[Methods of health economic evaluation for health services research]. / Methoden der gesundheitsökonomischen Evaluation in der Versorgungsforschung.

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

Psychological distress of patients undergoing intensified conditioning with radioimmunotherapy prior to allogeneic stem cell transplantation.

This is a pilot study comparing the emotional distress of patients receiving an intensified conditioning regimen (radioimmunotherapy=RIT) with patients receiving conventional conditioning for allogeneic stem cell transplantation. In total, 53 patients (18 received RIT) were given two questionnaires designed to measure emotional distress (HADS, POMS) before starting conditioning (t1) and at discharge (t2). During the in-patient period, patients answered questions daily relating to physical distress, psychological distress, and how they were "coping with the situation". At t2, the transplant team assessed the manner in which the patients were coping. The data displayed no relevant differences with regard to emotional distress between the two groups, both at t1 and t2. For both groups, anxiety and vigor decreased and fatigue increased between t1 and t2. On average, perceived distress was higher for those patients being treated with RIT during the in-patient time, but the differences between both groups were significant only regarding physical distress during the recovery period. No difference was found for the transplant team's assessment. We hypothesize that an intensified conditioning regimen with RIT per se has only a small distressing effect on the patients' psyche during their stay at the hospital. Differences between both groups probably result from independent factors such as, for example, the patients' pre-existing health conditions.

The clinician's illusion and the psychotherapy practice: an application of stochastic modeling.

The caseload of practicing clinicians tends to be unrepresentative of the population of psychotherapy patients. This results from the fact that, although the majority of patients use relatively few treatment sessions, the majority of a clinician's time is spent with longer term cases--a minority of patients consume the majority of services. Here, a stochastic model is used to describe the development of caseloads under 4 different treatment regimens. It is shown that a psychotherapy practice will reach a steady state (a stable case mix) in relatively short time and at that this will limit the open appointment slots available each week to serve new patients. Implications for training and clinic staffing are discussed.

Coping styles of pregnant women after prenatal ultrasound screening for fetal malformation.

OBJECTIVE: Ultrasound is a widespread noninvasive method of prenatal diagnosis. The detection of fetal abnormalities can provoke anxiety, which needs coping. The coping process of pregnant women with different risk conditions for fetal abnormality were studied in a longitudinal design and compared with a nonrisk control group of women with healthy uncomplicated pregnancies. METHODS: The coping strategies of women (n=664) during the second trimester were assessed with a questionnaire [Heim E, Augustiny KF, Blaser A, Schaffner L. Berner Bewältigungsformen (BEFO) Handbuch. Bern: Huber, 1991]. Data were collected at three points in time: immediately before the ultrasound scanning for fetal malformation, at 5-6 and 10-12 weeks after the prenatal ultrasound examination. Questionnaires were also used to collect information about sociodemographic data, anxiety, pregnancy data and personality. RESULTS: The analysis of the coping strategies of women with high-risk pregnancies (n=497) and as well of these with no-risk conditions in the control group (n=167) revealed three different factors of coping: Factor I: positive emotional attitude/distance, Factor II: negative emotional attitude/disapproval and Factor III: active coping. At all three points in time, Factor I correlated significantly with anxiety decrease, Factor II with increase and Factor III did not correlate with anxiety at all. CONCLUSIONS: Women with risk-pregnancies used coping strategies similar to those women in the control-group. Different spectrums of coping strategies corresponded significantly to increasing or decreasing anxiety. These women with high levels of anxiety, especially, should be offered sensitive care or psychotherapeutic counseling, as their coping processes did not lead to successful coping in the form of a reduction in anxiety.

Clinical and scientific aspects of the Ulm process model of psychoanalysis.

Theories of the psychoanalytic process inevitably influence the clinician's handling of the treatment. Investigations in the private theories of analysts point to the anchoring of these process conceptions in the personal experience of the analyst; therefore a normative, ideally constructed process model does not correspond to what is found when empirical studies are performed. For many reasons of social interactionism criticism applies also to so-called natural process conception which maintains that the process of working through has to pass ontogenetic phases from early to late. Though the concept of phase, known also as focus, is a very helpful notion, its empirical foundation is yet very weak. The paper describes empirical approaches to identify focal phases which are the basis of the Ulm process conception.

Defense mechanisms in patients with bone marrow transplantation: a retrospective study.

The impact of defense processes on coping with threatening life diseases has been shown in many studies. Systematic studies focusing on defense mechanisms in these conditions are still rare, however. We report here on the results of a retrospective study on patients after bone marrow transplantation. Thirty four transcripts of patients interviewed at various time spans from treatment were analyzed for the presence or absence of an inventory of defense mechanisms. Cluster-analytic analysis revealed 2 clinically meaningful factors, described in detail.

[Development, attachment and relationship: new psychoanalytical concepts]. / Rozwój, wiez i zwiazki: nowe koncepcje psychoanalityczne.

Authors present the evolution of psychoanalytical views of how a child perceives and contruct the world. They begin with Freud's thought and go through works of Klein, Spitz, Mahler, Bowlby, ending with modern thought of Stern. Developments in understanding of the infant by observations taken through the last thirty years are outlined and implications for psychoanalytical theory and treatment of mental problems are described.

[Diagnosis of attachment disorders]. / Diagnostik von Bindungsstörungen.

After an introduction about the basic concepts of attachment theory the diagnostic classification systems ICD, DSM and ZERO TO THREE are reviewed for descriptions and diagnosis of attachment disorders. It is demonstrated how over the last few years attachment theory has been partly adopted in those diagnostic systems. In addition different types of clinically relevant attachment disorders are described. The authors argue that it would be necessary to integrate attachment disorders on a broader base into the current diagnostic classification systems. The diagnostic importance of attachment disorders and their impact on the technique of child psychotherapy are finally discussed.

[Klaus Grawe's confession and the psychoanalytic profession]. / Klaus Grawes Konfession und die psychoanalytische Profession.

1994 saw the publication of the volume Psychotherapie im Wandel. Von der Konfession zur Profession ("Psychotherapy in Transition. From Confession to Profession") by K. Grawe et al. This book did much to fuel the professional policy debate on the purpose and efficiency of long-term and high-frequency analytic psychotherapies. The author examines Grawe's book, comparing its methodological approach with other (largely US-American) studies on psychotherapeutic research, and concludes that the studies analysed by Grawe do not do justice to the realities of psychoanalytic therapy. He advocates more naturalist designs reflecting the change from controlled therapies in institutions to clinical treatment in private practices. Finally he criticises psychoanalysts for having failed to provide evaluation of long-term and high-frequency analysis.

[Research in psychoanalytic therapy 1930-1990]. / Psychoanalytische Therapieforschung 1930-1990.

The author provides a survey of three phases of psychoanalytic therapy research, each one is being characterized by its most important representatives and their contributions. The first phase (1930-1970) sought in essence to justify, i.e. to prove, that analytical therapies are useful. The second phase (1960-1980) was dedicated to a deeper understanding of the relationship between the course of therapy and its results. The third phase, finally, can be identified as a thorough and detailed inquiry into the analytical process.

[Expert assessment within the scope of legal social determination of the extent of economic responsibility of insurance for analytic psychotherapy]. / Fachgutachten im Rahmen sozialgerichtlicher Klärung des Umfangs der Leistungspflicht einer Krankenkasse für analytische Psychotherapie.

Expert Opinions and Social Insurance Tribunal Rulings on the Scope of Medical Insurance Cover for Analytic Psychotherapy.--In Germany at present medical insurance cover is more or less automatic for a bone-marrow transplant costing anything up to 100,000 dollars--an operation where the death of the patients is by no means infrequent. In view of this state of affairs it is hard to comprehend the refusal on the part of insurance cover reviewers to approve ongoing cover for analytic psychotherapy beyond the 240-hour limit. In the case presented here, privately financed continuation by some 180 hours demonstrated that this prolongation and intensification of therapy was in fact essential to ensure the success of the treatment.