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.

[Office-based psychosomatic medicine with a focus on acute care]. / Das Praxismodell der Psychosomatischen Medizin und Psychotherapie mit Akut- beziehungsweise Versorgungsschwerpunkt neben der Richtlinienpsychotherapie.

Objectives: In Germany, the office-based psychosomatic medicine with focus on acute care offers psychosomatic treatment besides primary care by general practitioners and regular psychotherapy. The aim of this study is to determine specific characteristics of these innovative office-based practices. Methods: In a qualitative cross-sectional study, twelve board-certified specialists in psychosomatic medicine, practicing office-based psychosomatic medicine were surveyed by means of semi-structured telephone-interviews. After transcription and coding in MAXQDA 2020, a content analysis was conducted. Results: The innovative practice model was characterized by high numbers of initial contacts in walk-in or pre-planned consultation hours. Besides regular psychotherapy long-term and low-threshold treatment was offered. Physician assistants organised the workflow and administrative tasks. For settlement the EBM-number psychosomatic interview or short-term treatment was used. Focusses were set on somatopsychic and socio-medical treatment and consultant support. Psychotherapy often was realised in form of group sessions by integrating behavioural and psychodynamic psychotherapy. Discussion: The innovative psychosomatic practice model with focus on acute care shows an independent profile. A treatment based on medical understanding of complex somatic disease processes can be provided to somatopsychic patients. Future studies should compare this practice model to psychosomatic practices receiving a treatment by guideline psychotherapy. Conclusions: In Germany, the practices of psychosomatic medicine with a focus on acute care closes an increasing gap in psychosomatic care and augments treatment possibilities, especially for elderly and multimorbid patients.

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.

[DNVF-Discussion paper - Specificities, Challenges and Aims of Mental Health Service Research in Germany]. / DNVF-Diskussionspapier ­ Besonderheiten, Herausforderungen und Ziele der Versorgungsforschung im Feld der seelischen Gesundheit.

Research in mental health services in Germany is of increasing relevance. To this end, the recently founded "Mental Health Working Group" as part of the German Network of Health Services Research (DNVF) has written a discussion paper presenting key specifics, challenges, and goals of health service research in the field of mental health. Some research-relevant specifics in the area of mental health care, pragmatic challenges of research organization, ethical problems, and particular research topics in this field are presented and discussed critically.

Cancer surveillance and distress among adult pathogenic TP53 germline variant carriers in Germany: A multicenter feasibility and acceptance survey.

BACKGROUND: Li-Fraumeni syndrome (LFS) is a high-risk cancer predisposition syndrome caused by pathogenic germline variants of TP53. Cancer surveillance has noted a significant survival advantage in individuals with LFS; however, little is known about the feasibility, acceptance, and psychosocial effects of such a program. METHODS: Pathogenic TP53 germline variant carriers completed a 7-part questionnaire evaluating sociodemographics, cancer history, surveillance participation, reasons for nonadherence, worries, and distress adapted from the Cancer Worry Scale. Counselees' common concerns and suggestions were assessed in MAXQDA Analytics Pro 12. RESULTS: Forty-nine participants (46 females and 3 males), aged 40.0 ± 12.6 years, formed the study population; 43 (88%) had a personal cancer history (including multiple cancers in 10 [20%]). Forty-three individuals participated (88%) in surveillance during the study or formerly. Willingness to undergo surveillance was influenced by satisfaction with genetic testing and counseling (P = .019 [Fisher-Yates test]) but not by sociodemographics, cancer history, or distress level. Almost one-third of the participants reported logistical difficulties in implementing surveillance because of the high frequency of medical visits, scheduling difficulties, and the travel distance to their surveillance providers. Self-reported distress and perceived emotional burden for family members and partners were moderate (median for self-reported distress, 3.3; median for perceived emotional burden, 3.0). For both, the interquartile range was moderate to very high (2.7-3.7 and 3.0-3.7, respectively). CONCLUSIONS: Individuals with LFS require efficient counseling as well as an accessible, well-organized, interdisciplinary, standardized surveillance program to increase adherence and psychological coping.

Patients' Perspective on Mental Health Specialist Video Consultations in Primary Care: Qualitative Preimplementation Study of Anticipated Benefits and Barriers.

BACKGROUND: Due to limited access to specialist services, most patients with common mental disorders (depression or anxiety, or both) usually receive treatment in primary care. More recently, innovative technology-based care models (eg, video consultations) have been proposed to facilitate access to specialist services. Against this background, the PROVIDE (Improving Cross-Sectoral Collaboration Between Primary and Psychosocial Care: An Implementation Study on Video Consultations) project aims to improve the provision of psychosocial care through implementing video consultations integrated into routine primary care. OBJECTIVE: From the patients' perspective, this qualitative preimplementation study explored (1) anticipated benefits from and (2) barriers to implementing mental health specialist video consultations embedded in primary care services and (3) prerequisites for interacting with therapists via video consultations. METHODS: Using a purposive (ie, stratified) sampling strategy, we recruited 13 patients from primary care practices and a tertiary care hospital (psychosomatic outpatient clinic) for one-off semistructured interviews. In a computer-assisted thematic analysis, we inductively (bottom-up) derived key themes concerning the practicability of mental health specialist video consultations. To validate our results, we discussed our findings with the interviewees as part of a systematic member checking. RESULTS: Overall, we derived 3 key themes and 10 subthemes. Participants identified specific benefits in 2 areas: the accessibility of mental health specialist care (shorter waiting times: 11/13, 85%; lower threshold for seeking specialist mental health care: 6/13, 46%; shorter travel distances: 3/13, 23%); and the environment in primary care (familiar travel modalities, premises, and employees: 5/13, 38%). The main barriers to the implementation of mental health video consultations from the patients' perspective were the lack of face-to-face contact (13/13, 100%) and technical challenges (12/13, 92%). Notably, participants' prerequisites for interacting with therapists (12/13, 92%) did not seem to differ much from those concerning face-to-face contacts. CONCLUSIONS: Mental health service users mostly welcomed mental health specialist video consultations in primary care. Taking a pragmatic stance, service users, who are often frustrated about uncoordinated care, particularly valued the embedment of the consultations in the familiar environment of the primary care practice. With respect to interventional studies and implementation, our findings underscore the need to minimize technical disruptions during video consultations and to ensure optimal resemblance to face-to-face settings (eg, by training therapists in consistently reacting to nonverbal cues). TRIAL REGISTRATION: German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one.

Perspectives of Psychotherapists and Psychiatrists on Mental Health Care Integration Within Primary Care Via Video Consultations: Qualitative Preimplementation Study.

BACKGROUND: Many patients with mental disorders remain untreated. Video-based mental health care demonstrates comparable effectiveness to face-to-face treatments and is a promising mode for delivering specialized care within primary care. Nevertheless, professionals struggle with implementing video consultations in their daily practice. Specifically, little is known about mental health specialists' acceptance of mental health video consultations in routine practice. The PROVIDE (ImPROving cross-sectoral collaboration between primary and psychosocial care: An implementation study on VIDEo consultations) project aims to improve cross-sectoral collaboration between primary and psychosocial care through implementing video consultations in primary care. To increase the uptake of video consultations, it is crucial to account for necessary prerequisites and to tailor interventions to the needs of the target group prior to implementation. OBJECTIVE: The aim of this study was to explore the acceptance of video consultations embedded in primary care from the perspectives of mental health specialists in Germany. METHODS: We conducted a qualitative, exploratory, preimplementation study in urban and rural counties. We conducted three semistructured focus groups with 11 mental health specialists. We used qualitative content analysis combining an inductive-deductive approach, applying the Tailored Implementation in Chronic Diseases (TICD) framework to the text material, which comprises individual health professional factors; patient factors; professional interactions; incentives and resources; capacity for organizational change; social, political, and legal factors; and guideline factors. RESULTS: Against the background of long waiting times and a shortage of mental health specialists, especially in rural areas, participants valued video consultations as a potential means to improve access to mental health care. With respect to the TICD framework domains, the participants most often discussed individual health professional factors, followed by patient factors. All participants highlighted the importance of a trusting relationship between the patient and the therapist and doubted whether such a relationship could be established through video consultations (11/11, 100%). However, participants considered mental health specialist video consultations to be particularly suited for patients in rural areas, those with impaired mobility, and those who may otherwise remain untreated (6/11, 55%). Most participants expected video consultations to help the aforementioned patient groups avoid tedious searching for an available therapist and save on travel time and, therefore, improve access to specialized care for patients (7/11, 64%). Moreover, the participants expected video consultations to improve collaboration with the family physician (6/11, 55%). Finally, participants identified organizational aspects, such as reliable scheduling, the duration of the individual consultation (9/11, 82%), and reimbursement conditions (7/11, 67%), as key drivers for the acceptance and adoption of the model. CONCLUSIONS: While mental health specialists expect video consultations to improve access to specialized care for some patients, they consistently wonder whether such consultations can establish a trusting patient-therapist relationship. When implementing video consultations, these concerns should be addressed by training providers in managing technology-based treatment settings, with extra consideration for fostering the patients' and therapists' engagement. TRIAL REGISTRATION: German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one.

Emergency consultations in obstetrics: identification of decisive, contributing and associated factors.

PURPOSE: Psychosocial and biological factors influence the perception of physical changes during pregnancy. Some pregnant women present to the obstetric emergency department (ED) with diverse symptoms not requiring urgent medical action. These visits result in over-consultation, tying up resources and inflating health care expenses. This study outlines factors associated with multiple ED visits during pregnancy, measures the prevalence of anxiety and depression, and explores the choice of maternity clinic for delivery aiming to elucidate options for care strategies. METHODS: This prospective, cross-sectional, questionnaire-based bicentric study was performed in the obstetric outpatient departments of two university hospitals in Germany and recruited pregnant women between 12/2016 and 11/2017. The questionnaire included socio-demographics, obstetric history, anxiety (GAD-7), depression (PHQ-9), and health status (WHO-5, SF-12). RESULTS: This analysis included 496 women and showed that women with numerous ED visits were significantly younger (p < 0.0001), less educated (p = 0.0002), and more likely to be unemployed and single. Different prevalences for anxiety and depression were detected correlating with the number of ED visits although each showing only low effect sizes (0.024 resp. 0.015). CONCLUSIONS: Pregnant women attending the ED more often might benefit from health education, psychosomatic interventions, and social support to overcome their depression and anxiety to avoid non-urgent ED consultations. Further prospective studies are needed to support these findings.

Assessing decision regret in caregivers of deceased German people with cancer-A psychometric validation of the Decision Regret Scale for Caregivers.

BACKGROUND: Decisional regret during or after medical treatments is linked to significant distress. Regret affects not only patients but also caregivers having an active or passive role during decision making. The Decision Regret Scale (DRS) is a self-report measure for regret in patients after treatment decisions. However, practical and psychometrically robust instruments assessing regret in caregivers are lacking. OBJECTIVE: To develop and validate a caregiver version of the DRS (Decision Regret Scale for Caregivers [DRS-C]). DESIGN: Psychometric validation based on a web survey. SETTING AND PARTICIPANTS: 361 caregivers of deceased German people/patients with cancer. MAIN VARIABLES STUDIED: Besides structural validity and test-retest reliability, we evaluated measurement invariance accounting for gender, age and closeness of relationship, and tested hypotheses on convergent/discriminant validity. RESULTS: Forty-five per cent of all caregivers demonstrated decision regret. Confirmatory factor analyses strongly supported the unidimensional structure of the DRS-C and pointed to strict invariance. The DRS-C demonstrated very good internal consistency (α = 0.83, 95% CI [0.81, 0.86]) and test-retest reliability (ICC [A,1] = 0.73, 95% CI [0.59, 0.83]) along with sound convergent/discriminant validity. Concerning responsiveness, DRS-C scores remained stable over a 12-week period in 83.3% of all caregivers. Receiver operating characteristic analysis yielded a cut point of 43 for the identification of significant decision regret (AUC = 0.62, 95% CI [0.56, 0.68]). DISCUSSION AND CONCLUSIONS: The lack of a gold standard instrument prevented us from examining the criterion validity and determining a minimally important difference. Nevertheless, the DRS-C provides valid and reliable information regarding caregiver regret following medical decisions. Above all, it captures a crucial aspect of the treatment experience in caregivers.

Potential for Integrating Mental Health Specialist Video Consultations in Office-Based Routine Primary Care: Cross-Sectional Qualitative Study Among Family Physicians.

BACKGROUND: Although real-time mental health specialist video consultations have been proposed as an effective care model for treating patients with mental health conditions in primary care, little is known about their integration into routine practice from the perspective of family physicians. OBJECTIVE: This study aimed to determine the degree to which family physicians advocate that mental health specialist video consultations can be integrated into routine primary care, where most patients with mental health conditions receive treatment. METHODS: In a cross-sectional qualitative study, we conducted 4 semistructured focus groups and 3 telephonic interviews in a sample of 19 family physicians from urban and rural districts. We conducted a qualitative content analysis applying the Tailored Implementation in Chronic Diseases framework in a combined bottom-up (data-driven) and top-down strategy for deriving key domains. RESULTS: Family physicians indicated that mental health specialist video consultations are a promising and practical way to address the most pressing challenges in current practice, that is, to increase the accessibility and co-ordination of specialized care. Individual health professional factors were the most frequently discussed topics. Specifically, family physicians valued the anticipated clinical outcomes for patients and the anticipated resources set for the primary care practice as major facilitators (16/19, 84%). However, family physicians raised a concern regarding a lack of facial expressions and physical interaction (19/19, 100%), especially in emergency situations. Therefore, most family physicians considered a viable emergency plan for mental health specialist video consultations that clearly delineates the responsibilities and tasks of both family physicians and mental health specialists to be essential (11/19, 58%). Social, political, and legal factors, as well as guideline factors, were hardly discussed as prerequisites for individual family physicians to integrate mental health specialist video consultations into routine care. To facilitate the implementation of future mental health specialist video consultation models, we compiled a checklist of recommendations that covers (1) buy-in from practices (eg, emphasizing logistical and psychological relief for the practice), (2) the engagement of patients (eg, establishing a trusted patient-provider relationship), (3) the setup and conduct of consultations (eg, reliable emergency plans), and (4) the fostering of collaboration between family physicians and mental health specialists (eg, kick-off meetings to build trust). CONCLUSIONS: By leveraging the primary care practice as a familiar environment for patients, mental health specialist video consultations provide timely specialist support and potentially lead to benefits for patients and more efficient processes of care. Integration should account for the determinants of practice as described by the family physicians. TRIAL REGISTRATION: German Clinical Trials Register DRKS00012487; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=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.

Acceptance of a new non-invasive fetal monitoring system and attitude for telemedicine approaches in obstetrics: a case-control study.

PURPOSE: Reduction of maternal morbidity and mortality is a major worldwide objective anchored in the millennium goals of the United Nations. To improve fetal and maternal care, a constant attempt to discover groundbreaking technologies is ongoing. One approach is the enhancement of non-invasive fetal ECG devices. Most importantly, acceptance of new technologies by pregnant women is a prerequisite for successful implementation. METHODS: This questionnaire-based study conducted at the University Hospital Heidelberg, Germany between May and June 2017 evaluates pregnant women's attitudes towards a new device for fetal ECG monitoring and its potential home usage. The study population was questioned after exposure to the Parides/Atlantis prototype (Nemo Healthcare, Veldhoven, The Netherlands), whereas the maternal and gestational age-matched control group was left to envision telemedical topics. RESULTS: The prototype and its potential usage in a clinical and telemedical setting was highly accepted, and its comfort and appearance satisfied participants. Its use caused significantly improved telemedical understanding as envision increased (p = 0.0015). Implementation and integration of telemedical devices into antenatal care was significantly preferred by the study group (p = 0.0011), though participants desire more specific features for their personal use. Optional home-based self-monitoring to reduce scheduled doctoral visits (p = 0.0004) as well as self-assessment prior to self-initiated, unscheduled consultation (p < 0.0001) could be affected positively by such a device. Furthermore, it could reduce face-to-face interaction with the care provider (p = 0.0163). CONCLUSIONS: The positive feedback on remote self-monitoring might open options for a more "patient as partners" oriented prenatal care in the future. Safety and reliability remain a major issue. More comprehensive studies with new technologies are needed to diligently ensure quality of care. Finally, results for new technologies must be communicated to pregnant women for their acceptance and usage of new devices.

[Psycho-oncology care in rural areas : Results from a cross-sectional survey on the utilisation of community-based psychosocial support services]. / Psychoonkologische Versorgung im ländlichen Raum : Ergebnisse einer Querschnittsbefragung zur Inanspruchnahme ambulanter Unterstützungsangebote.

BACKGROUND: Clinically relevant distress and unmet psychosocial needs frequently occur in the course of cancer diseases. Particularly for thinly populated rural areas in Germany rates of distressed patients and uptake of community-based psycho-oncology services are unknown. OBJECTIVES: Determination of a) the proportion of cancer patients with psychosocial distress and unmet needs and b) the utilisation of community-based psycho-oncology services in thinly populated rural areas. MATERIALS AND METHODS: Prospective cross-sectional study of 229 cancer patients (colon, breast, prostate cancer) living in thinly populated rural areas. Indicators for clinically relevant distress and utilisation of psychosocial services were assessed by applying screening instruments. We conducted descriptive and multivariate analyses. RESULTS: More than one third of all cancer patients (39.3%) in thinly populated areas exhibited clinically relevant distress. However, only 15.6% of distressed patients consulted community-based psycho-oncology services. Most frequently, medical or psychological psychotherapists were contacted. Information deficits of patients and attending physicians alongside dispositional factors emerged as the main reasons for non-utilisation. DISCUSSION: This study presents first data on psycho-oncology care in rural areas in Germany stratifying the degree of urbanisation in line with the standards of the European Commission. Concerning limitations, we only accounted for structural service coverage, leaving aside other indicators for socio-spatial deprivation.

Accessibility, Availability, and Potential Benefits of Psycho-Oncology Services: The Perspective of Community-Based Physicians Providing Cancer Survivorship Care.

BACKGROUND: As persons of trust, community-based physicians providing survivorship care (e.g., general practitioners [GPs]) often serve as the primary contacts for cancer survivors disclosing distress. From the perspective of physicians providing survivorship care for cancer patients, this study explores (a) the accessibility, availability, and potential benefits of psycho-oncology services; (b) whether physicians themselves provide psychosocial support; and (c) predictors for impeded referrals of survivors to services. METHODS: In a cross-sectional survey, all GPs and community-based specialists in a defined region were interviewed. In addition to descriptive analyses, categorical data were investigated by applying chi-square tests. Predictors for impeded referrals were explored through logistic regression. RESULTS: Of 683 responding physicians, the vast majority stated that survivors benefit from psycho-oncology services (96.8%), but the physicians also articulated that insufficient coverage of psycho-oncology services (90.9%) was often accompanied by impeded referrals (77.7%). A substantial proportion (14.9%) of physicians did not offer any psychosocial support. The odds of physicians in rural areas reporting impeded referrals were 1.91 times greater than the odds of physicians in large urban areas making a similar report (95% confidence interval [1.07, 3.40]). CONCLUSION: Most community-based physicians providing survivorship care regard psycho-oncology services as highly beneficial. However, a large number of physicians report tremendous difficulty referring patients. Focusing on those physicians not providing any psychosocial support, health policy approaches should specifically (a) raise awareness of the role of physicians as persons of trust for survivors, (b) highlight the effectiveness of psycho-oncology services, and (c) encourage a proactive attitude toward the assessment of unmet needs and the initiation of comprehensive care. IMPLICATIONS FOR PRACTICE: Community-based physicians providing survivorship care for cancer patients regard psycho-oncology services as a highly reasonable and beneficial addition to medical care. In light of insufficient local coverage with services, difficulties with seamless referrals constitute a major challenge for physicians. Apart from emphasizing the effectiveness of psycho-oncology services and proactive attitudes toward the assessment of unmet needs, future policies should focus on the integration of medical and psychosocial follow-up of cancer survivors, especially in rural areas.

Early palliative care for adults with advanced cancer.

BACKGROUND: Incurable cancer, which often constitutes an enormous challenge for patients, their families, and medical professionals, profoundly affects the patient's physical and psychosocial well-being. In standard cancer care, palliative measures generally are initiated when it is evident that disease-modifying treatments have been unsuccessful, no treatments can be offered, or death is anticipated. In contrast, early palliative care is initiated much earlier in the disease trajectory and closer to the diagnosis of incurable cancer. OBJECTIVES: To compare effects of early palliative care interventions versus treatment as usual/standard cancer care on health-related quality of life, depression, symptom intensity, and survival among adults with a diagnosis of advanced cancer. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, OpenGrey (a database for grey literature), and three clinical trial registers to October 2016. We checked reference lists, searched citations, and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and cluster-randomised controlled trials (cRCTs) on professional palliative care services that provided or co-ordinated comprehensive care for adults at early advanced stages of cancer. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane. We assessed risk of bias, extracted data, and collected information on adverse events. For quantitative synthesis, we combined respective results on our primary outcomes of health-related quality of life, survival (death hazard ratio), depression, and symptom intensity across studies in meta-analyses using an inverse variance random-effects model. We expressed pooled effects as standardised mean differences (SMDs, or Hedges' adjusted g). We assessed certainty of evidence at the outcome level using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table. MAIN RESULTS: We included seven randomised and cluster-randomised controlled trials that together recruited 1614 participants. Four studies evaluated interventions delivered by specialised palliative care teams, and the remaining studies assessed models of co-ordinated care. Overall, risk of bias at the study level was mostly low, apart from possible selection bias in three studies and attrition bias in one study, along with insufficient information on blinding of participants and outcome assessment in six studies.Compared with usual/standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analysed at post treatment = 1028; evidence of low certainty). As re-expressed in natural units (absolute change in Functional Assessment of Cancer Therapy-General (FACT-G) score), health-related quality of life scores increased on average by 4.59 (95% CI 2.55 to 6.46) points more among participants given early palliative care than among control participants. Data on survival, available from four studies enrolling a total of 800 participants, did not indicate differences in efficacy (death hazard ratio 0.85, 95% CI 0.56 to 1.28; evidence of very low certainty). Levels of depressive symptoms among those receiving early palliative care did not differ significantly from levels among those receiving usual/standard cancer care (five studies; SMD -0.11, 95% CI -0.26 to 0.03; participants analysed at post treatment = 762; evidence of very low certainty). Results from seven studies that analysed 1054 participants post treatment suggest a small effect for significantly lower symptom intensity in early palliative care compared with the control condition (SMD -0.23, 95% CI -0.35 to -0.10; evidence of low certainty). The type of model used to provide early palliative care did not affect study results. One RCT reported potential adverse events of early palliative care, such as a higher percentage of participants with severe scores for pain and poor appetite; the remaining six studies did not report adverse events in study publications. For these six studies, principal investigators stated upon request that they had not observed any adverse events. AUTHORS' CONCLUSIONS: This systematic review of a small number of trials indicates that early palliative care interventions may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone. Although we found only small effect sizes, these may be clinically relevant at an advanced disease stage with limited prognosis, at which time further decline in quality of life is very common. At this point, effects on mortality and depression are uncertain. We have to interpret current results with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. Additional research now under way will present a clearer picture of the effect and specific indication of early palliative care. Upcoming results from several ongoing studies (N = 20) and studies awaiting assessment (N = 10) may increase the certainty of study results and may lead to improved decision making. In perspective, early palliative care is a newly emerging field, and well-conducted studies are needed to explicitly describe the components of early palliative care and control treatments, after blinding of participants and outcome assessors, and to report on possible adverse events.

When do we need to care about the caregiver? Supportive care needs, anxiety, and depression among informal caregivers of patients with cancer and cancer survivors.

BACKGROUND: Cancer not only affects patients but also their caregivers. The objective of the current study was to assess the unmet needs of cancer caregivers and to identify possible predictors of their supportive care needs. METHODS: In a cross-sectional survey, 188 dyads of patients diagnosed with lung, urological, or gastrointestinal cancer and their primary caregivers were recruited. Caregivers were asked to complete the Supportive Care Needs Survey self-report questionnaire (for partners and caregivers); patients completed the corresponding questionnaire. Both groups provided information regarding their distress (National Comprehensive Cancer Network Distress Thermometer), anxiety, and depression (Patient Health Questionnaire-4). Clinical characteristics were obtained from medical records. RESULTS: The mean age of the caregivers was 57.8 years. Approximately 72.3% were female. Patients had an average age of 62.5 years, with 33.0% being male. Caregivers were more distressed (P<.01) and exhibited higher anxiety scores (P<.01) compared with patients. Approximately 14.4% of caregivers reported no unmet need and 43.6% had at least 10 needs that were unmet. Main caregiver concerns were regarding health care service and information needs followed by emotional and psychological needs. To some degree, unmet needs in patients and caregivers' anxiety predicted unmet caregiver needs. Sociodemographic and clinical variables were not found to be significant predictors. CONCLUSIONS: A substantial percentage of caregivers have unmet needs for support, mainly with regard to fears concerning the patient's condition, receiving disease-related information, and emotional support for themselves. Prediction of unmet needs in caregivers from other clinical and psychological variables was rather poor. Therefore, by means of the frequency and disparity of caregivers unmet needs, they should be systematically assessed to direct specific offers.

Assessing patient-caregiver communication in cancer--a psychometric validation of the Cancer Communication Assessment Tool (CCAT-PF) in a German sample.

PURPOSE: The recently introduced Cancer Communication Assessment Tool (CCAT-PF) measures congruence in patient-caregiver communication and was initially validated in lung cancer patients. Contributing to a greater proportion of the variance in the conflict scores, primary caregivers were hypothesized to experience greater stress. For a detailed understanding of conflicting communication patterns of cancer-affected families, our study aimed for psychometric validation of the CCAT-PF in a sample covering heterogeneous tumor entities. METHODS: Subsequent to a cross-sectional survey of 189 pairs of cancer patients (31 % gastrointestinal, 34 % lung, and 35 % urological) and their caregivers' exploratory factor analysis with principal component condensation and varimax rotation was conducted (response rate, 74.2 %). Reliability and construct validity were assessed calculating Cronbach's α and Pearson correlation coefficients for CCAT-P and CCAT-F scales and related constructs, respectively. RESULTS: Cancer-related communication according to the CCAT-PF can be subdivided into four factors including the scales Disclosure, Limitation of treatment, Family involvement in treatment decisions, and Continuing treatment. Reliability ranged from α = .51-.68. The Disclosure scale, describing poor cancer-related communication of the patient, was correlated with patient's distress (QSC-R10: r = .30, p < .0001), unmet needs in several areas (SCNS-SF-34: r = .25-.32, p < .001), and negatively with social/family well-being (FACT: r = -0.31, p < .0001). Higher scores on the scale were significantly associated with considerable decrements in emotional well-being especially for caregivers perceiving patients' disclosure as problematic. CONCLUSIONS: The Disclosure scale originating from the CCAT-PF emerged as a short, valid, and reliable stand-alone instrument for identifying conflicting communication in patient-caregiver-dyads at risk.

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).