Neuroimaging of hypothalamic mechanisms related to glucose metabolism in anorexia nervosa and obesity.

BACKGROUNDGiven the heightened tolerance to self-starvation in anorexia nervosa (AN), a hypothalamic dysregulation of energy and glucose homeostasis has been hypothesized. Therefore, we investigated whether hypothalamic reactivity to glucose metabolism is impaired in AN.METHODSTwenty-four participants with AN, 28 normal-weight participants, and 24 healthy participants with obesity underwent 2 MRI sessions in a single-blind, randomized, case-controlled crossover study. We used an intragastric infusion of glucose and water to bypass the cephalic phase of food intake. The responsivity of the hypothalamus and the crosstalk of the hypothalamus with reward-related brain regions were investigated using high-resolution MRI.RESULTSNormal-weight control participants displayed the expected glucose-induced deactivation of hypothalamic activation, whereas patients with AN and participants with obesity showed blunted hypothalamic reactivity. Furthermore, patients with AN displayed blunted reactivity in the nucleus accumbens and amygdala. Compared with the normal-weight participants and control participants with obesity, the patients with AN failed to show functional connectivity between the hypothalamus and the reward-related brain regions during water infusion relative to glucose infusion. Finally, the patients with AN displayed typical baseline levels of peripheral appetite hormones during a negative energy balance.CONCLUSIONThese results indicate that blunted hypothalamic glucose reactivity might be related to the pathophysiology of AN. This study provides insights for future research, as it is an extended perspective of the traditional primary nonhomeostatic understanding of the disease.FUNDINGThis study was supported by a grant from the DFG (SI 2087/2-1).

Secondary Traumatization, Psychological Stress, and Resilience in Psychosocial Emergency Care Personnel.

Volunteers active in psychosocial emergency care offer psychological first aid to survivors of accidents and trauma, their relatives, eye witnesses, bystanders, and other first responders. So far, there are no studies that investigate the secondary and primary traumatization of this group of first responders. We included N = 75 volunteers, who filled out questionnaires to assess their secondary (QST/FST) and primary traumatization (PDS), and levels of comorbid psychological stress (PHQ-9, GAD-7, SF-12). We investigated factors of resilience by measuring attachment behavior (ECR-RD, RQ-2), level of personality functioning (OPD-SFK), sense of coherence (SOC-29), social support (F-SozU), and mindfulness (MAAS). The volunteers' levels of secondary and primary traumatization were below cut-off scores. Their levels of comorbid psychological stress were comparable to representative norm samples. Additionally, the volunteers presented high levels of resilience. Gender (ß = 0.26; p < 0.05), case discussions (ß = -0.37; p < 0.05), and social support (ß = 0.45; p < 0.01) were revealed to be predictors of secondary traumatization, while mindfulness turned out to be a predictor of primary traumatization (ß = -0.34; p = 0.008). However, we cannot rule out that the low prevalence of traumatization and comorbid psychological stress in our study sample might not be explained by a positive response bias.

Impact of Depression and Psychosocial Treatment on Heart Rate Variability in Patients with Type 2 Diabetes Mellitus: An Exploratory Analysis Based on the HEIDIS Trial.

OBJECTIVES: To explore the impact of depression on heart rate (HR) and heart rate variability (HRV) as a marker of autonomic nervous system (ANS) impairment in depressed and non-depressed patients with advanced type 2 diabetes mellitus (T2DM) and to explore possible effects of an acceptance- and mindfulness-based group intervention (MBSR) on HR and HRV. METHODS: Alongside a prospective clinical trial, we collected demographic, psychosocial and clinical data from 113 chronic T2DM patients in a standardized setting. At baseline and after one year, depressive mood was assessed with the Patient Health Questionnaire (PHQ-9), and autonomic function was determined by measuring HR and HRV markers. A subsample was randomly assigned to take part in eight MBSR sessions. RESULTS: Of the 113 T2DM patients (77.9% men; mean age=58.8±7.0 years; diabetes duration 11.5±7.0 years), 33 showed clinically relevant depressive symptoms at baseline. In cross-sectional analysis, we found no association between depression and HR/HRV (all comparisons p>0.05). In prospective regression analysis depression did not predict follow-up scores of HRV. The patients who participated in the MBSR intervention showed a tendency toward improved parasympathetic control (RMSSD, CV, E-I-Ratio) with small-to-moderate effect sizes (d≤0.38). CONCLUSIONS: Depression was not directly associated with cardiac autonomic control in this sample, but MBSR training may have positively influenced HR and HRV. In advanced diabetes, somatic and behavioral parameters seem to be more predictive than depression for the course of autonomic functioning, but the pathways remain unclear.

A short intervention targeting psychosomatic care in older adults with complex health care needs-results of a randomized controlled trial.

OBJECTIVE: The aim of this randomized controlled trial (RCT) was to assess the efficacy of a short intervention targeting psychosomatic care in older adults with complex health care needs. METHODS: Participants were recruited in the frame of the 11-year follow-up of a large population-based study by means of the INTERMED interview. The INTERMED interview is an integrative assessment method to identify bio-psycho-social health care needs. Persons with high health care needs (interview score ≥ 17) were invited to take part. Participants were randomized with a 1:1 ratio to a control and an intervention group. The intervention group received a home visit conducted by a doctor trained in psychosomatic medicine. The primary hypothesis stated that the intervention group would have a better outcome with respect to health related quality of life (HRQOL) measured by the 12-item short-form health survey (mental component score, MCS) 6 months after randomization (T1). Secondary outcomes were physical HRQOL, health care needs, depression, anxiety, and somatic symptom severity. RESULTS: In total, 175 participants were included. At the three-year follow-up (T2), 97 participants (55.4%) were included. At T1, we did not find a difference regarding MCS between the intervention and control groups. At T2, the intervention group showed significantly lower health care needs compared with the control group. Regarding HRQOL, depression, and somatic symptom severity the two groups did not differ at T2. CONCLUSIONS: The primary hypothesis was not confirmed. However, results indicate that a short intervention with complex patients could lead to reduced bio-psycho-social health care needs.

[Psychosomatic Specialist Consultation in the General Practitioner's Office - A New Model of Integrated Care]. / Psychosomatische Sprechstunde in der Hausarztpraxis ­ ein neues Kooperationsmodell von Psychosomatik und Allgemeinmedizin.

A high number of patients with mental health disorders currently do not receive minimally adequate treatment, but remain solely in general practice. This is often due to long waiting times for psychotherapy, patient related barriers or diagnostic insecurity. For this reason, we have developed a care model that is applied directly in the general practitioner's (GP) office and is open to any form of psychosomatic disorder. The cornerstone of the model consists of a psychosomatic specialist consultation in the GP's office. Preliminary results concerning utilization and the target population show a high level of acceptance among patients, GPs, and psychosomatic specialists.

A Comparison of Stress Perception in International and Local First Semester Medical Students Using Psychometric, Psychophysiological, and Humoral Methods.

(1) Medical doctors and medical students show increased psychological stress levels. International medical students seem to be particularly vulnerable. (2) We compared different methods of assessing stress levels in international and local first year medical students. First, study participants completed questionnaires related to stress, depression, empathy, and self-efficacy (MBI, PSQ, PHQ-9, JSPE-S, and GSE) at three separate points in time (T1 to T3). Second, their heart rate variabilities (HRVs) were recorded in an oral examination, a seminar, and in a relaxing situation. Third, hair samples were collected at the beginning and at the end of the semester to assess the cortisol concentration. (3) Included were 20 international and 20 local first semester medical students. At T1, we found considerable differences between international and local students in the JSPE-S; at T2 in the MBI factor "professional efficacy", the PHQ-9, and in the JSPE-S; and at T3 in the MBI factors "cynicism" and "professional efficacy", the PHQ-9, and in the JSPE-S. International and local students also differed concerning their HRVs during relaxation. Over the course of the semester, international students showed changes in the MBI factors "emotional exhaustion" and "professional efficacy", the PHQ-9, and the GSE. Local students showed changes in the GSE. No effects were found for students' hair cortisol concentrations. (4) All participants showed low levels of stress. However, while international students experienced their stress levels to decrease over the course of the semester, local students found their stress levels to increase.

Healthy ageing at work- Efficacy of group interventions on the mental health of nurses aged 45 and older: Results of a randomised, controlled trial.

OBJECTIVE: This multicentre, randomised controlled trial (RCT) aimed to evaluate the efficacy of a small-group intervention promoting successful ageing at work in older nurses (aged ≥45). METHOD: A sample of 115 nurses aged ≥45 from 4 trial sites in Germany were randomly assigned to either the intervention group (IG), that received a small-group intervention of seven weekly sessions of 120 min with a booster session after six weeks or to a wait-list control condition (WLC). Outcomes were measured via validated self-report questionnaires at baseline (T1) and at post-treatment (T2). Primary outcomes were mental health-related well-being and mental health-related quality of life (QOL). The secondary outcomes included mental health-related and work-related measures. RESULTS: The intention to treat (ITT) analysis showed significant positive effects of the intervention on mental health. A significant small effect (d = 0.3) in favour of the IG was found for psychological health-related quality of life. Positive small effects (d = 0.24 to d = 0.31) were also found for work related mental strain. CONCLUSIONS: Our small-group intervention based on a theory of successful ageing for nurses aged ≥45 was found to be effective with regard to improvements of psychological health related quality of life and other mental health-related outcomes. Thus, our study shows that the ageing workforce can be reached through specifically designed preventive interventions. The components of our intervention could be easily adapted to the belongings of other professions. Our results suggest that these components should be evaluated in various settings outside the healthcare sector.

Depression profile in cancer patients and patients without a chronic somatic disease.

BACKGROUND: To investigate whether depressed oncology patients show a specific depressive symptom profile, we compared depression symptoms in depressed cancer patients (CANCER-DEP) and depressed patients without a chronic somatic disease (NONCANCER-DEP). METHODS: Of a total of 2493 outpatients from a comprehensive cancer center and a center for psychosocial medicine, 1054 (42.3%) met the DSM-5 criteria for depression, measured with the Patient Health Questionnaire 9. Based on the Patient Health Questionnaire 9 scores, differences in severity of each of the 9 individual DSM-5 depression symptoms between CANCER-DEP (n = 542) and NONCANCER-DEP (n = 512) were examined. Non-depressed cancer patients (CANCER-NONDEP; n = 1216) served as a comparison group for somatic symptoms independent of depression in cancer. To control for depression severity, group comparisons were performed separately for patients with major depression and any depressive disorders. RESULTS: Depressed cancer patients reported significantly lower levels of the cognitive-emotional depression symptoms "worthlessness" and "suicidal thoughts" than NONCANCER-DEP. Only 1 out of 5 somatic depression symptoms ("changes in appetite") was more pronounced in CANCER-DEP than in NONCANCER-DEP. Confirming previous research, somatic depression symptoms occurred more frequently in CANCER-DEP than in CANCER-NONDEP. CONCLUSIONS: The lower level of cognitive-emotional symptoms in CANCER-DEP than in NONCANCER-DEP is discussed in relation to different psychosocial phenomena. Our results indicate that somatic depression symptoms are similarly pronounced in CANCER-DEP and NONCANCER-DEP, and that CANCER-DEP show greater somatic depression symptoms than CANCER-NONDEP. The presence of high levels of somatic symptoms should alert clinicians to investigate for a potential comorbid depression in cancer patients.

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.

[Normative-empirical determination of personnel requirements in psychosomatic medicine and psychotherapy]. / Normativ-empirische Bestimmung des Personalbedarfs in der Psychosomatischen Medizin und Psychotherapie.

OBJECTIVES: There is a high degree of misallocated medical care for patients with somatoform disorders and patients with concomitant mental diseases. This complex of problems could be reduced remarkably by integrating psychosomatic departments into hospitals with maximum medical care. Admitting a few big psychosomatic specialist clinics into the calculation basis decreased the Day-Mix Index (DMI). The massive reduction of the calculated costs per day leads to a gap in funding resulting in a loss of the necessary personnel requirements - at least in university psychosomatic departments. The objective of this article is therefore to empirically verify the reference numbers of personnel resources calculated on the basis of the new German lump-sum reimbursement system in psychiatry and psychosomatics (PEPP). METHODS: The minute values of the reference numbers of Heuft (1999) are contrasted with the minute values of the PEPP reimbursement system in the years 2013 and 2014, as calculated by the Institute for Payment Systems in Hospitals (InEK). RESULTS: The minute values derived from the PEPP data show a remarkable convergence with the minute values of Heuft's reference numbers (1999). CONCLUSIONS: A pure pricing system like the PEPP reimbursement system as designed so far threatens empirically verifiable and qualified personnel requirements of psychosomatic departments. In order to ensure the necessary therapy dosage and display it in minute values according to the valid OPS procedure codes, the minimum limit of the reference numbers is mandatory to maintain the substance of psychosomatic care. Based on the present calculation, a base rate of at least 285 e has to be politically demanded. Future developments in personnel costs have to be refinanced at 100 %.

[Learning objectives for psychosomatic medicine and psychotherapy in light of the National Competency-Based Catalogue of Learning Objectives for Medicine (NKLM)]. / Lernziele der Psychosomatischen Medizin und Psychotherapie vor dem Hintergrund des Nationalen Kompetenzbasierten Lernzielkataloges Medizin (NKLM).

OBJECTIVE: The "National Competency-Based Catalogue of Learning Objectives for Medicine" ("Nationaler Kompetenzbasierter Lernzielkatalog Medizin,"NKLM) is a core curriculum developed for medical training. Here, the classic division by discipline and organ system has been abandoned, which requires each discipline to define its own core curriculum in specific catalogues of learning objectives. This article presents such a catalogue for Psychosomatic Medicine and Psychotherapy. METHOD: A two-step DELPHI-method was used to survey faculty representatives for Psychosomatic Medicine and Psychotherapy. It reflected the discipline-specific university catalogues of learning objectives as well as the NKLM. A catalogue of learning objectives was then developed and approved. RESULTS: The catalogue consists of two parts: (1) a 12-module core curriculum for Psychosomatic Medicine and Psychotherapy and (2) selected interdisciplinary learning objectives from the NKLM with relevant participation of the discipline in ten modules. DISCUSSION: For the first time in Germany, this article presents a catalogue of learning objectives for Psychosomatic Medicine and Psychotherapy that is agreed upon by the relevant representatives. This enables the integration of psychosomatic and psychotherapeutic teaching contents from a department into the overall curriculum as required by the NKLM. In the future, methods should be established to allow regular updating and further development of this catalogue.

[Day-clinic and Inpatient Psychotherapy of Depression (DIP-D)--Secondary Outcomes and Follow-up Results of a Randomized-Controlled Pilot Trial]. / Tagesklinische und stationäre Psychotherapie der Depression (DIP-D)--Sekundäre Erfolgsmaße und Katamneseergebnis einer randomisiert-kontrollierten Pilotstudie.

Depressions are frequent disorders in psychosomatic medicine and psychotherapy. However, there are only few controlled studies comparing different levels of care for depressed patients. Especially the efficacy of day-clinic psychotherapy for depression remains understudied. The pilot study aims to close this gap by examining the feasibility of a randomized-controlled trial comparing day-clinic and inpatient psychotherapy for depression in a routine hospital setting. The current paper adds the secondary outcome measures on patient self-reported symptoms and interpersonal problems. In addition, findings of a 6-month follow-up are analyzed. Overall, 44 patients were recruited and randomly allocated to either day clinic or inpatient psychotherapy for 8 weeks. Depressive symptoms and interpersonal problems decreased during treatment, and follow-up scores stayed below intake scores. There were no differences between the treatment groups in this pilot study. For the future, it is desirable to compare randomized patients with those patients who received their preferred treatment option. Although the findings need to be replicated in larger samples, they appear promising for day-clinic psychotherapy. The better understanding of differential effectiveness of different levels of care of patient subgroups remains an important goal.

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.

[Psychosomatic and psychotherapeutic outpatient care in Germany - Capacity profile based on data from the National Association of Statutory Health Insurance Physicians]. / Ambulante psychosomatische und psychotherapeutische Versorgung in Deutschland - Versorgungsprofile abgebildet durch Daten der Kassenärztlichen Bundesvereingung (KBV).

OBJECTIVES: At the centre of the study lay a representation of outpatient psychosomatic and psychotherapeutic care with a focus on different groups of medical and psychological therapists. METHODS: The routine data of the National Association of Statutory Health Insurance Physicians (KBV) from the year 2008 were analyzed based on a systematic literature review (Medline, ISI, to November 2010). RESULTS: Neurologists and psychiatrists see the most patients (n = 3,172 vs n = 1,347 cases per practice), but they rarely provide services according to the directives for psychotherapy (4,4 %). However, specialists for psychosomatic medicine and psychotherapy (65 %), physicians providing only psychotherapy (66 %) and psychological psychotherapists (73 %) provide care mainly according to the directives for psychotherapy and therefore see fewer patients (170-190 cases per practice).Medical psychotherapists work more often on a psychodynamic basis, while psychological psychotherapists perform more often behavioral therapy. CONCLUSIONS: The treatment of patients with mental and psychosomatic disorders is based on three columns of care, which differ in their supply profile and each make a specific contribution to the treatment.

Psychosocial support in patients with multiple myeloma at time of diagnosis: who wants what?

OBJECTIVE: The aim of this study was to examine interest in psychosocial interventions among patients with multiple myeloma at time of diagnosis as well as associated factors. METHODS: Patients with newly diagnosed multiple myeloma were recruited from our outpatient myeloma unit at the Heidelberg University Hospital. Patients completed questionnaires that included a checklist on desired psychosocial interventions and the Patient Health Questionnaire 9-item (PHQ-9) depression and Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety scales. Medical data were extracted from the patients' electronic records. RESULTS: The survey was completed by 114 out of the 130 myeloma patients. Half of the patients (51%) desired psychosocial interventions. The most common preferences were relaxation techniques (21%), psychological counseling (20%), and peer support groups (18%). Approximately 24% of the patients reported symptoms of depression, and 8% reported symptoms of anxiety. Patients with symptoms of depression had twice as many preferences for psychosocial interventions as nondepressed patients. They more frequently desired individual psychotherapy (p = 0.035) and peer support groups (p = 0.015). In general, lower age was associated with greater interest in psychosocial interventions. Medical status was not strongly associated with interest in psychosocial interventions. CONCLUSIONS: A high percentage (51%) of patients with multiple myeloma has psychosocial intervention desires at the time of diagnosis. The greatest interest was found in depressed and younger patients. However, depressed patients do not prefer a single intervention form but rather show a broad variability of wishes, so 'one size does not fit all'. Therefore, to reach all patients in need, a choice of psychosocial interventions should be offered.

[The future of psychotherapy in psychosomatic medicine]. / Zukunft der Psychotherapie in der Psychosomatischen Medizin.

OBJECTIVE: To review the current perspectives and trends of psychotherapy as a key area of psychosomatic medicine with regard to both societal and scientific challenges as well as patient health care services. Also, to draw conclusions regarding the future training and practice of psychosomatic medicine and psychotherapy. RESULTS: Psychotherapy is confronted with many new challenges because of the high prevalence of mental and psychosomatic disorders, because of their increasing recognition as major health problems and because of the rapid technological and demographic changes going on in modern society. Despite its growth, psychotherapeutic care is still limited in many, especially rural, regions and for patients with complex psychosomatic and somatopsychic disorders. CONCLUSIONS: New models of training as well as integrated and multimodal care are needed in order to provide both, rapid, low-threshold and specialized, disorder-specific care.