Physician resilience and perceived quality of care among medical doctors with training in psychosomatic medicine during the COVID-19 pandemic: a quantitative and qualitative analysis.

BACKGROUND: At an individual level, physician resilience protects against burnout and against its known negative effects on individual physicians, patient safety, and quality of care. However, it remains uncertain whether physician resilience also correlates with maintaining a high level of healthcare quality during crises such as a pandemic. This study aimed to investigate whether higher resilience among physicians, who had received training in resilience-related competences in the past, would be associated with higher quality of care delivered during the COVID-19 pandemic. METHODS: This study enrolled physicians working in family medicine, psychiatry, internal medicine, and other medical specialties, who had obtained at least one of three consecutive diplomas in psychosomatic medicine in the past. Participants completed a quantitative and qualitative anonymous online survey. Resilience was measured using the Connor-Davidson Resilience Scale, and healthcare quality was assessed through single-item quality indicators, including perceived quality of care, professional autonomy, adequate time for patient care, and job satisfaction. RESULTS: The study included 229 physicians (70 males/159 females) with additional training in psychosomatic medicine, working in family medicine (42.5%), psychiatry (28.1%), internal medicine (7.0%), or other medical specialties (22.4%). Participants represented four intensity levels of training background (level 1 to level 4: 9.2%, 32.3%, 46.3%, and 12.2% of participants). Training background in psychosomatic medicine was positively associated with resilience (B = 0.08, SE = 0.04, p <.05). Resilience and training background independently predicted perceived quality of care, even after controlling for variables such as own health concerns, involvement in the treatment of COVID-19 patients, financial strain, percentage of working hours spent on patient care, age, and gender (resilience: B = 0.33, SE = 0.12, p <.01; training background: B = 0.17, SE = 0.07, p <.05). Both resilience and training background predicted job satisfaction (resilience: B = 0.42, SE = 0.12, p <.001; training background: B = 0.18, SE = 0.07, p <.05), while resilience alone predicted professional autonomy (B = 0.27, SE = 0.12, p <.05). In response to an open question about their resources, resilient physicians more frequently reported applying conscious resilient skills/emotion regulation (p <.05) and personal coping strategies (p <.01) compared to less resilient medical doctors. CONCLUSION: Physician resilience appears to play a significant role in the perceived quality of patient care, professional autonomy, and job satisfaction during healthcare crises.

Determinants of workload-related clinician stress levels in general hospital consultation liaison psychiatry services during the COVID-19 pandemic in England and Ireland. Short report.

OBJECTIVE: To explore workload-related stress levels experienced by consultation liaison psychiatry (CLP) staff in England and Ireland, and factors relevant to such a burden, during the COVID-19 pandemic. METHODS: Data were obtained for England and Ireland from a European survey among CLP services in general hospitals spread via CLP networks (11th June - 3rd October 2021). The heads of respective CLP services in general hospitals responded on behalf of each service, on 100 CLP hospital staff in total. DEPENDENT VARIABLE: workload-related stress levels in CLP services due to COVID-19 (0-10 point scale). INDEPENDENT VARIABLES: hospital size, CLP service size, degree of hospital involvement in COVID-19-related care, and the number of support options available to hospital staff. Spearman's rho correlation analyses were performed. RESULTS: There was a significant association between the hospital's involvement in COVID-19-related care and workload-related stress levels as reported by CLP staff: r(22) = 0.41, p = 0.045, R2 = 0.17. There were no significant associations between workload-related stress levels and other variables including staff support (p = 0.74). CONCLUSION: Our findings suggest that perceived workload-related stress levels of CLP staff during the COVID-19 pandemic can be an indicator of COVID-19 involvement of the hospitals. Staff support seemed not to alleviate work stress in the context of the pandemic. Healthcare policies should improve working conditions for CLP hospital staff that play an essential role from a population health perspective. Rigorous measures may be needed to ensure mental healthcare provision remains tenable and sustainable in the long term.

COVID-19-related consultation-liaison (CL) mental health services in general hospitals: A perspective from Europe and beyond.

OBJECTIVE: The COVID-19 pandemic posed new challenges for integrated health care worldwide. Our study aimed to describe newly implemented structures and procedures of psychosocial consultation and liaison (CL) services in Europe and beyond, and to highlight emerging needs for co-operation. METHODS: Cross-sectional online survey from June to October 2021, using a self-developed 25-item questionnaire in four language versions (English, French, Italian, German). Dissemination was via national professional societies, working groups, and heads of CL services. RESULTS: Of the participating 259 CL services from Europe, Iran, and parts of Canada, 222 reported COVID-19 related psychosocial care (COVID-psyCare) in their hospital. Among these, 86.5% indicated that specific COVID-psyCare co-operation structures had been established. 50.8% provided specific COVID-psyCare for patients, 38.2% for relatives, and 77.0% for staff. Over half of the time resources were invested for patients. About a quarter of the time was used for staff, and these interventions, typically associated with the liaison function of CL services, were reported as most useful. Concerning emerging needs, 58.1% of the CL services providing COVID-psyCare expressed wishes for mutual information exchange and support, and 64.0% suggested specific changes or improvements that they considered essential for the future. CONCLUSION: Over 80% of participating CL services established specific structures to provide COVID-psyCare for patients, their relatives, or staff. Mostly, resources were committed to patient care and specific interventions were largely implemented for staff support. Future development of COVID-psyCare warrants intensified intra- and inter-institutional exchange and co-operation.

The Dimensionality of the Brief COPE Before and During the COVID-19 Pandemic.

The Brief COPE (Coping Orientation to Problems Experienced) is a frequently used questionnaire assessing 14 theoretically derived coping mechanisms, but psychometric research has suggested inconsistent results concerning its factor structure. The aim of this study was to investigate primary and secondary order factor structures of the Brief COPE during the COVID-19 pandemic by testing 11 different models by confirmatory factor analyses and to assess differences between sex, age groups, and relationship status. Altogether, 529 respondents from Austria and Germany participated in a web-based survey. Results supported the originally hypothesized 14-factor structure but did not support previously described higher-order structures. However, bass-ackwards analyses suggested systematic overlap between different factors, which might have contributed to different factor solutions in previous research. Measurement invariance across sex, age groups, and relationship status could be confirmed. Findings suggest that cultural and situational aspects as well as the functional level should be considered in research on theoretical framing of coping behavior.

COVID-19-Related Psychosocial Care in General Hospitals: Results of an Online Survey of Psychosomatic, Psychiatric, and Psychological Consultation and Liaison Services in Germany, Austria, and Switzerland.

Background: The coronavirus disease 2019 (COVID-19) pandemic was accompanied by new challenges for psychosocial health care to enable the support of affected patients, their families, and staff in general hospitals. In this study, we aimed to describe the structures and procedures put in place by psychosomatic, psychiatric, and psychological consultation and liaison (CL) services in German, Austrian, and Swiss general hospitals, and to elucidate the emerging needs for cooperation, networking, and improvement. Methods: We conducted a cross-sectional online survey between December 2020 and May 2021, using a 25-item questionnaire derived from relevant literature, professional experience, and consultation with the participating professional societies. The survey was disseminated via national professional societies, relevant working and interest groups, and heads of the above-mentioned CL services. Results: We included responses from 98 CL services in the analyses, with a total response rate of 55% of surveyed hospital CL services; 52 responses originated from Germany, 20 from Austria, and 26 from Switzerland. A total of 77 (79%) of the 98 responding CL services reported that "COVID-19-related psychosocial care" (COVID-psyCare) was provided in their hospital. Among these, 47 CL services (61%) indicated that specific cooperation structures for COVID-psyCare had been established within the hospital. A total of 26 CL services (34%) reported providing specific COVID-psyCare for patients, 19 (25%) for relatives, and 46 (60%) for staff, with 61, 12, and 27% of time resources invested for these target groups, respectively. Regarding emerging needs, 37 (48%) CL services expressed wishes for mutual exchange and support regarding COVID-psyCare, and 39 (51%) suggested future changes or improvements that they considered essential. Conclusion: More than three-quarters of the participating CL services provided COVID-psyCare for patients, their relatives, or staff. The high prevalence of COVID-psyCare services targeting hospital staff emphasizes the liaison function of CL services and indicates the increased psychosocial strain on health care personnel during the COVID-19 pandemic. Future development of COVID-psyCare warrants intensified intra- and interinstitutional exchange and support. Trial Registration: ClinicalTrials.gov NCT04753242, version 11 February 2021.

Development of a visual tool to assess six dimensions of health and its validation in patients with endocrine disorders.

BACKGROUND: Psychosocial factors significantly influence patient care in many fields of medicine, among these in the field of endocrinology. Easily applicable validated assessment tools for such psychosocial factors are lacking. Visual instruments may facilitate doctor-patient communication. This study describes the development and validation of a multidimensional visual tool for the self-assessment of health. METHODS: An expert panel performed the multistep development of the psychosomatic assessment health disc (PAHD). Assessment of face validity was performed by means of a focus group of medical doctors (n = 6) and patient interviews (n = 24). For determining test-retest reliability, internal consistency and construct validity, patients of an endocrine outpatient clinic in Graz, Austria, completed the PAHD and the following questionnaires: short-form 36 health survey, work ability index, Pittsburgh sleep quality index and the social life scales of the life satisfaction questionnaire. RESULTS: A numeric six-item analogue scale was developed in the form of a disc. It addresses the following aspects of health: physical well-being, social life, sexuality, mental well-being, sleep, working ability/performance. For the validation process, 177 patients (57.1% females) participated in the study. Correlation coefficients of the six items with other questionnaires ranged between r = 0.51 (social life) and r = 0.72 (sleep). Test-retest reliability was assessed among 98 patients and was ≥ 0.74 for all 6 items, while Cronbach's alpha was 0.78. CONCLUSION: The psychometric properties of the PAHD support its use in clinical encounters with patients suffering from endocrine disorders. Further validation studies may be required to extend its application to other fields of medicine.

Interpreting physical sensations to guide health-related behavior : An introductory review on psychosomatic competence.

From a biopsychosocial perspective, maintaining health requires sufficient autoregulatory and self-regulatory capacity to both regulate somatic physiology and manage human-environment interactions. Increasing evidence from neuroscientific and psychological research suggests a functional link between so called interoceptive awareness and self-regulatory behavior. Self-regulation can, again, influence autoregulatory patterns as it is known from biofeedback training or meditation practices. In this review, we propose the psychosomatic competence model that provides a novel framework for the interrelation between interoceptive and self-regulatiory skills and health behavior. The term psychosomatic competence refers to a set of mind- and body-related abilities which foster an adequate interpretation of interoceptive signals to drive health-related behavior and physical well-being. Current related empirical findings and future directions of research on interoception and self-regulation are discussed.

Interoceptive awareness and self-regulation contribute to psychosomatic competence as measured by a new inventory.

BACKGROUND: The interrelation of interoception, cognitive appraisal of bodily signals and conscious self-regulatory behavior is insufficiently understood although it may be relevant for health and disease. Therefore, it was intended to develop a novel self-report measure targeting this link. METHODS: Item development was theoretically based on the multidimensional conceptual framework of the psychosomatic intelligence hypothesis and included an iterative process of refinement of items. In a preliminary test a principal components analysis (PROMAX rotation) and item analysis were calculated for item reduction. In the field test an item response theory approach was used for development of final scales and items. For validation purposes, associations with established measures of related constructs were analyzed. RESULTS: The final 44-item questionnaire consisted of 6 interrelated scales: (1) interoceptive awareness, (2) mentalization, (3) body-related cognitive congruence, (4) body-related health literacy, (5) general self-regulation, and (6) stress experience and stress regulation. Psychometric properties of this instrument demonstrated good model fit, internal consistency and construct validity. According to the validation, the final instrument measures a form of competence rather than intelligence and was termed the psychosomatic competence inventory. CONCLUSION: Interoceptive awareness and conscious body-related self-regulation seem to jointly contribute to a basic competence which may serve homeostatic/allostatic control; however, further research is needed to confirm the reported preliminary findings in a large-scale test.

COVID-19 Pandemic Stress-Induced Somatization in Transplant Waiting List Patients.

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in widespread socioeconomic restrictions including quarantine, social distancing and self-isolation. This is the first study investigating the psychological impact of the pandemic on patients waiting for liver or kidney transplantation, a particularly vulnerable group. Methods: Twenty-seven patients on the transplantation waiting list and 43 healthy controls took part in an online survey including the Beck Depression Inventory (BDI-2), the Brief Symptom Inventory-18 (BSI-18), the Pittsburgh Sleep Quality Index (PSQI), the Alcohol Use Identification Test (AUDIT-C), the 12-item Operationalized Psychodynamic Diagnosis Structure Questionnaire (OPD-SQS) and a questionnaire to determine cognitions and beliefs, attitude and fear related to COVID-19. Results: BSI-18 Somatization was increased in waiting list patients compared to controls. Correlation analyses indicated a relationship between Somatization and the fear of contracting the coronavirus in the patient group; however this association was weak. In patients and controls, other psychologicial symptoms (depression, anxiety) correlated highly with emotional distress due to social distancing. There were no differences between patients and controls in depression scores and sleep disturbances. Alcohol consumption and personality structure were not related to COVID-19 fears. Conclusion: In times of the first lockdown during the COVID-19 pandemic, patients on the transplantation waiting list have high somatization symptoms associated with COVID-19 fears. As vulnerable group, they need psychological counseling to improve mental well-being during times of crisis.

Health-related quality of life, workability, and return to work of patients after liver transplantation.

BACKGROUND: Health-related quality of life (HrQoL) and workability are related parameters to measure success of therapy. Both have been insufficiently explored in patients after liver transplantation (LT). Particularly little is known about patients' attitude to return to work, employment status before LT, and how frequently there is any employment at any time after LT. METHODS: This is a single-center retrospective cohort study including 150 adult outpatients after LT. Liver transplantations had been performed between 1993 and 2018. The study was carried out from February to July 2018. The exclusion criteria were combined transplantations, positive screening for current alcohol abuse, and anxiety or depression. To evaluate HrQoL and fitness to work, the patients were tested using the Short Form 36, the Chronic Liver Disease Questionnaire, and the Work Ability Index. KEY RESULTS: The return rate of sufficiently filled-in questionnaires was 46.8% (66 patients). The mean age of patients was 59.9 years (SD=10.8), ranging from 25 to 78 years old. HrQoL was partly comparable to the normal population. Workability sum scores with a mean value of 31.61 (SD 9.79) suggested moderate workability at present. While only 28.8% of respondents were ever employed after LT, 45.5% currently wished to work or would have wished to work. CONCLUSIONS: HRQL seems to be partly similar to population data, and subjective workability seems to be moderate in patients after LT. Despite a positive attitude to return to work in almost half of respondents, a lower rate of actual return to work was found in this study.

Association of fibroblast growth factor 21 with alcohol consumption and alcohol liver cirrhosis.

BACKGROUND: Fibroblast growth factor 21 (FGF21) is produced in the liver and binds to different complex receptor/coreceptor systems. Besides many other processes, FGF21 regulates the intake of simple sugars and alcohol. Increased levels of FGF21 decrease harmful alcohol intake in mice. To increase our understanding on the relationship between FGF21 and alcohol intake in humans, we aimed to measure FGF21 levels in patients with alcoholic liver cirrhosis (ALC) in comparison to patients with nonalcoholic liver cirrhosis (NALC) and healthy persons based on their present alcohol consumption. METHODS: Alcohol intake was verified by urinary ethyl glucuronide (uETG) levels, eating and drinking behaviour by a Food Frequency Questionnaire and FGF 21 plasma levels were determined by ELISA in 96 persons (ALC n = 41; NALC n = 34; healthy n = 21). RESULTS: Both ALC and NALC patients with elevated ETG levels (≥0.5 µg/ml; indicating alcohol consumption in the last 12-72 h) showed significantly higher FGF21 plasma levels in comparison to patients with negative ETG levels. Eating behaviour did not have an impact on FGF21 plasma levels. CONCLUSIONS: Increased FGF21 levels in patients with recent alcohol consumption (verified by ETG) confirmed the first part of the liver-brain endocrine axis: alcohol consumption was associated with increased FGF21 levels. We could not confirm that elevated FGF21 levels were associated with reduced alcohol intake as a result. That points towards a pathology in this pathway, which might be caused by a malfunction of ß­Klotho or FGF receptors according to other studies and chronic alcohol dependency. Further research is required to clarify these pathologies, which may open new pharmacological treatment for patients with alcohol use disorder and alcohol dependence.

Association of allostatic load with health-related quality of life in patients with arterial hypertension: a cross-sectional analysis.

AIMS OF THE STUDY: Allostatic load (AL), as a marker of cumulative stress, is associated with higher morbidity and mortality, and reduced health-related quality of life (HrQoL) in healthy adults. In patients with hypertension, AL and its association with HrQoL have not been investigated. Therefore, this study aimed to (1) explore AL in a cohort of hypertensive patients and to (2) determine its association with HrQoL, while controlling for other health-related variables. METHODS: Cross-sectional data from the Styrian Hypertension Study were analysed and included 126 participants (50% female) with a history of arterial hypertension; the mean age was 60.9 years (standard deviation 9.9). AL was derived from a set of 10 biomarkers including neurophysiological, neuroendocrine, metabolic, cardiovascular and inflammatory parameters. The 36-Item Short Form Health Survey (SF-36) was administered for assessment of HrQoL. Additional health-related variables included sociodemographic data, lifestyle factors and comorbidities. RESULTS: Calculation of AL resulted in sum scores based on 10 binary variables, which were used to categorise patients as either “low AL” (<3) or “high AL” (≥3). Multivariate adjusted analyses revealed that higher AL was associated with better HrQoL with regard to the mental health domain F(1,1243) = 7.017; p = 0.009). All other components of HrQoL were not related to AL. CONCLUSIONS: In contrast to results in healthy populations, we found a positive association between AL and the mental health domain of HrQoL. This finding suggests a specific coping pattern among a subgroup of hypertensive patients, possibly influencing their clinical management and outcome.

Combining walking and relaxation for stress reduction-A randomized cross-over trial in healthy adults.

Both physical activity and relaxation have stress-relieving potential. This study investigates their combined impact on the relaxation response while considering participants' initial stress level. In a randomized cross-over trial, 81 healthy adults completed 4 types of short-term interventions for stress reduction, each lasting for 1 hr: (1) physical activity (walking) combined with resting, (2) walking combined with balneotherapy, (3) combined resting and balneotherapy, and (4) resting only. Saliva cortisol, blood pressure, state of mood, and relaxation were measured preintervention and postintervention. Stress levels were determined by validated questionnaires. All interventions were associated with relaxation responses in the variables saliva cortisol, blood pressure, state of mood, and subjective relaxation. No significant differences were found regarding the reduction of salivary cortisol (F = 1.30; p = .281). The systolic blood pressure was reduced best when walking was combined with balneotherapy or resting (F = 7.34; p < .001). Participants with high stress levels (n = 25) felt more alert after interventions including balneotherapy, whereas they reported an increase of tiredness when walking was combined with resting (F = 3.20; p = .044). Results suggest that combining physical activity and relaxation (resting or balneotherapy) is an advantageous short-term strategy for stress reduction as systolic blood pressure is reduced best while similar levels of relaxation can be obtained.

Tako-tsubo cardiomyopathy and post-traumatic stress disorder after a skiing accident: a case report.

BACKGROUND: Symptoms of a post-traumatic stress disorder can follow Tako-tsubo cardiomyopathy. This vignette describes such a linkage and exemplifies the risk that these symptoms may remain undetected. CASE PRESENTATION: After a skiing accident that had evoked existential fear of suffocation, a post-menopausal woman was diagnosed with Tako-tsubo syndrome and myocardial contusion. Symptoms of post-traumatic stress disorder appeared 2 weeks after remission of the cardiomyopathy. Two months later, a psychological assessment was conducted during cardiac rehabilitation. A post-traumatic stress disorder was diagnosed and successfully treated by narrative exposure. CONCLUSION: This case report suggests that these patients should be informed during the initial hospital stay that post-traumatic stress symptoms could appear. It also suggests including a screening for post-traumatic stress disorder in the follow-up of these patients.

Stress-relieving effects of short-term balneotherapy - a randomized controlled pilot study in healthy adults.

BACKGROUND: Stress-relieving effects of balneotherapy compared to progressive muscle relaxation (PMR) and to resting were investigated by measuring subjective relaxation and salivary cortisol. It was also examined whether participants with a high versus low stress level would have a different relaxation response. METHODS: A sample of healthy volunteers was randomized to balneotherapy, PMR, or a resting control group, each intervention lasting for 25 min. Pre- and post-intervention salivary cortisol samples were collected, and participants rated their status of relaxation on a quantitative scale. In addition, 3 questionnaires were applied to detect participants' stress level and bodily complaints. RESULTS: 49 healthy participants were recruited (65.3% female). In a pre-post comparison, salivary cortisol decreased (F = 23.53, p < 0.001) and subjective relaxation ratings increased (F = 132.18, p < 0.001) in all 3 groups. Study participants in the balneotherapy group rated themselves as more relaxed after the intervention as compared to the other groups (F = 5.22, p < 0.009). Participants with a high versus low stress level differed in somatic symptoms and in morning cortisol levels, but showed a similar relaxation response. CONCLUSION: Findings suggest that compared to PMR and resting, balneotherapy seems to be more beneficial with regard to subjective relaxation effects and similarly beneficial with regard to a decrease in salivary cortisol.

[Is there adequate care for patients with psychosomatic disorders in Austria? Analysis of the need and a proposal for a model of quality assurance in Austrian psychosomatic medicine]. / Werden in Osterreich Patienten mit psychosomatischen Storungen ausreichend versorgt? Eine Bedarfserhebung mit Losungsvorschlag zur Qualitats-sicherung fur die Psychosomatische Medizin in Osterreich.

INTRODUCTION: Quality assurance in psychosomatic medicine in Austria is currently based on a voluntary continuing medical education programme in psychosocial, psychosomatic and psychotherapeutic medicine. It is questionable whether psychosomatic care can be sufficiently provided in this manner. In addition, a broadly based proposal to create a subspecialty in psychosomatic medicine in order to facilitate quality assurance, is investigated. METHODS: The necessity to reorganize psychosomatic care was explored through semi-structured qualitative interviews with experts. Data-based analyses probed the labour market of the proposed subspecialty, and the literature was reviewed to look into the cost-benefit ratio of psychosomatic treatment. RESULTS: All experts expressed a need to restructure psychosomatic care in Austria. Examples exist for psychosomatic treatment with an efficient cost-benefit relation in diverse medical settings. CONCLUSION: Establishing a subspecialty in Psychosomatic Medicine seems feasible and could contribute to increased quality assurance and the nationwide provision of psychosomatic care.

No impact of adult attachment and temperament on clinical variability in patients with clinically isolated syndrome and early multiple sclerosis.

OBJECTIVE: Attachment style and temperament could influence a stress-relapse relationship in multiple sclerosis. We therefore aimed to probe for an association of these personality-related variables with disease activity in patients with clinically isolated syndrome and early multiple sclerosis (MS). METHODS: Study participants completed following psychometric instruments: Adult Attachment Scale (AAS), Temperament and Character Inventory (TCI-125), Hospital Anxiety and Depression Scale (HADS). Clinical data encompassed the expanded disability status scale (EDSS), annualized relapse rate, disease duration and therapy. Relapses and MRI data were recorded at regular outpatient visits. RESULTS: Study participants (n=84), 38 with a clinically isolated syndrome suggestive of MS (CIS) and 46 with relapsing remitting MS (RRMS), were assessed with a low EDSS (median 2). No significant differences concerning personality-related variables were revealed by group comparisons between CIS and RRMS and within the RRMS subgroup based on clinical measures (EDSS/year; within RRMS subgroup: annualized relapse rate). However, a higher lesion load per years of disease duration within the RRMS subgroup was associated with higher values in the temperament trait harm avoidance (p<0.05). CONCLUSIONS: Although harm avoidance may be related to subclinical disease activity in early RRMS adult attachment and temperament do not seem to contribute to differences between CIS and RRMS or clinical variability in early multiple sclerosis.

Biopsychosocial health care needs at the emergency room: challenge of complexity.

BACKGROUND: In an emergency room of internal medicine, triage and treatment of patients deserve first priority. However, biopsychosocial case complexity may also affect patient health outcome but has not yet been explored in this setting. Therefore, the aims of the study are (1) to estimate prevalence rates of complex patients in the emergency room (ER), (2) to describe biopsychosocial complexity in this population and (3) to evaluate possible correlations between patient profiles regarding case complexity and further clinical treatment. METHODS: During a study period of one week, all patients of an emergency room of internal medicine who were triaged to Manchester levels three to five were invited to participate in the study. Biopsychosocial case complexity was assessed by the INTERMED method. Psychosocial interventions were evaluated based on all documented interventions and recommendations given at the emergency room and during inpatient treatment. RESULTS: Study participants consisted of 167 patients with a subgroup of 19% (n = 32) receiving subsequent inpatient-treatment at the department. High biopsychosocial case complexity was found in 12% (n = 20) of the total sample (INTERMED score >20). This finding was paralleled by a cluster analysis suggesting three clusters with one highly complex patient group of 14%. These highly complex patients differed significantly from the other clusters as they had visited the emergency room more often within the last year and lived alone more frequently. In addition, admission rates were highest in this group. During ER treatment and subsequent inpatient treatment, 21% of highly complex patients received interventions addressing psychosocial factors as compared to 6% and 7%, respectively, in the other clusters. CONCLUSIONS: A standardized screening of biopsychosocial case complexity among 'frequent utilizers' of the ER would be helpful to detect specific multidisciplinary health care needs among this particularly burdened patient group.