Screening for depression: Psychometric properties of the German version of the Glasgow depression scale for people with a learning disability (individual and carer version).

BACKGROUND: Adults with intellectual disabilities should participate in the diagnostics of their mental health. The Glasgow Depression Scale for people with a Learning Disability (GDS-LD) and its Carer Supplement (GDS-CS) were translated into German and tested. METHODS: Internal consistency, criterion validity and inter-test reliability were tested in 64 adults with borderline, mild or moderate intellectual disabilities and their carers. Convergent validity was analysed in 57 adults without intellectual disabilities. RESULTS: Internal consistency was good (α = 0.81) for GDS-LD and acceptable (α = 0.72) for GDS-CS. The GDS-LD did not differentiate between groups with and without depression. The GDS-CS significantly differentiated between these groups. Convergent validity of the GDS-LD was high. The correlation of GDS-LD and GDS-CS was non-significant. CONCLUSIONS: In its present form the German version of the GDS-LD does not meet the psychometric properties to be used in clinical practice. This leads to the broader question, how to measure depression in people with learning disabilities with the knowledge of the fallibility of existing measures when utilised with this clinical cohort. Also, future studies need to investigate the role of self-rating.

The association of early response with the outcome of psychosomatic rehabilitation in patients with mental disorders and its link to treatment and illness beliefs-A prospective longitudinal cohort study.

Early response is considered to be an important predictor for therapy outcomes; yet little is known about its relevance in psychosomatic rehabilitation. This paper aims to describe the association of early response in psychosomatic rehabilitation, as well as the associations of early response with pre-rehabilitative factors such as illness and treatment beliefs.A longitudinal study with three measurement points was applied. Early response was defined using the percent improvement method after two weeks of treatment. Its association with therapy outcome and with illness and treatment beliefs was analyzed using multiple regression analyses.A total of 264 participants took part. Early response was a significant predictor of psychosomatic rehabilitation outcome, explaining an incremental variance of 1-30% after controlling for initial symptom burden. Illness and treatment beliefs predicted 6-20% variance in early response. Important illness beliefs referred to perceived symptoms, consequences and comprehensibility of the illness. Important treatment beliefs referred to expectations about rehabilitation structure, processes and concerns.Early response is associated with the therapy outcome of psychosomatic rehabilitation, with illness and treatment beliefs found to be associated with early response. Further research on the predictors of early response in psychosomatic rehabilitation is needed.

Effects of a Web-Based Behavioral Activation Intervention on Depressive Symptoms, Activation, Motivation, and Volition: Results of a Randomized Controlled Trial.

INTRODUCTION: Behavioral activation (BA) is effective for the treatment of depression. The Health Action Process Approach (HAPA), which is derived from health psychology, can provide a motivational-volitional framework of BA. OBJECTIVE: This study investigated the efficacy of a HAPA-based internet-delivered BA intervention (iBA; called InterAKTIV) in individuals with depression, also assessing HAPA-based motivational and volitional outcomes. METHODS: In a two-arm randomized controlled efficacy trial with a parallel design, 128 participants with a major depressive episode were randomly allocated to the intervention group (IG; TAU + immediate access to iBA) or control group (CG; TAU + access to iBA after follow-up). The primary outcome of clinician-rated depressive symptoms and secondary outcomes were assessed at baseline (T1), 8 weeks (T2), 6-month after randomization (T3). Data were analyzed on an intention-to-treat basis. RESULTS: Linear mixed model analyses revealed a significant group*time interaction effect on clinician-rated depressive symptoms favoring the IG (F2, 156.0 = 7.40; p < 0.001, d = 0.79 at T2, d = 0.25 at T3). The IG was also superior regarding self-rated depressive symptoms, BA, most motivational, and all volitional outcomes. CONCLUSION: This study shows that HAPA-based iBA can significantly improve clinician-rated depressive symptoms, as well as outcomes used in the HAPA model in people with depression. Building on these efficacy results, in the next step, the relationship between BA interventions and activity levels should be investigated, taking into account motivation and volition as potential mediators.

Local, collaborative, stepped, and personalized care management for older people with chronic diseases - results from the randomized controlled LoChro-trial.

BACKGROUND: In the aging population of Western societies, an increasing number of older adults have multiple chronic diseases. As multifaceted health problems imply the involvement of several healthcare professionals, multimorbid older people frequently face a fragmentation of health care. Addressing these challenges, we developed a local, collaborative, stepped, and personalized care management approach (LoChro-Care) and evaluated its effectiveness. METHODS: A two-group, parallel randomized controlled trial was conducted comparing LoChro-Care recipients (IG) to participants with usual care (CG). Patients aged 65 + with chronic conditions were recruited at inpatient and outpatient departments of the Medical Center, University of Freiburg. Participants were allocated using block randomization (nIG = 261, nCG = 263). LoChro-Care comprised individualized care provided by chronic care managers with 7 to 13 contacts over 12 months. Questionnaires were given at 3 time points (T0: baseline, T1: after 12 months, T2: after 18 months). The primary outcome was the physical, psychological, and social health status represented by a composite score of functional health and depressive symptoms. Secondary outcomes were the participants' evaluation of their health care situation, health-related quality of life (HRQL), and life-satisfaction (LS). The data were analyzed using linear mixed modelling. RESULTS: We analyzed N = 491 participants (nIG = 244, nCG = 247), aged M = 76.78 years (SD = 6.35). For the composite endpoint, neither a significant difference between IG and CG (p = .88) nor a group-time interaction (p = .52; p = .88) could be observed. Participants in both groups showed a significant decline on the primary outcome between T0 and T2 (p < .001). Post hoc analyses revealed a decline in both functional health (p < .001) and depressive symptoms (p = .02). Both groups did not differ in their evaluation of their health care situation (p = .93), HRQL (p = .44) or LS (p = .32). Relevant confounding variables were female gender and multimorbidity. CONCLUSION: Supporting patients' self-management in coordinating their individual care network through LoChro-Care did not result in any significant effect on the primary and secondary outcomes. A decline of functional health and depressive symptoms was observed among all participants. Potential future intervention adaptations are discussed, such as a more active case management through direct referral to (in-)formal support, an earlier treatment initiation, and the consideration of specific sociodemographic factors in care management planning. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013904 (02.02.2018), https://drks.de/search/de/trial/DRKS00013904.

Decreased mental health, quality of life, and utilization of professional help in cancer patients with unexpressed needs: A longitudinal analysis.

BACKGROUND: Cancer patients' mental health and quality of life can be improved through professional support according to their needs. In previous analyses of the UNSAID study, we showed that a relevant proportion of cancer patients did not express their needs during the admission interview of inpatient rehabilitation. We now examine trajectories of mental health, quality of life, and utilization of professional help in cancer patients with unexpressed needs. METHODS: We enrolled 449 patients with breast, prostate, and colon cancer at beginning (T0) and end (T1) of a 3-week inpatient rehabilitation and 3 (T2) and 9 (T3) months after discharge. We explored depression (PHQ-2), anxiety (GAD-2), emotional functioning (EORTC QLQ-C30), fear of progression (FoP-Q-SF), and global quality of life (EORTC QLQ-C30) using structuring equation models. Furthermore, we evaluated self-reports about expressing needs and utilization of professional help at follow-up. RESULTS: Patients with unexpressed needs (24.3%, n = 107) showed decreased mental health compared to other patients (e.g., depression: d T0 = 0.32, d T1-T3 = 0.39). They showed a significant decline in global quality of life at discharge and follow-up (d = 0.28). Furthermore, they had a higher need for support (Cramer's V T2 = 0.10, T3 = 0.15), talked less about their needs (Cramer's V T2 = 0.18), and made less use of different health care services at follow-up. CONCLUSION: Unexpressed needs in cancer patients may be a risk factor for decreased mental health, quality of life, and non-utilization of professional help in the long term. Further research should clarify causal relationships and focus on this specific group of patients to improve cancer care.

Kontextfaktoren der patient*innenseitigen Selbstregulation in der psychosomatischen Rehabilitation ­ eine Querschnittsanalyse vor Rehabilitationsbeginn.

BACKGROUND: Contextual factors are a central element of the ICF and important factors for therapy planning in psychosomatic rehabilitation. At the same time, little is known about the relationship between contextual factors and patient self-regulation, an important goal of rehabilitation.The aim of this study is therefore to investigate the relationship between contextual factors and illness belies. Illness beliefs are a core element of self-regulation in psychosomatic rehabilitation and part of the common sense model of self-regulation. METHODS: Between April 2019 and January 2020, a cross-sectional questionnaire study was conducted in a psychosomatic rehabilitation clinic, in which registered rehabilitation patients were questioned about their illness beliefs using the Illness Perception Questionnaire (IPQ-R). Contextual factors were divided into clinically modifiable and non-clinically modifiable and included gender, age, duration of illness, subjective social status, main diagnosis (dichotomised: F3/F4), occupational stress, depressive stress as well as activity and participation (operationalised by the Health-49). Multiple regressions were used for the analysis, in which the scales of the IPQ-R served as dependent variables. RESULTS: N=264 rehabilitants took part in the survey, 50% of them were female. The average age was 50 years. With regard to the non-clinically modifiable contextual factors, it was shown that a younger age was associated with higher control assumptions, but that younger rehabilitation patients simultaneously perceived more symptoms due to their illness (identity). A longer duration of illness showed a connection with the chronic timeline assumptions. A lower social status showed correlations with lower control assumptions and more assumptions about the cyclical timeline. Regarding clinically modifiable contextual factors, an F3 diagnosis was associated with more expected consequence, but also with a higher perceived personal control than an F4 diagnosis. A higher occupational burden was associated with the assumption of a more chronic course of the disease. Reduced activity and participation were associated with more expected consequences and more perceived symptoms (identity). Depressive stress showed associations with six out of eight domains of illness beliefs. CONCLUSION: The study supports the relevance of contextual factors, which in majority can be discussed as person-related factors, for patient self-regulation in psychosomatic rehabilitation. Interventions to increase self-regulation, e. g. by taking illness beliefs into account, have already achieved promising results, also in the context of rehabilitation. The patient-oriented approach of these interventions could be further strengthened by a stronger inclusion of contextual factors.

Effectiveness of a Guided Web-Based Intervention to Reduce Depressive Symptoms before Outpatient Psychotherapy: A Pragmatic Randomized Controlled Trial.

INTRODUCTION: Psychotherapy is a first-line treatment for depression. However, capacities are limited, leading to long waiting times for outpatient psychotherapy in health care systems. Web-based interventions (WBI) could help to bridge this treatment gap. OBJECTIVE: This study investigates the effectiveness of a guided cognitive-behavioral WBI in depressive patients seeking face-to-face psychotherapy. METHODS: A 2-arm randomized controlled trial was conducted. Depressive patients (n = 136) recruited from the waiting lists of outpatient clinics were randomly assigned to an intervention group (IG; treatment as usual [TAU] + immediate access to WBI) or a control group (CG; TAU + access to WBI after follow-up). Depressive symptoms and secondary outcomes were assessed at baseline, 7 weeks, and 5 months after randomization. RESULTS: Mixed-model analyses revealed a significant group × time interaction effect on depressive symptoms (F2, 121.5 = 3.91; p < 0.05). Between-group effect sizes were d = 0.55 at 7 weeks and d = 0.52 at 5 months. The IG was superior regarding psychological symptoms and mental health quality of life but not on physical health quality of life, attitudes, motivation for psychotherapy, or subjective need and uptake of psychotherapy. CONCLUSIONS: Patients waiting for face-to-face psychotherapy can benefit from a WBI when compared to TAU. Despite the reduction of depressive symptoms in the IG, the uptake of subsequent psychotherapy was still high in both groups. The effects remained stable at the 5-month follow-up. However, this study could not determine the proportion of specific intervention effects vs. nonspecific effects, such as positive outcome expectations or attention. Future research should focus on the long-term effects and cost-effectiveness of WBI before psychotherapy.

Effectiveness of a Guided Internet- and Mobile-Based Intervention for Patients with Chronic Back Pain and Depression (WARD-BP): A Multicenter, Pragmatic Randomized Controlled Trial.

INTRODUCTION: There is neither strong evidence on effective treatments for patients with chronic back pain (CBP) and depressive disorder nor sufficiently available mental health care offers. OBJECTIVE: The aim is to assess the effectiveness of internet- and mobile-based interventions (IMI) as a scalable approach for treating depression in a routine care setting. METHODS: This is an observer-masked, multicenter, pragmatic randomized controlled trial with a randomization ratio of 1:1.Patients with CBP and diagnosed depressive disorder (mild to moderate severity) were recruited from 82 orthopedic rehabilitation clinics across Germany. The intervention group (IG) received a guided depression IMI tailored to CBP next to treatment-as-usual (TAU; including medication), while the control group (CG) received TAU. The primary outcome was observer-masked clinician-rated Hamilton depression severity (9-week follow-up). The secondary outcomes were: further depression outcomes, pain-related outcomes, health-related quality of life, and work capacity. Biostatistician blinded analyses using regression models were conducted by intention-to-treat and per protocol analysis. RESULTS: Between October 2015 and July 2017, we randomly assigned 210 participants (IG, n = 105; CG, n = 105), mostly with only a mild pain intensity but substantial pain disability. No statistically significant difference in depression severity between IG and CG was observed at the 9-week follow-up (ß = -0.19, 95% CI -0.43 to 0.05). Explorative secondary depression (4/9) and pain-related (4/6) outcomes were in part significant (p < 0.05). Health-related quality of life was significantly higher in the IG. No differences were found in work capacity. CONCLUSION: The results indicate that an IMI for patients with CBP and depression in a routine care setting has limited impact on depression. Benefits in pain and health-related outcomes suggest that an IMI might still be a useful measure to improve routine care.

Prevention of depression in adults with long-term physical conditions.

BACKGROUND: Major depression is one of the world's leading causes of disability in adults with long-term physical conditions compared to those without physical illness. This co-morbidity is associated with a negative prognosis in terms of increased morbidity and mortality rates, increased healthcare costs, decreased adherence to treatment regimens, and a substantial decline in quality of life. Therefore, preventing the onset of depressive episodes in adults with long-term physical conditions should be a global healthcare aim. In this review, primary or tertiary (in cases of preventing recurrences in those with a history of depression) prevention are the focus. While primary prevention aims at preventing the onset of depression, tertiary prevention comprises both preventing recurrences and prohibiting relapses. Tertiary prevention aims to address a depressive episode that might still be present, is about to subside, or has recently resolved. We included tertiary prevention in the case where the focus was preventing the onset of depression in those with a history of depression (preventing recurrences) but excluded it if it specifically focused on maintaining an condition or implementing rehabilitation services (relapse prevention). Secondary prevention of depression seeks to prevent the progression of depressive symptoms by early detection and treatment and may therefore be considered a 'treatment,' rather than prevention. We therefore exclude the whole spectrum of secondary prevention. OBJECTIVES: To assess the effectiveness, acceptability and tolerability of psychological or pharmacological interventions, in comparison to control conditions, in preventing depression in adults with long-term physical conditions; either before first ever onset of depressive symptoms (i.e. primary prevention) or before first onset of depressive symptoms in patients with a history of depression (i.e. tertiary prevention). SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registries, up to 6 February 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of preventive psychological or pharmacological interventions, specifically targeting incidence of depression in comparison to treatment as usual (TAU), waiting list, attention/psychological placebo, or placebo. Participants had to be age 18 years or older, with at least one long-term physical condition, and no diagnosis of major depression at baseline (primary prevention). In addition, we included studies comprising mixed samples of patients with and without a history of depression, which explored tertiary prevention of recurrent depression. We excluded other tertiary prevention studies. We also excluded secondary preventive interventions. Primary outcomes included incidence of depression, tolerability, and acceptability. Secondary outcomes included severity of depression, cost-effectiveness and cost-utility. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 11 RCTs, with one trial on psychological interventions, and 10 trials on pharmacological interventions. Data analyses on the psychological intervention (problem-solving therapy compared to TAU) included 194 participants with age-related macular degeneration. Data analyses on pharmacological interventions included 837 participants comparing citalopram (one trial), escitalopram (three trials), a mixed sample of fluoxetine/nortriptyline (one trial), melatonin (one trial), milnacipran (one trial), and sertraline (three trials), each to placebo. Included types of long-term physical conditions were acute coronary syndrome (one trial), breast cancer (one trial), head and neck cancer (two trials), stroke (five trials), and traumatic brain injury (one trial). Psychological interventions Very low-certainty evidence of one study suggests that problem solving therapy may be slightly more effective than TAU in preventing the incidence of depression, immediately post-intervention (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.20 to 0.95; 194 participants). However, there may be little to no difference between groups at six months follow-up (OR 0.71, 95% CI 0.36 to 1.38; 190 participants; one study; very low-certainty evidence). No data were available regarding incidence of depression after six months. Regarding acceptability (drop-outs due to any cause), slightly fewer drop-outs occurred in the TAU group immediately post-intervention (OR 5.21, 95% CI 1.11 to 24.40; 206 participants; low-certainty evidence). After six months, however, the groups did not differ (OR 1.67, 95% CI 0.58 to 4.77; 206 participants; low-certainty evidence). This study did not measure tolerability. Pharmacological interventions Post-intervention, compared to placebo, antidepressants may be beneficial in preventing depression in adults with different types of long-term physical conditions, but the evidence is very uncertain (OR 0.31, 95% CI 0.20 to 0.49; 814 participants; nine studies; I2 =0%; very low-certainty evidence). There may be little to no difference between groups both immediately and at six months follow-up (OR 0.44, 95% CI 0.08 to 2.46; 23 participants; one study; very low-certainty evidence) as well as at six to 12 months follow-up (OR 0.81, 95% CI 0.23 to 2.82; 233 participants; three studies; I2 = 49%; very low-certainty evidence). There was very low-certainty evidence from five studies regarding the tolerability of the pharmacological intervention. A total of 669 adverse events were observed in 316 participants from the pharmacological intervention group, and 610 adverse events from 311 participants in the placebo group. There was very low-certainty evidence that drop-outs due to adverse events may be less frequent in the placebo group (OR 2.05, 95% CI 1.07 to 3.89; 561 participants; five studies; I2 = 0%). There was also very low-certainty evidence that drop-outs due to any cause may not differ between groups either post-intervention (OR 1.13, 95% CI 0.73 to 1.73; 962 participants; nine studies; I2 = 28%), or at six to 12 months (OR 1.13, 95% CI 0.69 to 1.86; 327 participants; three studies; I2 = 0%). AUTHORS' CONCLUSIONS: Based on evidence of very low certainty, our results may indicate the benefit of pharmacological interventions, during or directly after preventive treatment. Few trials examined short-term outcomes up to six months, nor the follow-up effects at six to 12 months, with studies suffering from great numbers of drop-outs and inconclusive results. Generalisation of results is limited as study populations and treatment regimes were very heterogeneous. Based on the results of this review, we conclude that for adults with long-term physical conditions, there is only very uncertain evidence regarding the implementation of any primary preventive interventions (psychological/pharmacological) for depression.

Psychological and pharmacological interventions for depression in patients with coronary artery disease.

BACKGROUND: Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis. OBJECTIVES: To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression. SEARCH METHODS: We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions. SELECTION CRITERIA: We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects. DATA COLLECTION AND ANALYSIS: Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes. MAIN RESULTS: Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I2 = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I2 = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I2 = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I2 = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I2 = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I2 = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention. AUTHORS' CONCLUSIONS: In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.

Unexpressed psychosocial needs in cancer patients at the beginning of inpatient rehabilitation: a qualitative analysis.

OBJECTIVE: Cancer patients often need professional help to alleviate their psychosocial distress. However, not all patients express their needs. In this study, we explored possible barriers to patients' expressing needs, contents of needs difficult to express, and conditions facilitating expressing needs. METHODS: We conducted semi-structured interviews with 29 oncological inpatient rehabilitation patients, 7 members of self-help groups, and 10 health professionals. We analyzed data with structuring content analysis. RESULTS: Fear of stigmatization and difficulties in the physician-patient-relationship were the most critical expression barriers reported. Sexuality deemed to be one of the most challenging themes for patients. Changes in the physician's behavior and sufficient resources were mentioned as the main facilitating conditions. Our results indicate a wide diversity within the barriers and topics, but a general consistency between patients and health professionals. CONCLUSION: This study provides evidence for the existence of a variety of barriers to cancer patients' expressing their needs. PRACTICE IMPLICATIONS: Health professionals should be aware of the different possible expression barriers to facilitate patient communication.

[Implementation of a Web-Based Self-Help Intervention for Mood Enhancement during Waiting Times for Outpatient Psychotherapy - A Qualitative Study Exploring Participants' Perspectives]. / Webbasierte Selbsthilfe zur Stimmungsverbesserung in der Wartezeit auf ambulante Psychotherapie ­ Eine qualitative Erhebung der Teilnehmerperspektive.

OBJECTIVE: In Germany, waiting times for outpatient psychotherapy are on average 5 months long. Guided web-based interventions can be implemented to reduce depressive symptoms during waiting times. The study aims to explore how patients experience the usage of a web-based intervention for mood enhancement. METHODS: Patients on the waiting lists of cooperating outpatient clinics were invited to participate in the study and apply a web-based intervention for mood enhancement. Eleven participating patients were interviewed about their experiences with the intervention. The data was analyzed based on the Grounded-Theory methodology. RESULTS: Three categories could be derived from the data: prior expectations, experiences with the intervention and factors influencing adherence. The web-based intervention was experienced very differently and was associated with both positive and negative experiences. The participants could be grouped into 3 user types. DISCUSSION: Not all patients report positive experiences with the intervention and some fail to adhere. In order to prepare patients adequately, they should be informed about the application and goals of the intervention in advance. Interventions should be implemented in accordance with the individual's need of support in order to enhance adherence and allow positive experiences.

Prevalence and predictors of cancer patients' unexpressed needs in the admission interview of inpatient rehabilitation.

OBJECTIVE: The admission interview in oncological inpatient rehabilitation might be a good opportunity to identify cancer patients' needs present after acute treatment. However, a relevant number of patients may not express their needs. In this study, we examined (a) the proportion of cancer patients with unexpressed needs, (b) topics of unexpressed needs and reasons for not expressing needs, (c) correlations of not expressing needs with several patient characteristics, and (d) predictors of not expressing needs. METHODS: We enrolled 449 patients with breast, prostate, and colon cancer at beginning and end of inpatient rehabilitation. We obtained self-reports about unexpressed needs and health-related variables (quality of life, depression, anxiety, adjustment disorder, and health literacy). We estimated frequencies and conducted correlation and ordinal logistic regression analyses. RESULTS: A quarter of patients stated they had "rather not" or "not at all" expressed all relevant needs. Patients mostly omitted fear of cancer recurrence. Most frequent reasons for not expressing needs were being focused on physical consequences of cancer, concerns emerging only later, and not knowing about the possibility of talking about distress. Not expressing needs was associated with several health-related outcomes, for example, emotional functioning, adjustment disorder, fear of progression, and health literacy. Depression measured at the beginning of rehabilitation showed only small correlations and is therefore not sufficient to identify patients with unexpressed needs. CONCLUSIONS: A relevant proportion of cancer patients reported unexpressed needs in the admission interview. This was associated with decreased mental health. Therefore, it seems necessary to support patients in expressing needs.

[The Culturally Sensitive Therapy Relationship: A Concept for the Training and Further Education of Psychotherapists]. / Die kultursensible Therapiebeziehung: Ein Konzept für die Aus-, Fort- und Weiterbildung von Psychotherapeutinnen und Psychotherapeuten.

Already in 2002, the Sonnenberger Leitlinien called for the development of further training programs for psychotherapists in the context of the intercultural opening of the psychosocial health care system [1]. However, so far, there has been a lack of evaluated, accessible (published) training concepts to enhance the intercultural and transcultural competences of psychotherapists in German-speaking countries. This article presents a training concept for medical and psychological psychotherapists as well as for psychologists in training based on the guidelines for trainings in inter-/transcultural competence for psychotherapists [2]. The concept focusses especially on the reflection of one's own culturally influenced values as well as on knowledge and skills that facilitate the development of a therapeutic relationship in an intercultural setting. Implementation tips are presented to help readers to apply the concept.

[Differential Indication in Mental Health Care of Patients with Mental Disorders]. / Differentielle Indikation in der Versorgung von Patienten mit psychischen Störungen.

BACKGROUND: Patients with mental disorders are treated in different care sectors and professional disciplines. In Germany, differential indication between psychiatric and psychosomatic care, between regular hospitals and psychosomatic rehabilitation clinics as well as between outpatient, day clinic, and inpatient treatment is not precise. Differential decisions for the treatment in specific sectors are not discernable. OBJECTIVE: Overview of empiric evidence about differential indication criteria. METHODS: Evidence for eligible differential allocation criteria is presented. RESULTS: Patient criteria are categorized into medical criteria, treatment needs, and individual features. Seldom, indication criteria suggest or eliminate a certain care sector. DISCUSSION: Evidence generally is scarce and is limited to comparisons of patients already treated in different care sectors. To describe differential indication criteria and allocation decisions the structure of the mental health care system must be included. CONCLUSION: Meaningful studies about differential indication for patients with mental disorders are needed. Perspectives for systematic treatment allocation are discussed.

[Parents' and Childcare Teachers' Agreement on Mental Health Problems, Psychosocial Ressources and Need for Action]. / Übereinstimmung von Eltern und Fachkräften in der Beurteilung von psychischen Auffälligkeiten, psychosozialen Ressourcen und Handlungsbedarf im Kindergartenalter.

Parents' and Childcare Teachers' Agreement on Mental Health Problems, Psychosocial Ressources and Need for Action Young Children with mental health problems rarely receive professional help. Recognising a problem is one key factor for mental health care utilisation in kindergarten age. In this study psychosocial problems and ressources of 255 children (age 3,0-6,6 years) were assessed by parents and childcare teachers with the instrument "Verhaltensskalen für das Kindergartenalter" (VSK, Koglin u. Petermann, 2016). Subjective need for action was also measured. Teachers announced a need for action in 19.8 % of the children, while parents did so for 17.3 % of the children, but they agreed only for 18.9 % of these children. So agreement on need for action was low (κ = .16). Agreement was also low for psychosocial problems (Median ICC = .32), and very low with respect to the borderline/clinical range (κ = .13). No agreement was found for psychosocial ressources. Results underline the importance for Early Education and Care professionals to cooperate with institutions like social-pediatric centers to avoid blind spots in the identification of mental health problems in preschool age.

Prevalence, symptomatology, risk factors and healthcare services utilization regarding paternal depression in Germany: study protocol of a controlled cross-sectional epidemiological study.

BACKGROUND: While postpartum depression is a well-researched disorder in mothers, there is growing evidence indicating that some fathers also develop depressive symptoms (paternal postpartum depression, PPD). A recent meta-analysis revealed a total prevalence of paternal depression during pregnancy and up to one year postpartum of 8.4%, with significant heterogeneity observed among prevalence rates. International studies suggest that PPD is characterized by additional symptoms compared to maternal postpartum depression. Furthermore, various risk factors of PPD have been identified. However, the prevalence, symptomatology, risk factors and healthcare situation of fathers affected by PPD in Germany are unknown. METHODS/DESIGN: This study comprises a controlled, cross-sectional epidemiological survey administered via postal questionnaires. The primary objective is to compare the prevalence of depressive symptoms in fathers with a 0-12-month-old infant to the prevalence of depressive symptoms in men without recent paternity. Two structurally differing regions (concerning birthrate, employment status, socioeconomic structure, and nationality of inhabitants) will be included. A random sample of 4600 fathers (2300 in each region) in the postpartum period and 4600 men without recent paternity matched by age, nationality and marital status will be assessed regarding depressive symptoms using the PHQ-9. Contact data will be extracted from residents' registration offices. As secondary objectives, the study aims to provide insights into symptoms and risk factors of PPD in fathers and to assess the current healthcare situation of fathers with PPD in Germany. In an add-on study, genetic and epigenetic mechanisms of PPD will be explored. DISCUSSION: This study will conduct the first direct comparison between fathers in the postpartum period of one year after childbirth and a matched sample of men without a newborn child. Besides closing this research gap, the findings will provide prevalence estimates as well as insights into specific symptomatology, risk factors, and the current healthcare situation regarding fathers with PPD in Germany. The results will identify low-threshold approaches as a relevant issue for healthcare. Moreover, the findings should inform the development of PPD-specific screening instruments and healthcare offers addressing fathers with PPD. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013339 ; Trial registration date: August 20, 2018; Universal Trial Number (UTN): U1111-1218-8185.

Local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro): study protocol of a randomised comparative effectiveness trial.

BACKGROUND: Multimorbid older adults suffering from a long-term health condition like depression, diabetes mellitus type 2, dementia or frailty are at high risk of losing their autonomy. Disability and multimorbidity in the older population are associated with social inequality and lead to soaring costs. Our local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro-Care) aims at improving outcomes for older multimorbid patients with chronic conditions whose social and medical care must be improved. METHODS: The study will evaluate the effects of LoChro-Care on functional health, depressive symptoms and satisfaction with care, resource utilisation as well as health costs in older persons with long-term conditions. The trial will compare the effectiveness of LoChro-Care and usual care in a cross-sectoral setting from hospital to community care. We will recruit 606 older adults (65+) admitted to local hospital inpatient or outpatient departments who are at risk of loss of independence. Half of them will be randomised to receive the LoChro-Care intervention, comprising seven to 16 contacts with chronic care managers (CCM) within 12 months. The hypothesis that LoChro-Care will result in better patient-centred outcomes will be tested through mixed-method process and outcome evaluation and valid measures completed at baseline and at 12 and 18 months. Cost-effectiveness analyses from the healthcare perspective will include incremental cost-effectiveness ratios. DISCUSSION: The trial will provide evidence about the effectiveness of local, collaborative, stepped and personalised care management for multimorbid patients with more than one functional impairment or chronic condition. Positive results will be a first step towards the implementation of a systematic cross-sectoral chronic care management to facilitate the appropriate use of available medical and nursing services and to enhance self-management of older people. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013904 ; Trial registration date: 02. February 2018.

[Low-Intensity Interventions to Reduce Depressive Symptoms before Outpatient Psychotherapy - A Systematic Literature Review]. / Niedrigintensive Interventionen zur Reduktion depressiver Symptome vor Beginn einer ambulanten Psychotherapie.

Psychotherapeutic resources are limited, leading to prolonged waiting periods prior to outpatient psychotherapy. Low-intensity interventions have the potential to bridge such treatment gaps. This systematic review aims to identify interventions targeting depressive symptoms implemented prior to outpatient psychotherapy, and to assess their effectiveness and acceptance. 22 studies were identified. Interventions were classified as active waiting, self-help, guided self-help, brief single-strand interventions, and low-intensity psychotherapy. Evidence of intervention effectiveness is limited; intervention acceptance varies between interventions. The resulting classification illustrates a range of innovative interventions which can be implemented into routine care depending on existing resources and preferences. Different models for the provision of low-intensity interventions are discussed.

[New Media in Psychotherapy: Blended Therapy from the Perspective of Outpatient Psychotherapists]. / Neue Medien in der Psychotherapie: Blended Therapy aus der Sicht ambulanter Psychotherapeuten.

The aim of the study was to generate a model describing psychotherapists' use of new media in outpatient psychotherapy. Problem-centered interviews were conducted with 12 outpatient psychotherapists. Data was analyzed following the Grounded Theory approach. The interviews revealed five categories that were integrated into the model "Use of new media in outpatient therapy" (MAP): First, psychotherapists' characteristics determine whether new media use is considered. When new media is in use, patient characteristics define its intensity and content. Additionally, decision making rules and communication rules shape therapists' use of new media. MAP identifies barriers and facilitators of new media application in outpatient psychotherapy and describes psychotherapists' decision making process. Options for implementing blended therapy in outpatient psychotherapeutic care are discussed.