consultations have recently gained a major role in the delivery of healthcare services; however, until now, most psychotherapists have little experience with conducting video consultations, not least because of poor possibilities for reimbursement from the statutory health insurance. This article provides (1) an overview of the effectiveness of psychotherapy interventions delivered via video consultations for depression and anxiety disorders, (2) recommendations for setting up and conducting these consultations and (3) first experiences of psychotherapists from a German feasibility study and from the provision in routine care in hospital during the COVID-19 pandemic.

Mental health specialist video consultations for patients with depression or anxiety disorders in primary care: protocol for a randomised controlled feasibility trial.

INTRODUCTION: Most people suffering from depression and anxiety disorders are entirely treated in primary care. Due to growing challenges in ageing societies, for example, patients' immobility and multimorbidity, the transition to specialised care becomes increasingly difficult. Although the co-location of general practitioners and mental health specialists improves the access to psychosocial care, integrated in-person approaches are not practical for rural and single-doctor practices with limited personnel and financial resources. Treating primary care patients via internet-based video consultations by remotely located mental health specialists bears the potential to overcome structural barriers and provide low-threshold care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing of mental health specialist video consultations in primary care practices. METHODS AND ANALYSIS: Fifty primary care patients with significant depression and/or anxiety symptomatology will be randomised in two groups receiving either the treatment as usual as provided by their general practitioner or up to five video consultations conducted by a mental health specialist. The video consultations focus on (1) systematic diagnosis plus proactive monitoring using validated clinical rating scales, (2) the establishment of an effective working alliance and (3) a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters. ETHICS AND DISSEMINATION: This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-634/2018). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial. TRIAL REGISTRATION NUMBER: DRKS00015812.

Quantitative Review of Oral Cancer Research Output from Pakistan.

BACKGROUND: Oral cancer is the most common cancer among men and second only to breast cancer among women in Pakistan. For the effective control and prevention of oral cancer, Pakistan needs to recognize the importance of research and generation of the evidence-base which can inform policy making and planning and implementation of intervention programs. The objective of this review was to quantify oral cancer research output in Pakistan. MATERIALS AND METHODS: A systematic electronic search in "Medline", "ISI-Web of Science" and "Pakmedinet", supplemented by a Google search, was carried out in January and February, 2014, to identify literature from Pakistan relevant to oral cancer. The selection of publications for the review was carried out according to preset criteria. Data were recorded and analyzed using Microsoft Excel. RESULTS: A total of 166 publications comprising 62 case series, 36 cross sectional, 31 case control, 10 basic laboratory research, eleven reviews and two trials, were included in this review. Some 35 % of the publications focused on risk factors for oral cancer. COMSATS Institute of Information Technology was the institution with the highest contribution. CONCLUSIONS: There is a lack of research in the field of oral cancer research in Pakistan. Focused efforts should be put in place to improve both quality and quantity of oral cancer research in the country.

Smokeless tobacco and oral cancer in South Asia: a systematic review with meta-analysis.

Introduction. Smokeless tobacco is considered one of the major risk factors for oral cancer. It is estimated that over 90% of the global smokeless tobacco use burden is in South Asia. This paper aims to systematically review publications reporting epidemiological observational studies published in South Asia from 1984 till 2013. Methods. An electronic search in "Medline" and "ISI Web of Knowledge" yielded 734 publications out of which 21 were included in this review. All publications were assessed for quality using a standard quality assessment tool. Effect estimates (odds ratios (OR)) were abstracted or calculated from the given data. A random effects meta-analysis was performed to assess the risk of oral cancer with the use of different forms of smokeless tobacco. Results and Conclusion. The pooled OR for chewing tobacco and risk of oral cancer was 4.7 [3.1-7.1] and for paan with tobacco and risk of oral cancer was 7.1 [4.5-11.1]. The findings of this study suggest a strong causal link between oral cancer and various forms of smokeless tobacco. Public health policies in affected countries should consider SLT specific cessation programs in addition to campaigns and activities incorporated into smoking cessation programs.