[Utilisation of Psychotherapeutic Assistance By Diabetes Patients with a History of Migration]. / Die Inanspruchnahme psychotherapeutischer Leistungen durch Diabetes Patienten mit Migrationshintergrund.

According to available studies, migrant patients are more often affected by diabetes mellitus and comorbid psychological complaints than patients without a history of migration. Less is known about whether these patients receive psychotherapeutic assistance for their complaints and which factors may influence the utilisation of psychotherapy in this patient group. We sought to answer these questions by using culture sensitive material which included a screening for depressive symptoms (the Patient Health Questionnaire) and sociodemographic items. The material was completed once by patients of 2 collaborating family practices in the Düsseldorf Metropolitan Area during the total research period of 12 months. Both practices were participating in the Disease Management Programme (DMP) for diabetes mellitus (type 2). 42% of the 90 included patients had a clinically relevant depressive symptomatology. One third of these patients were in psychotherapy. One of the major barriers for the utilisation of psychotherapeutic help independent of the severity of depressive complaints was the existence of language barriers on the part of the patient. Patients with language barriers were about 10 times less likely to be in psychotherapy. Neither the duration that patients were living in Germany, nor the cultural match with the family practitioner, age or gender of patients played a significant role. The existence of death or suicidal fantasies, on the contrary, significantly increased the likelihood of being in psychotherapy. Implications of these data are discussed together with suggestions for future research.

[Psychodynamic Traumatherapy of Refugees with PTSD and Somatisation]. / Stabilisierende psychodynamische Traumatherapie für Flüchtlinge: Ein Leitfaden für das therapeutische Vorgehen bei PTBS und Somatisierung.

The medical care of refugees and asylum seekers requires culturally sensitive and diverse structuring of the healthcare. In the psychotherapeutic and psychosomatic treatment of these patients the culture-specific and social aspects and also the high ratio of patients with post traumatic stress disorders and somatoform disorders have to be considered. The principles of stabilizing psychodynamic traumatherapie of refugees will be introduced, which efficacy was determined by controlled study. The specific adaptations of the trauma-orientated psychotherapy to the specific situation of refugees and asylum seekers will be described.

['How strange is the patient to me?'] / "Wie fremd ist mir der Patient?".

'How strange is the patient to me?' Physicians' attitudes and expectations toward treating patients with a migration background Objectives: Undergraduate and postgraduate training in cultural competence remains a challenging issue. It might be useful to integrate culturally sensitive learning objectives in existing curricula. As part of a needs assessment, this qualitative study examined the prototypical experiences in clinical routines with patients with a migration background. METHODS: Twenty physicians took part in half-structured narrative interviews, which were then analyzed by linguistic-ethnographic conversation analysis. RESULTS: The main reasons for difficulties in patient-physician relation proved to be language barriers. Assignments of professional interpreters were rated critically. Physicians attributed the responsibility for successful communication mainly to the patient. The physicians saw little need for training in cultural competence. CONCLUSIONS: The integration of learning objectives related to cultural sensibility in existing curricula would seem to be useful, especially because the physicians interviewed reported little need for additional training on their own. The importance of implied negative attitudes and stereotypes in creating a culturally sensitive approach should be taken into account.

[Basic thoughts on psychopharmacological interventions through psychotherapy of severe forms of post-traumatic stress disorder: a case study]. / Pharmakotherapeutische Interventionen in der Psychotherapie von schweren Traumafolgestorungen: Grundsatzliche Uberlegungen anhand einer Fallstudie.

The present paper focuses on clinical issues concerning the psychopharmacological treatment of severe forms of post-traumatic stress disorder (PTSD).Using a case study, we discuss problems in this field against the background of psychodynamic and psychotraumatological theories. We also present strategies for the appropriate use of psychotropic drugs in the psychotherapy of PTSD.

Effects of trauma-focused psychotherapy upon war refugees.

The aim of this study is to evaluate the effects of a trauma-focused psychotherapy upon war refugees from Bosnia. Seventy refugees who met the criteria for posttraumatic stress disorder (PTSD) and somatoform disorders were included. The first 35 refugees were offered psychotherapy and the following 35 refugees received usual care. Outcome variables were changes in self-reported PTSD symptoms, psychological symptoms, and health status. At 12-month follow-up, participants in the intervention group reported significantly lower scores on the PTSD scale and the measure of psychological symptoms than the comparison group participants. Our results suggest that psychotherapy reduces symptoms of PTSD and somatoform disorders among war refugees even in the presence of insecure residence status.

[12-Month Prevalence and Consequences of Current Experiences of Physical and Psychological Violence in a Sample of Patients who Entered First Time a Psychotherapeutic Outpatient Clinic]. / 12-Monats-Prävalenz und Bedeutung aktueller körperlicher und psychischer Gewalterfahrungen bei Patientinnen und Patienten einer psychosomatisch-psychotherapeutischen Hochschulambulanz.

Objective To examine current experiences of violence and its relationship with psychological burden in a psychotherapeutic outpatient sample. Methods 1074 patients of a psychotherapeutic outpatient-clinic of a university hospital completed a written violence screening questionnaire. Results Current experienced physical and psychological violence was two times higher compared to general population. Patients who experienced current violence reported significantly more psychological burden. Conclusion Use of violence screening in daily routine of a psychotherapeutic outpatient-clinic seems to be a promising approach to detect violence experiences.

Does migration affect the outcome of inpatient psychotherapy? Results from a retrospective cohort study.

OBJECTIVE: Reliable data to determine whether migrant patients benefit sufficiently from evidence-based mental health interventions are scarce. Our aim was to examine the effect of migration on the outcome of inpatient psychotherapy. METHODS: We conducted a retrospective cohort study and predicted the course of the global severity index of the Symptom Checklist 90 during therapy based on data from our routine clinical practice (N=542). We used mixed models for our analysis and included relevant clinical characteristics. RESULTS: One hundred and twenty-one patients of our sample had a history of migration which was consistently associated with more symptoms at baseline assessment. Patients with direct experiences of migration had the highest level of symptoms before therapy but also showed the largest decrease of symptoms during therapy (B=-0.09, SD=0.04, p=0.030). This interaction effect could be accounted for by our clinical variables. Patients with indirect experiences of migration did not differ from other patients in their level of improvement (B=-0.05, SD=0.04, p=0.149). CONCLUSION: According to our preliminary data, migration does not seem to negatively affect the outcome of inpatient psychotherapy. Limitations of these promising findings are discussed together with the strong need for more advanced studies in this area of research.

Determinants of altered intracellular endocrine-immune interplay in Bosnian war refugees suffering from PTSD.

Posttraumatic Stress Disorder (PTSD) has been repeatedly linked to changes in glucocorticoid (GC) sensitivity. To increase our understanding of this phenomenon and its potential relevance for PTSD development and treatment, the current study investigates the interplay between two key moderators, glucocorticoid receptor (GRα) and GR co-chaperone FKBP5, and their relation to GC sensitivity. A GC sensitivity assay was performed in 52 Bosnian war refugees (19m; 40.8±8.7 years) clinically diagnosed with PTSD to divide the patient group into a high (HS) and a low (LS) GC sensitivity group. Expression of GRα and FKBP5 mRNA was quantified by real-time RT-PCR. Links between gene expression and GC sensitivity were driven by the HS group of PTSD patients, which also showed increased expression of GRα but not FKBP5 compared to the LS group. Further, expressions of FKBP5 and GRα were strongly correlated in the HS patient group, while this association was missing in the LS PTSD group. Our findings suggest that PTSD phenotypes may be characterized by differences in intracellular signaling transduction processes. The associations of expression of GRα and FKBP5 in the high-sensitive PTSD subgroup may thereby reflect physiological adaptation to preserve immune-relevant GC signaling. Further research is needed to understand the role and consequences of GRα-FKBP5 dissociation in low GC sensitivity PTSD patients.

Hypocortisolism and increased glucocorticoid sensitivity of pro-Inflammatory cytokine production in Bosnian war refugees with posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with dysregulation of the hypothalamus pituitary adrenal (HPA) axis. Alterations include various responses to HPA axis stimulation, different basal hormone levels, and changes in glucocorticoid receptor (GR) numbers on lymphocytes. The functional significance of these latter changes remains elusive. METHODS: Twelve Bosnian war refugees with PTSD and 13 control subjects were studied. On 2 consecutive days, they collected saliva samples after awakening and at 11, 15, and 20 hours. Glucocorticoid (GC) sensitivity was measured by dexamethasone (DEX) inhibition of lipopolysaccharide (LPS)-induced interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) production in whole blood. RESULTS: The PTSD patients showed no cortisol response after awakening and had lower daytime cortisol levels (F = 14.57, p <.001). Less DEX was required for cytokine suppression in PTSD patients (IL-6: t = -2.82, p =.01; TNF-alpha: t = 5.03, p <.001), reflecting higher GC sensitivity of pro-inflammatory cytokine production. The LPS-stimulated production of IL-6, but not TNF-alpha, was markedly increased in patients (IL-6: F = 10.01, p <.004; TNF-alpha: F =.89, p =.34). CONCLUSIONS: In refugees with PTSD, hypocortisolism is associated with increased GC sensitivity of immunologic tissues. Whether this pattern reflects an adaptive mechanism and whether this is sufficient to protect from detrimental effects of low cortisol remains to be investigated.

Evaluation of a community-level health policy intervention.

In this article an evaluation approach towards an innovative community-level health policy intervention in Germany is presented. The aim of the intervention was basically to establish new structures of health planning and co-ordination at the community level in order to improve health monitoring and health care as well as health promotion. To realise this aim Round Tables, Working Groups and Project Offices were implemented in the communities. Based on the theory of change and using a developmental perspective the evaluation was focussed on the links between contexts, activities and outputs of the initiative. A mixed-method design with triangulation of quantitative and qualitative methods was applied. Results show that most of the communities succeeded in convening all major organisations and institutions of the local health care system within the Round Tables. Working climate was rated favourably by most of the involved actors. All communities succeeded in developing and enacting recommendations for action programmes, and about 40% of these programmes were implemented during the observation period of the project. Probability of programme implementation was high if measures remained within the scope of the communities' range of decision authority. Potential effects on population health produced by the action programmes could not be assessed both for logistic reasons and due to the short observation period. Finally, some major characteristics of health policy evaluation at the community level are discussed briefly.

Altered salivary alpha-amylase awakening response in Bosnian War refugees with posttraumatic stress disorder.

In posttraumatic stress disorder (PTSD), chronic activation of the sympathetic nervous system (SNS) has been suggested. No study so far has investigated diurnal secretion patterns of salivary alpha-amylase (sAA) in PTSD, a promising candidate for non-invasive assessment of SNS activity. We compared sAA diurnal profiles between a group of Bosnian War refugees with PTSD and a healthy control group, and further analyzed for associations with psychiatric symptoms and glucocorticoid (GC) sensitivity of inflammatory regulation. PTSD patients showed a sAA awakening response profile that was opposite to those seen in healthy controls, i.e. an increase instead of a sharp decrease. Patterns of sAA secretion were further positively associated with psychiatric symptoms of PTSD. Finally, higher sAA awakening responses were associated with higher GC sensitivity of inflammatory cytokine production. These findings are in line with altered SNS function in PTSD, and lend further support for employing assessment of diurnal sAA profiles as non-invasive biomarkers in stress-related disease.

[Effort-reward imbalance at work and depressive symptoms--a cross-sectional investigation of middle-aged employees]. / Berufliche Gratifikationskrisen und depressive Symptome--Eine Querschnittsstudie bei Erwerbstätigen im mittleren Erwachsenenalter.

This study explored associations of psychosocial stress at work with depressive symptoms in a group of middle-aged employees. Psychosocial stress at work was conceptualized in terms of the model of effort-reward imbalance. This model is measured by a psychometric scale containing 23 Likert-scaled items. Depressive symptoms were assessed by the German version of the CES-D scale. The sample consisted of 316 (44.6 +/- 7.5 years) men and women employed in an urban transport enterprise. Multivariate logistic regression analysis adjusting for relevant confounders indicated an odds ratio of 5.9 (95 % CI 2.4 - 14.3) for depressive symptoms among employees defined by imbalance of high effort and low reward at work. An association of similar strength was found among employees characterized by a high level of work-related over-commitment. Findings reported for the first time in Germany are in line with two international investigations.

Perceived work stress, overcommitment, and self-reported musculoskeletal pain: a cross-sectional investigation.

The objective of this study was to analyze associations of three indicators of perceived work stress (physical job demand, low control at work, and an imbalance between effort and reward), and of overcommitment, a personal pattern of coping with work demands, with musculoskeletal pain. A standardized questionnaire measuring these conditions in addition to self-reported musculoskeletal pain at different locations was administered to a group of 316 male and female employees of a public transport enterprise. After we adjusted for confounding effects of age, sex, socioeconomic status, shift work, and negative affectivity, we observed elevated prevalence odds ratios in employees who scored high on overcommitment, who were exposed to physical job demand, and, to a lesser extent, who reported psychosocial work stress. Results have implications for a more comprehensive approach to primary and secondary prevention of musculoskeletal pain.