["Psychiatry Takes its Time  " Why Does One Become a Psychiatrist? - A Qualitative Study]. / "Die Psychiatrie nimmt sich Zeit  " Warum Psychiater*in werden? ­ Eine qualitative Studie.

OBJECTIVE: Identification of intrinsic motivators involved in choosing psychiatry as a career path. METHODS: 14 qualitative in-depth interviews were analysed systematically using coding frames. RESULTS: Positive findings were the interpersonal focus and the holistic approach of psychiatry. Negative dimensions were the unfavorable image among colleagues, the lack of precision, prejudices and stigmatization. To interest more medical students, cases should be presented weighing psychiatric aspects as equally important to other medical aspects. CONCLUSIONS: To increase the popularity of psychiatry, the prejudices inherent in the medical system need urgent addressing. Teaching should be conducted in case presentations. Psychiatric conditions, which are highly prevalent across all medical fields, need to be adequately represented.

Parental feeding practices and the relationship with parents in female adolescents and young adults with eating disorders: A case control study.

OBJECTIVE: Perceived parental influence on diet in early adolescence in the context of the parental relationship had previously not been studied in a clinical sample. The aim of this study was to investigate a possible association between eating disorders and characteristics of the relationship with parents and the parental feeding practices in early adolescence. METHODS: 21 female adolescents and young adults with an eating disorder (ED)-bulimia nervosa or anorexia nervosa-and 22 females without eating disorder (healthy control; HC), aged between 16 and 26, were assessed via self-report questionnaires for problematic eating behaviour, relationship with parents, perceptions of parent's feeding practices at the age of 10-13 years and personality. Statistical evaluation was performed by means of group comparisons, effect sizes, regression analyses and mediator analyses. RESULTS: Adolescent and young adult females with ED reported more fears/overprotection and rejection/neglect by their mothers and less self-responsibility in terms of eating behaviour during adolescence than did the HC. The relationship with the fathers did not differ significantly. Females who perceived more cohesion, rejection/neglect and fears/overprotection by the mother were more likely to suffer from an ED. Rejection/neglect by both parents were associated with less self-acceptance of the young females with even stronger effect sizes for the fathers than the mothers. Harm prevention in the young females was a partial mediator between fears/overprotection and the drive for thinness. CONCLUSIONS: The parental relationship is partly reflected in the self-acceptance and self-responsibility in eating of the adolescent and young females, both of them are particularly affected in EDs. Stressors in the parent-child relationship should be targeted in treatment of eating disorders. Nutritional counselling for parents might be useful in early adolescence.

The excess economic burden of mental disorders: findings from a cross-sectional prevalence survey in Austria.

Information about the scope of mental disorders (MDs), resource use patterns in health and social care sectors and economic cost is crucial for adequate mental healthcare planning. This study provides the first representative estimates about the overall utilisation of resources by people with MDs and the excess healthcare and productivity loss costs associated with MDs in Austria. Data were collected in a cross-sectional survey conducted on a representative sample (n = 1008) between June 2015 and June 2016. Information on mental health diagnoses, 12-month health and social care use, medication use, comorbidities, informal care, early retirement, sick leave and unemployment was collected via face-to-face interviews. Generalised linear model was used to assess the excess cost of MDs. The healthcare cost was 37% higher (p = 0.06) and the total cost was twice as high (p < 0.001) for the respondents with MDs compared to those without MDs. Lost productivity cost was over 2.5-times higher (p < 0.001) for those with MDs. Participants with severe MDs had over 2.5-times higher health and social care cost (p < 0.001) and 9-times higher mental health services cost (p < 0.001), compared to those with non-severe MDs. The presence of two or more physical comorbidities was a statistically significant determinant of the total cost. Findings suggest that the overall excess economic burden on health and social care depends on the severity of MDs and the number of comorbidities. Both non-severe and severe MDs contribute to substantially higher loss productivity costs compared to no MDs. Future resource allocation and service planning should take this into consideration.

Social anxiety disorder and emotion regulation problems in adolescents.

BACKGROUND: Social anxiety disorder (SAD) in adolescents may be associated with the use of maladaptive emotion regulation (ER) strategies. The present study examined the use of maladaptive and adaptive ER strategies in adolescents with SAD. METHODS: 30 adolescents with SAD (CLIN) and 36 healthy adolescents for the control group (CON) aged between 11 and 16 years were assessed with the standardized questionnaires PHOKI (Phobiefragebogen für Kinder und Jugendliche) for self-reported fears as well as FEEL-KJ (Fragebogen zur Erhebung der Emotionsregulation bei Kindern und Jugendlichen) for different emotion regulation strategies. RESULTS: Compared to controls, adolescents with SAD used adaptive ER strategies significantly less often, but made use of maladaptive ER strategies significantly more often. There was a significant positive correlation between maladaptive ER and social anxiety in adolescents. Examining group differences of single ER strategy use, the CLIN and CON differed significantly in the use of the adaptive ER strategy reappraisal with CLIN reporting less use of reappraisal than CON. Group differences regarding the maladaptive ER strategies withdrawal and rumination, as well as the adaptive ER strategy problem-solving were found present, with CLIN reporting more use of withdrawal and rumination and less use of problem-solving than CON. CONCLUSIONS: Promoting adaptive emotion regulation should be a central component of psychotherapy (cognitive behavioral therapy-CBT) for social anxiety in adolescents from the beginning of the therapy process. These findings provide rationale for special therapy programs concentrating on the establishment of different adaptive ER strategies (including reappraisal). As an increased use of maladaptive ER may be associated with SAD in adolescents, it may be paramount to focus on reduction of maladaptive ER (for example withdrawal and rumination) from the beginning of the psychotherapy process. Incorporating more ER components into psychotherapy (CBT) could increase the treatment efficacy. Further investigations of the patterns of emotion regulation in specific anxiety groups like SAD in adolescents is needed to continue to optimize the psychotherapy (CBT) concept.

[Criterion Validity of the 15-item Geriatric Depression Scale in the Austrian Population]. / Die Kriteriumsvalidität der 15-Item Geriatrischen Depressionsskala in der österreichischen Bevölkerung.

OBJECTIVE: The "Geriatric Depression Scale" consisting of 15 items (GDS-15) is a well-known screening tool for depression among the elderly. Until now the criterion validity of the German language GDS-15 was not investigated in a sample of the adult general population. METHODS: 504 persons of the Austrian general population completed the GDS-15. Using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) ICD-10 diagnoses were established. Receiver Operating Characteristics (ROC) analysis was conducted. Possible gender and age differences were explored. RESULTS: The overall discrimination of the GDS-15 was sufficient (ROC-AUC 0,851). The cut-off value developed on the basis of our sample was 2/3 with a sensitivity of 71.8 % und a specificity of 82.8 %. We could not find significant gender or age group differences. CONCLUSION: This is the first study investigating the criterion validity of the German language GDS-15 in the adult general population. The sensitivity and specificity are sufficient and comparable with the findings among other screening tools.

Somatic complaints in children and adolescents with social anxiety disorder.

BACKGROUND: Associations of social anxiety disorder (SAD) with various somatic symptoms have been already reported in the literature several times. The present study investigated somatic complaints in children and adolescents with SAD compared to controls and evaluated the relationship between social anxiety and somatic symptom severity. METHODS: Thirty children and adolescents with SAD were compared with 36 healthy age-matched controls. Self-reported fears were assessed using the Phobiefragebogen für Kinder und Jugendliche (PHOKI); emotional and behavioral problems were assessed using the Child Behavior Checklist (CBCL/4-18); and the Gießener Beschwerdebogen für Kinder und Jugendliche (GBB-KJ) was used to assess 59 somatic symptoms. RESULTS: Parents and youth with SAD reported higher somatic symptom severity compared to controls. Youth with SAD more frequently reported stomach pain, circulatory complaints, and fatigue than controls. Specific group differences between SAD and control youth were found for the following single somatic symptoms: faintness, quickly exhausted, sensation of heat, stomachache, nausea, dizziness, and sudden heart complaints. Parents of girls with SAD reported higher somatic symptom severity than parents of boys with SAD. CONCLUSIONS: The results demonstrated a significant positive association between somatic symptoms and social anxiety in youth. The results of the present study can help to develop improved screening measurements, which increase the proportion of children and adolescents with SAD receiving proper treatment.

Assessing the dimensionality of the CES-D using multi-dimensional multi-level Rasch models.

OBJECTIVES: The CES-D is a widely used depression screening instrument. While numerous studies have analysed its psychometric properties using exploratory and various kinds of confirmatory factor analyses, only few studies used Rasch models and none a multidimensional one. METHODS: The present study applies a multidimensional Rasch model using a sample of 518 respondents representative for the Austrian general population aged 18 to 65. A one-dimensional model, a four-dimensional model reflecting the subscale structure suggested by [1], and a four-dimensional model with the background variables gender and age were applied. RESULTS: While the one-dimensional model showed relatively good fit, the four-dimensional model fitted much better. EAP reliability indices were generally satisfying and the latent correlations varied between 0.31 and 0.88. In the analysis involving background variables, we found a limited effect of the participants' gender. DIF effects were found unveiling some peculiarities. The two-items subscale Interpersonal Difficulties showed severe weaknesses and the Positive Affect subscale with the reversed item wordings also showed unexpected results. CONCLUSIONS: While a one-dimensional over-all score might still contain helpful information, the differentiation according to the latent dimension is strongly preferable. Altogether, the CES-D can be recommended as a screening instrument, however, some modifications seem indicated.

[Criterion Validity of the German Version of the CES-D in the General Population]. / Kriteriumsvalidität der deutschsprachigen Version der CES-D in der Allgemeinbevölkerung.

OBJECTIVE: The "Center of Epidemiologic Studies - Depression scale" (CES-D) is a well-known screening tool for depression. Until now the criterion validity of the German version of the CES-D was not investigated in a sample of the adult general population. METHODS: 508 study participants of the Austrian general population completed the CES-D. ICD-10 diagnoses were established by using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Receiver Operating Characteristics (ROC) analysis was conducted. Possible gender differences were explored. RESULTS: Overall discriminating performance of the CES-D was sufficient (ROC-AUC 0,836). Using the traditional cut-off values of 15/16 and 21/22 respectively the sensitivity was 43.2 % and 32.4 %, respectively. The cut-off value developed on the basis of our sample was 9/10 with a sensitivity of 81.1 % und a specificity of 74.3 %. There were no significant gender differences. CONCLUSION: This is the first study investigating the criterion validity of the German version of the CES-D in the general population. The optimal cut-off values yielded sufficient sensitivity and specificity, comparable to the values of other screening tools.

['Barbie Doll Syndrome'. A case report of body dysmorphic disorder]. / "Das Barbie Syndrom". Ein Fallbericht über die Körperdysmorphe Störung.

BACKGROUND: This case report aims to present a 37-year-old women striving to shape her body like a Barbie doll of which she has been fascinated since childhood. She could hardly tolerate any deviation from this beauty ideal. She has been admitted to the psychosomatic ward due to an eating disorder. METHODS: The ICD-10 and DSM-5 criteria were established for axis I disorders and the German version of the SCID II interview (for DSM-4) was applied for axis II disorders. Additionally, the "modified Yale-Brown Obsessive Compulsive Scale for body dysmorphic disorder" was carried out. RESULTS: The diagnosis of dysmorphophobia (ICD-10: F45.21) or body dysmorphic disorder (DSM-5: 300.7) and bulimia nervosa (ICD-10: F50.2; DSM-5: 307.51) was confirmed. The patient fulfilled criteria of an avoidant, depressive and histrionic personality disorder. Psychopharmacological treatment with Fluoxetine was started and the patient participated in an intensive inpatient psychosomatic program. The body image, self-concept and the sense of shame were therapeutic key topics. CONCLUSION: The present case report focuses on body dysmorphic disorder as a distinctive entity with high prevalence. Diagnostic criteria of different classification systems were contrasted and comorbidity with eating disorders was discussed. In clinical praxis, body dysmorphic disorder remains underdiagnosed, especially when cooccurring with an eating disorder. However, the correct diagnosis could be relevant for therapy planning.

Development of a clinical version of the Carers' Needs Assessment for Schizophrenia.

OBJECTIVE: Based on the research version of the Carers' Needs Assessment for Schizophrenia (CNA-S) a shortened clinical version was developed for routine assessment of interventions needed by the caregivers of schizophrenia patients in everyday clinical work. METHODS: The development of this questionnaire (including a manual explaining its use) was based on results from earlier studies and suggestions from Austrian researchers involved in previous studies using the research version. Based on discussions with researchers the questionnaire and the manual were improved step by step. A clinical test version was investigated for feasibility and practicability in two waves of 15 caregivers of schizophrenia patients each. RESULTS: More than 90% of caregivers perceived the clinical version of the CNA-S as a useful instrument to assess all relevant aspects of caregivers' needs and problems. They reported feeling well during the interview for the CNA-S. Clinicians using the clinical version of the CNA-S reported similar views. CONCLUSION: These results suggest that the clinical version of the CNA-S is both feasible and practicable in everyday clinical work.

The importance of statistical modelling in clinical research : Comparing multidimensional Rasch-, structural equation and linear regression models for analyzing the depression of relatives of psychiatric patients.

BACKGROUND: Various studies have shown that caregiving relatives of schizophrenic patients are at risk of suffering from depression. These studies differ with respect to the applied statistical methods, which could influence the findings. Therefore, the present study analyzes to which extent different methods may cause differing results. METHODS: The present study contrasts by means of one data set the results of three different modelling approaches, Rasch Modelling (RM), Structural Equation Modelling (SEM), and Linear Regression Modelling (LRM). RESULTS: The results of the three models varied considerably, reflecting the different assumptions of the respective models. CONCLUSIONS: Latent trait models (i. e., RM and SEM) generally provide more convincing results by correcting for measurement error and the RM specifically proves superior for it treats ordered categorical data most adequately.

[Projections about the future number of dementia sufferers: increasing life expectancy not sufficiently considered?].

BACKGROUND: Several authors pointed out that in the next decades dementia will affect a considerably increasing number of the elderly. The question was raised if life-expectancy was projected to conservative, resulting in revisions with higher life-expectancy and larger numbers of the oldest population. The present paper analyses the influence of such revisions on the future numbers of dementia sufferers in Austria. SUBJECTS AND METHODS: For this purpose we used meta-analyses of epidemiological studies and the population projections for the period until 2050 of the Austrian Bureau of Statistics as well as of the United Nations Population Division of the year 2001 as well of the year 2005. RESULTS: Using the extrapolations of the Austrian Bureau of Statistics of the year 1999 as well as of the United Nations Population Division of the year 2001, the number of dementia cases in Austria in the year 2050 will rise to about 233 thousands. According to the four years later performed extrapolations of the United Nations Population Division of the year 2005, dementia cases in Austria will raise to about 262 thousands in the year 2050. CONCLUSIONS: In the next decades, the number of persons suffering from dementia will rise considerably. Increasing life-expectancy will result in markedly higher numbers of persons with dementia than estimated from earlier population projections. Nevertheless, this is the first analysis of future dementia cases based on projections from two different dates, but using the same source. We must conclude that the dramatically increasing number of dementia cases requires comprehensive planning of the health and social care system.

Using Rasch-models to compare the 30-, 20-, and 12-items version of the general health questionnaire taking four recoding schemes into account.

BACKGROUND: The present study compares the 30-, 20-, and 12-items versions of the General Health Questionnaire (GHQ) in the original coding and four different recoding schemes (Bimodal, Chronic, Modified Likert and a newly proposed Modified Chronic) with respect to their psychometric qualities. METHODS: The dichotomized versions (i.e. Bimodal, Chronic and Modified Chronic) were evaluated with the Rasch-Model and the polytomous original version and the Modified Likert version were evaluated with the Partial Credit Model. RESULTS: In general, the versions under consideration showed agreement with the model assumption. However, the recoded versions exhibited some deficits with respect to the Outfit index. CONCLUSIONS: Because of the item deficits and for theoretical reasons we argue in favor of using the any of the three length versions with the original four-categorical coding scheme. Nevertheless, any of the versions appears apt for clinical use from a psychometric perspective.

Insulin glargine dosing before next-day surgery: comparing three strategies.

STUDY OBJECTIVE: To evaluate three evening insulin glargine dosing strategies for achievement of target (100-179 mg/dL; 5.5 - 9.8 mmol/L) and widened (80-249 mg/dL; 4.4 - 13.7 mmol/L) preoperative fasting blood glucose (FBG) ranges on the day of surgery. DESIGN: Prospective, randomized, open trial. SETTING: Preoperative units at two sites of a suburban hospital system. PATIENTS: 401 adult, ASA physical status 3 and 4 patients with type 1 and type 2 diabetes, undergoing elective noncardiac surgery. INTERVENTIONS: Patients were divided into two groups according to absence of daily rapid-acting/short-acting insulin (insulin glargine-only group) or presence of daily rapid-acting/short-acting insulin (insulin glargine plus bolus group). Subjects were then randomized to three evening insulin glargine dosing strategies: (a) take 80% of usual dose, (b) call physician for dose, or (c) refer to dosing table, based on self-reported usual FBG and insulin regimen. In the prehospital setting, patients administered the instructed insulin glargine dose on the evening before surgery. MEASUREMENTS: Venous blood glucose values were recorded in the preoperative holding area on the day of surgery. MAIN RESULTS: No significant differences in target preoperative FBG achievement were detected among strategies in the insulin glargine-only group (n = 174) or the insulin glargine plus bolus group (n = 227). In widened preoperative FBG achievement, no significant difference was noted among strategies in the insulin glargine-only group. In the insulin glargine plus bolus group, fewer subjects following the dosing table had FBG > 249 mg/dL (> 13.7 mmol/L; P = 0.031). CONCLUSIONS: Target preoperative FBG achievement was similar among strategies in both insulin glargine groups. An insulin glargine adjustment strategy based on usual glycemic control may better prevent severe preoperative hyperglycemia in patients receiving basal/bolus regimens.

Systematic review of surgical treatments for benign prostatic hyperplasia and presentation of an approach to investigate therapeutic equivalence (non-inferiority).

OBJECTIVE: • To assess the potential additional benefit of non-standard vs standard surgical treatments for benign prostatic hyperplasia (BPH) and to present a new methodological approach to investigate therapeutic equivalence (non-inferiority) regarding symptom reduction. PATIENTS AND METHODS: • We conducted a systematic review and searched MEDLINE, Embase and the Cochrane Library (last search: 10/2009) for randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs). • Eligible studies were those that included patients with symptomatic BPH requiring surgical treatment and which compared non-standard procedures (e.g. minimally invasive technologies) with standard ones (e.g. transurethral resection of the prostate, TURP). In addition, only studies analysing patient-relevant outcomes were considered (e.g. irritative and obstructive symptoms, length of hospital stay, quality of life and adverse events). • The main outcome of interest for the present analysis was superiority or non-inferiority for symptom reduction. • As no trial investigated non-inferiority, we defined a non-inferiority threshold (0.25 standard deviation) on the basis of published literature. If a non-standard procedure showed non-inferiority for symptom reduction, additional outcomes were assessed. Meta-analyses were conducted if feasible and meaningful. RESULTS: • In all, 43 mainly low-quality trials (RCTs only) compared nine non-standard surgical treatments with standard ones. • Mean follow-up ranged from 6 to 84 months. • No non-standard procedure was superior for symptom reduction. Non-inferiority for symptom reduction was shown in patients who had undergone holmium laser resection of the prostate (HoLRP) or thulium laser resection of the prostate (TmLRP). • As procedural advantages (e.g. no occurrence of transurethral resection syndrome) and other advantages (e.g. shortened hospital stay) were found, an indication of an additional benefit of HoLRP and TmLRP was determined. CONCLUSIONS: • No proof of superiority for symptom reduction has been shown for non-standard surgical treatments in patients with BPH. • There is a lack of high-quality RCTs and trials designed to investigate non-inferiority. • Future studies should define a non-inferiority threshold (ideally, uniform) a priori, so that results of individual studies are interpretable and comparable, and future systematic reviews should consider this issue.

Effect of guideline orientation on the outcomes of peripheral arterial disease in primary care.

OBJECTIVE: Peripheral arterial disease (PAD), an established marker of premature death and cardiovascular risk in general, is highly prevalent. We analysed factors associated with poor outcomes in an observational cohort, with particular focus on the effect of guideline orientation in the management of these patients. METHODS: PACE-PAD is a multicentre, prospective, observational study of PAD patients in primary care. PAD guideline orientation was stated, if patients received the following: exercise training, (if applicable) advice for smoking cessation and diet, therapy for diabetes mellitus, hypertension, hypercholesterolaemia, or antiplatelets/anticoagulants. Multivariate regression models were applied to assess factors associated with all cause death, cardiovascular/cerebrovascular death, or cardiovascular/cerebrovascular/peripheral vascular non-fatal events. RESULTS: After an 18-month follow-up, of the 5099 PAD patients analysed (mean age 68.0 ± 9.0 years, 68.5% males), only 28.4% of patients met all applicable quality indicators for guideline-oriented treatment. However, most patients were to a large extent managed in line with guidelines. While exercise training was reported in 41.8%, rates were very high for smoking cessation (90.7%), therapy for hypertension (92.5%), diabetes mellitus (82.0%), hypercholesterolemia (83.3%) and antiplatelet therapy (86.7%). Regarding events, there were inhomogeneous results with a statistically significant higher rate of cardiovascular/cerebrovascular deaths and all-cause deaths, but a lower rate of non-fatal vascular events in patients treated according to guidelines compared to those who were not. Limitations of this study include the open, non-controlled design, possible patient selection bias and misclassification of events. CONCLUSION: Even if the guideline orientation for the various indicators was remarkably stable across the three follow-up visits, the rate of patients comprehensively treated according to the guidelines was relatively low, which calls for optimisation. There was a lack of differentiation between the guideline-oriented and non-guideline-oriented therapy in terms of outcomes, which may be due to patient-related or other factors, and warrants further research.