Isolation, Loneliness and Aloneness in the Age of Covid-19: Reflections on Clinical Experiences.

The Covid-19 pandemic brought a heightened fear of death and illness, and increased experiences of isolation, loneliness and aloneness. In this article we describe clinical experiences of psychotherapists in Argentina, the UK and Germany in order to explore how the impacts of the pandemic are variously felt and mediated by inner resources. We explore the capacity to relate internally to good experiences of infancy and a secure internal world, and the risks of loneliness, and interpersonal and intrapsychic withdrawal, that lead to vulnerability in patients and therapists. We contrast instances where psychotherapy in response to increased fears of death, infection and isolation is facilitative of change and growth, with situations where perverse, destructive or defensive relating predominate. We ask if we are witnessing and, through our therapeutic activities, contributing to the emergence of new ways of understanding the internal conflicts of this Covid-19 age, and tentatively identify some key emerging themes; the capacity for facilitative interactions and change; identifications with the powerful virus; an increase in paranoid anxieties and the potential for a more considerate, 'care-full' way of relating.

[Suicidality in older adults]. / Suizidalität im Alter.

Older people have the highest suicide risk compared to all other age groups. Expressions of no longer wanting to live are also found in a large number of older people. The reasons are usually multifactorial and sometimes go back a long way in the personal biography. Limitations resulting from physical illness, mental disorders and social problems make an important contribution. Doctors are often the contact person, even though many older people avoid direct communication in this respect. It is important to perceive and actively address indirect notes, because suicidality is also changeable in very old age. Suicide prevention includes the multimodal treatment of the physical and mental illness, including the (re)activation of resources; however, it also begins in advance, when differentiated images of old age are communicated at the societal level, social participation of older people is practised and the quality of life is maintained until the end.

Psychoanalytic understanding of the request for assisted suicide.

The legalisation of assisted dying, including euthanasia and physician assisted suicide, is increasing in countries across the world and constitutes a key contemporary debate, reflecting social changes, in which two views of suicide conflict; that (1) rational reasons justify assisted suicide, providing dignity and control of terminal illness and (2) suicidal wishes are driven by unconscious and disturbing internal conflicts. In this paper we explore the unconscious motives and meanings of requests for assisted suicide. Although there is a paucity of psychoanalytic literature on the subject, and an absence of practice examples, we make two links, firstly, with the literature of palliative and end of life care, and, secondly, with psychoanalytic understanding of suicide, in order to develop the view that unconscious factors are crucial to understanding requests for assisted suicide. We provide an illustrative case example of psychodynamic psychotherapy with a 94-year-old woman, drawing out theoretical and practice implications. We show that unconscious factors and motives lie behind apparently rational requests for assisted suicide, and attention to these through psychoanalytically informed treatment can bring about therapeutic change.

'Desire to Die' in palliative care patients-legal framework and recommendations of the national evidence-based guideline on palliative care in Germany.

BACKGROUND: Desire to die, understood as a broad phenomenon, is common in patients receiving palliative care. Euthanasia ("termination of life on request", §216 German Criminal Code) is currently forbidden in Germany, the legal restrictions with regard to assisted suicide ("assistance of suicide with intent of repeated conduct", §217 German Criminal Code) has recently been repealed by the national Federal Constitutional Court. This dynamically changing legal situation adds to health professionals reported uncertainty in dealing appropriately with a desire to die. METHODS: As part of the new extended version of the German Palliative Care Guideline for Patients with Incurable Cancer, evidence and consensus-based statements and recommendations on desire to die were developed by an interdisciplinary and multi-professional working group. The best available evidence was identified through systematic literature searches and by asking experts for further known quantitative as well as qualitative literature. Included publications were assessed as recommended by the Scottish Intercollegiate Guidelines Network (SIGN). Due to the limited availability of high-quality empirical publications related to desire to die, close attention was paid to national clinical expertise to develop recommendations. Consensus for these recommendations was reached at a conference of the guideline group consisting of elected representatives from 61 professional societies and patient associations. Each recommendation was approved by at least 75% of those present. RESULTS: The expert panel developed and agreed on 21 statements and recommendations on desire to die and related phenomena. A descriptive definition was agreed upon of desire to die as a complex phenomenon with individual causes, manifestations, and consequences. The potential background of desire to die, its meanings, functions and possible interventions are described. The guideline recommends proactively addressing and exploring a potential desire to die as the intervention that should be considered before all others, because evidence from studies on suicidality found no negative effect when asking study participants about suicidality. CONCLUSIONS: The guideline informs health professionals working within the German statutory framework, how to care for and communicate with patients who are receiving palliative care and who express a desire to die.

A systematic review of older adults' request for or attitude toward euthanasia or assisted-suicide.

OBJECTIVES: Prevalence rates of death by euthanasia (EUT) and physician-assisted suicide (PAS) have increased among older adults, and public debates on these practices are still taking place. In this context, it seemed important to conduct a systematic review of the predictors (demographic, physical health, psychological, social, quality of life, religious, or existential) associated with attitudes toward, wishes and requests for, as well as death by EUT/PAS among individuals aged 60 years and over. METHOD: The search for quantitative studies in PsycINFO and MEDLINE databases was conducted three times from February 2016 until April 2018. Articles of probable relevance (n = 327) were assessed for eligibility. Studies that only presented descriptive data (n = 306) were excluded. RESULTS: This review identified 21 studies with predictive analyses, but in only 4 did older adults face actual end-of-life decisions. Most studies (17) investigated attitudes toward EUT/PAS (9 through hypothetical scenarios). Younger age, lower religiosity, higher education, and higher socio-economic status were the most consistent predictors of endorsement of EUT/PAS. Findings were heterogeneous with regard to physical health, psychological, and social factors. Findings were difficult to compare across studies because of the variety of sample characteristics and outcomes measures. CONCLUSION: Future studies should adopt common and explicit definitions of EUT/PAS, as well as research designs (e.g. mixed longitudinal) that allow for better consideration of personal, social, and cultural factors, and their interplay, on EUT/PAS decisions.

Neurogeriatrics-a vision for improved care and research for geriatric patients with predominating neurological disabilities.

Geriatric medicine is a rapidly evolving field that addresses diagnostic, therapeutic and care aspects of older adults. Some disabilities and disorders affecting cognition (e.g. dementia), motor function (e.g. stroke, Parkinson's disease, neuropathies), mood (e.g. depression), behavior (e.g. delirium) and chronic pain disorders are particularly frequent in old subjects. As knowledge about these age-associated conditions and disabilities is steadily increasing, the integral implementation of neurogeriatric knowledge in geriatric medicine and specific neurogeriatric research is essential to develop the field. This article discusses how neurological know-how could be integrated in academic geriatric medicine to improve care of neurogeriatric patients, to foster neurogeriatric research and training concepts and to provide innovative care concepts for geriatric patients with predominant neurological conditions and disabilities.

[Survey on psychosomatic treatment options in geriatric clinical routine: state of the art]. / Umfrage zur Psychosomatik im geriatrischen Klinikalltag: eine Bestandsaufnahme.

BACKGROUND: Mental and physical disorders form a common body of experience and suffering in old age that can negatively influence aging. Experience and handling of age-associated functional impairments are challenging for multimorbid patients, their relatives and the healthcare providers involved. Among patients aged 70 years or older more than 50% suffer from psychopathological symptoms and 30-40% of geriatric inpatients have a psychosomatic or psychiatric comorbidity; however, despite this high prevalence of mental problems in older patients they are hardly ever treated and if treatment is offered it is carried out by specialists for somatic medicine. The aim of the present study of the working group on gerontopsychosomatics of the German Geriatric Society (DGG) was the evaluation of interdisciplinary co-management opportunities for geriatricians who treat inpatients with gerontopsychosomatic needs. METHOD: Online survey among members of the DGG regarding experiences with interdisciplinary co-management of inpatients with gerontopsychosomatic needs. RESULTS: The majority of the respondents were senior physicians in a department for geriatrics. While every second institution had access to a psychiatric consultation service, psychosomatic cooperation was only offered in every fifth department. Psychosomatic co-management was particularly required in connection with neurogeriatric problems. CONCLUSION: There is need of gerontopsychosomatic co-management among geriatric inpatients; however, in comparison to gerontopsychiatric co-management the options are deficient and need to be strengthened.

The effectiveness of psychoanalytic/psychodynamic psychotherapy for reducing suicide attempts and self-harm: systematic review and meta-analysis.

BACKGROUND: Preventing suicide and self-harm is a global health priority. Although there is a growing evidence base for the effectiveness of psychoanalytic and psychodynamic psychotherapies for a range of disorders, to date there has been no systematic review of its effectiveness in reducing suicidal and self-harming behaviours.AimsTo systematically review randomised controlled trials of psychoanalytic and psychodynamic psychotherapies for suicidal attempts and self-harm. METHOD: We searched PubMed, PsycINFO, Psycharticles, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials for randomise controlled trials of psychoanalytic and psychodynamic psychotherapies for reducing suicide attempts and self-harm. RESULTS: Twelve trials (17 articles) were included in the meta-analyses. Psychoanalytic and psychodynamic therapies were effective in reducing the number of patients attempting suicide (pooled odds ratio, 0.469; 95% CI 0.274-0.804). We found some evidence for significantly reduced repetition of self-harm at 6-month but not 12-month follow-up. Significant treatment effects were also found for improvements in psychosocial functioning and reduction in number of hospital admissions. CONCLUSIONS: Psychoanalytic and psychodynamic psychotherapies are indicated to be effective in reducing suicidal behaviour and to have short-term effectiveness in reducing self-harm. They can also be beneficial in improving psychosocial well-being. However, the small number of trials and moderate quality of the evidence means further high-quality trials are needed to confirm our findings and to identity which specific components of the psychotherapies are effective.Declaration of interestNone.

[Gerontopsychosomatic consultation/liaison service in inpatient acute geriatrics : Effects of trust and support on patient-nurse interaction]. / Gerontopsychosomatischer Konsil­/Liaisondienst in der stationären Akutgeriatrie : Effekte des Vertrauens und der Unterstützung auf die Patient-Pflegenden-Interaktion.

BACKGROUND: Geriatric and psychosomatic medicine follow a biopsychosocial paradigm. Despite this similar "Menschenbild" in general, collaboration between geriatrics and psychosomatics is still rare. OBJECTIVES: This comparative interventional study aims to find possible effects of psychosomatic work in geriatrics on the interaction between patients and nursing staff and contentment of patients with treatment in general. MATERIAL AND METHODS: In the period of one year 238 geriatric patients (return rate 22.2%) of the intervention ward (psychosomatic consultation-/liaison service) and the control ward (TAU) were investigated with an anonymized questionnaire. Two questions were evaluated, concerning the patients trust in the nurses and their experience of being able to speak with them about their anxieties and concerns. This is interpreted as an indicator for the advancement of patients' contentment with treatment. RESULTS: In comparison with the control ward during the intervention the answers to both questions showed an increasing trust in the nurses and an increasing experience of speaking about anxieties and concerns with the nurses. This is evaluated as some evidence for the promotion of the patients' contentment with the treatment CONCLUSION: A psychosomatic consultation-/liaison service in geriatric medicine generates a positive effect on the relationship between patients and nursing staff, especially concerning trust and acceptance in existential situations of illness and limitation in hospital.

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults.

OBJECTIVES: To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older. METHOD: Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review. RESULTS: Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed. CONCLUSION: Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.

[Psychotherapy on the domestic couch]. / Psychotherapie auf der Couch des Patienten.

Despite the high morbidity of mental disorders in old age, psychotherapy take-up, especially by multi-morbid, very old patients, is still negligible, immobility being a significant constraining factor of access. So far, variations of standard psychotherapy adapted to meet these circumstances, such as home visits providing psychotherapy are not widespread and their effectiveness unexplored. An explorative study applying the 'Grounded Theory' method examined medical letters, consultation reports and session protocols of 7 psychotherapies involving 77-89-year-old patients; it also described the setting, nature and content of the therapeutic relationship. Psychotherapy at a patient's home - compared with conventional out-patient therapy - considerably alters the therapeutic relationship in as much as an undifferentiated fullness of experience and information has to be gathered and interpreted by the therapist. Current and previous relationships, as well as the experience of disease and imminent dying are important thematic fields. Within the framework of a supportive, defence-strengthening psychodynamic psychotherapy, clarifications, interpretations, and the accompaniment of existential conflicts and developments are possible. Conflicts of identity, aggression, closeness vs. distance and power can be named. Disease, constraint, dying and death are frequent topics. The therapist is more active, enactments are possible but a reflective attitude towards the patient's inner world can be maintained. Psychodynamic psychotherapy is possible in the patient's domestic environment. Further research on indications, psychotherapeutic attitudes, strategies, techniques and effectiveness of this psychotherapy variation is necessary.

Key considerations for preventing suicide in older adults: consensus opinions of an expert panel.

BACKGROUND: The number of older adults is growing rapidly. This fact, combined with the high rates of suicide in later life, indicates that many more older adults will die by their own hands before rigorous trials can be conducted to fully understand the best approaches to prevent late life suicide. AIMS: To disseminate key considerations for interventions addressing senior suicidal behavior. METHODS: An international expert panel has reviewed and discussed key considerations for interventions against suicide in older adults based on existing evidence, where available, and expert opinion. RESULTS: A set of new key considerations is divided into: universal, selective, and indicated prevention as well as a section on general considerations. CONCLUSIONS: The suggestions span a wide range and are offered for consideration by local groups preparing new interventions, as well as large scale public health care planning.

[Psychodynamic hypothesis about suicidality in elderly men]. / Psychodynamische Hypothesen zur Suizidalität bei älteren Männern.

Old men are overrepresented in the whole of all suicides. In contrast, only very few elderly men find their way to specialised treatment facilities. Elderly accept psychotherapy more rarely than younger persons. Therefore presentations on the psychodynamics of suicidality in old men are rare and mostly casuistical. By means of a stepwise reconstructable qualitative case comparison of five randomly chosen elderly suicidal men with ideal types of suicidal (younger) men concerning biography, suicidal symptoms and transference, psychodynamic hypothesis of suicidality in elderly men are developed. All patients came into psychotherapy in a specialised academic out-patient clinic for psychodynamic treatment of acute and chronic suicidality. The five elderly suicidal men predominantly were living in long-term, conflictuous sexual relationships and also had ambivalent relationships to their children. Suicidality in old age refers to lifelong existing intrapsychic conflicts, concerning (male) identity, self-esteem and a core conflict between fusion and separation wishes. The body gets a central role in suicidal experiences, being a defensive instance modified by age and/or physical illness, which brings up to consciousness aggressive and envious impulses, but also feelings of emptiness and insecurity, which have to be warded off again by projection into the body. In transference relationships there are on the one hand the regular transference, on the other hand an age specific turned around transference, with their counter transference reactions. The chosen methodological approach serves the systematic finding of hypotheses with a higher degree in evidence than hypotheses generated from single case studies.

Adherence to medication in patients with dementia: predictors and strategies for improvement.

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence. Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons' strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants' cognitive function is rare. In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person's responsibility if cognitive decline progresses. Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients' attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient's ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient's cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.