Depression, anxiety, and health-related quality of life in normal weight, overweight and obese individuals with diabetes: a representative study in Germany.

OBJECTIVE: Diabetes in the course of lifetime is related to a higher risk for mental disorders. The present study addresses the comparison of individuals with diabetes and non-diabetic individuals in depressive symptoms, generalized anxiety symptoms, and health-related quality of life. Furthermore, mediator effect of BMI and health-related quality of life (HRQOL) on the association between diabetes, depression, and generalized anxiety was analyzed. METHODS: In this cross-sectional study, the three questionnaires PHQ-9, GAD-7, EQ-5D-5L were measured in a representative sample of the German population (N = 2386). In addition, the presence of diabetes and BMI were assessed via self-report. RESULTS: There were higher values in depressive and anxiety symptoms as well as lower score in HRQOL in individuals with diabetes compared to non-diabetic individuals. Obese individuals with diabetes showed the highest rates in depressive symptoms and generalized anxiety as well as lowest score in HRQOL. With regard to the mediator analyses, association between diabetes, depressive symptoms, and anxiety symptoms is partially mediated by the BMI and fully mediated by the HRQOL. CONCLUSIONS: In conclusion, individuals with diabetes have an increased risk in the development of depressive and anxiety symptoms as well as lower health-related quality of life. Future research and strategies in the public health policies among individuals with diabetes should take into account that the association between diabetes, depression, and anxiety is mediated by BMI and HRQOL.

Suicidal ideation in patients with diabetes and childhood abuse - The mediating role of personality functioning: Results of a German representative population-based study.

AIMS: Suicidal ideation (SID) in patients with diabetes mellitus is increasingly acknowledged. Still, the underlying mechanisms are unclear. We examined SID prevalences in patients with diabetes, its association with different types of abuse, and a mediating effect of personality functioning. METHODS: In a representative population sample (N = 2,515), diabetes, SID, abuse (ICAST-R), personality functioning (OPD-SQS), and depression/anxiety (PHQ-4) were assessed by self-report. Statistical analyses comprised Chi2-Tests, logistic regression and mediation analyses. RESULTS: The prevalence of SID (21.8 %) was three fold higher in patients with diabetes compared to the general population. Abuse further increased the likelihood to report SID in diabetes patients (sexual: 48.1 % vs. 18.2 %; χ2(1) = 12.233, p <.001; emotional: 35.7 % vs. 15.7 %; χ2(1) = 10.892, p <.001). A dose-response relationship between the number of abuse experiences and SID was observed (one abuse experience: OR = 1.138, 95 %-CI [0.433, 2.990], p =.793, >2 abuse experiences: OR = 2.693, 95 %-CI [1.278, 5.675], p =.009). Impaired personality functioning had an indirect effect on the association between emotional abuse and SID (b = 0.25, 95 %-CI [0.037, 0.551]). CONCLUSIONS: Diabetes patients experience increased SID prevalences, especially those with emotional or sexual abuse. In individuals with a history of emotional abuse, impaired personality functioning partly explained SID and should therefore be considered and addressed in this patient group.

Outpatient Psychotherapy in Germany­An Evaluation of the Structural Reform.

BACKGROUND: A structural reform of the German psychotherapy guideline in 2017 was intended to facilitate access to outpatient guideline psychotherapy. In the present study, we evaluate the effects of this reform in particular for patients a comorbidity of mental disorders and chronic physical conditions (cMP). METHODS: Pre-post analyses of the two primary endpoints "percentage of mentally ill persons who have made an initial contact with a psychotherapist" and "waiting time for guideline psychotherapy" were carried out employing population-based and weighted routine statutory health insurance data from the German BARMER. The secondary endpoints included evaluations from the patients' perspective, based on a representative survey of patients in psychotherapy, and an overview of the health care situation based on data from the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) (study registration number: DRKS00020344). RESULTS: From 2015 to 2018, the percentage of mentally ill persons who had made an initial contact with a psychotherapist rose moderately, from 3.7% (95% confidence interval, [3.6; 3.7]) to 3.9% [3.8; 3.9] among persons with cMP and from 7.3% [7.2; 7.4] to 7.6% [7.5; 7.7] among those with mental disorders but without any chronic phyisical condition (MnoP). The new structural elements were integrated into patient care. The interval of time between the initial contact and the beginning of guideline psychotherapy became longer in both groups, from a mean of 80.6 [79.4; 81.8] to 114.8 [113.4; 116.2] days among persons with complex disease and from 80.2 [79.2; 81.3] to 109.6 [108.4; 111.0] days among persons with non-complex disease; most patients considered the waiting time. Approximately 8% of the patients who sought psychotherapy reported that they had not obtained access to a psychotherapist. CONCLUSION: Neither in general nor for patients with cMP did the introduction of the structural reform appreciably lower the access barriers to psychotherapy. Further steps are needed so that outpatient care can meet the needs of all patients and particularly those with cMP.

The impact of mental health on health-related quality of life in patients with NF2-related Schwannomatosis.

NF2-related schwannomatosis (NF2-SWN) is a rare genetic disorder and is associated with progressive morbidities. This study aimed to investigate the relationship between NF2-SWN disease severity, health-related Quality of Life (QoL), and mental health aspects of patients. Standardised questionnaires assessing mental health problems (symptoms of depression, anxiety, and somatic burden), psychological factors (resilience, loneliness, and personality functioning), and health-related QoL were administered to 97 patients with NF2-SWN. The results of these questionnaires were compared with physician-rated disease severity. Questionnaires were completed by 77 patients. Physician-rated disease severity scores were available for 55 patients. NF2-SWN patients showed a high prevalence of clinically relevant symptoms of depression (30%), anxiety (16%), and somatic burden (32%). Almost all variables showed moderate to high correlations with NF2-SWN-related QoL. NF2-SWN-related QoL was associated with physician-reported disease severity (r = 0.614). In the stepwise hierarchical linear regression analysis, a significant model with four predictors (disease severity type, depression symptoms, personality functioning, and gender) explained 64% of the variance in NF2-SWN-related QoL. Our results showed a strong association between NF2-SWN-related QoL and depression symptoms. Moreover, personality functioning is an important influencing factor, representing a modifiable construct that can be targeted by prevention programs or psychotherapy.

Prospective health care costs and lost work days associated with diabetes-related distress and depression symptoms among 1488 individuals with diabetes.

The aim of this study was to investigating the impact of major depression symptoms and diabetes-related distress on future health care costs and lost workdays in individuals with diabetes. We linked survey data from a random sample of a German statutory health insurance (SHI) with diabetes (n = 1488, 63.0% male, mean age 66.9 years) with their SHI data one year after the survey. Within the survey data we identified major depression symptoms (Patient Health Questionnaire-9) and diabetes-related distress (Problem Areas in Diabetes Scale). We retrieved health care costs and lost workdays from SHI data. To assess the impact of major depression symptoms and diabetes-related distress on health care costs and lost workdays, we adjusted regression models for age, sex, education, employment status, and diabetes duration, type, and severity. Major depression symptoms were associated with significantly higher costs (by a factor of 1.49; 95% CI: 1.18-1.88). Lost workdays were also more likely for respondents with depression symptoms (RR1.34; 0.97-1.86). Health care costs (by a factor of 0.81; 0.66-1.01) and the risk of lost workdays (RR 0.86; 0.62-1.18) may be lower among respondents with high diabetes-related distress. While major depression and diabetes-related distress have overlapping indicators, our results indicate different impacts on health care costs.

Predicting dynamic stability from static features in power grid models using machine learning.

A reliable supply with electric power is vital for our society. Transmission line failures are among the biggest threats for power grid stability as they may lead to a splitting of the grid into mutual asynchronous fragments. New conceptual methods are needed to assess system stability that complement existing simulation models. In this article, we propose a combination of network science metrics and machine learning models to predict the risk of desynchronization events. Network science provides metrics for essential properties of transmission lines such as their redundancy or centrality. Machine learning models perform inherent feature selection and, thus, reveal key factors that determine network robustness and vulnerability. As a case study, we train and test such models on simulated data from several synthetic test grids. We find that the integrated models are capable of predicting desynchronization events after line failures with an average precision greater than 0.996 when averaging over all datasets. Learning transfer between different datasets is generally possible, at a slight loss of prediction performance. Our results suggest that power grid desynchronization is essentially governed by only a few network metrics that quantify the networks' ability to reroute the flow without creating exceedingly high static line loadings.

To trust or not to trust in the thrall of the COVID-19 pandemic: Conspiracy endorsement and the role of adverse childhood experiences, epistemic trust, and personality functioning.

RATIONALE: Conspiracy endorsement is a public health challenge for the successful containment of the COVID-19 pandemic. While usually considered a societal phenomenon, little is known about the equally important developmental backdrops and personality characteristics like mistrust that render an individual prone to conspiracy endorsement. There is a growing body of evidence implying a detrimental role of adverse childhood experiences (ACEs) - a highly prevalent developmental burden - in the development of epistemic trust and personality functioning. This study aimed to investigate the association between ACEs and conspiracy endorsement in the general population, specifically questioning a mediating role of epistemic trust and personality functioning. METHODS: Based on cross-sectional data from a representative German survey collected during the COVID-19 pandemic (N = 2501), we conducted structural equation modelling (SEM) where personality functioning (OPD-SQS) and epistemic trust (ETMCQ) were included as mediators of the association between ACEs and conspiracy endorsement. Bootstrapped confidence intervals (5000 samples, 95%-CI) are presented for all paths. RESULTS: ACEs were significantly associated with conspiracy endorsement (ß = 0.25, p < 0.001) and explained 6% of its variance. Adding epistemic trust and personality functioning as mediators increased the explained variance of conspiracy endorsement to 19% while the direct association between ACEs and conspiracy endorsement was diminished (ß = 0.12, p < 0.001), indicating an indirect effect of personality functioning and epistemic trust in the association between ACEs and conspiracy endorsement. Fit indices confirmed good model fit. CONCLUSIONS: Establishing an association between ACEs and conspiracy endorsement further increases the evidence for early childhood adversities' far-reaching and detrimental effects. By including epistemic trust and personality functioning, these findings contribute to a deeper understanding of the underlying mechanisms in the way that ACEs may be associated with conspiracy endorsement.

Cancer advance care planning: development of a screening tool.

OBJECTIVES: Advance care discussions are a useful communication tools for medical preferences and beneficial for shared decision-making processes in hospital settings. The present study developed the first screening tool for need for advance care planning (ACP). METHODS: In phase 1 (n=92), items were evaluated using feasibility analysis and item reduction. In phase 2 (n=201), reduced screening items were analysed for predictive value of need for ACP. Statistical analysis included receiver-operating characteristics analysis (area under the curve>0.80), optimal cut-off based on sensitivity and specificity, interpretation of OR and construct validity using correlation with death anxiety, communication avoidance within families and trust based on the relationship with the treating physician. RESULTS: Participants in both phases were approximately 60 years old with non-curative prognosis. After item reduction, predictive values of four possible items with good item difficulty and discrimination were compared for mild, moderate and great levels of death anxiety. A two-item combination of I am burdened by thoughts of an unfavourable course of the disease and I am burdened by the feeling of being ill-prepared for the end of life showed best prediction of death anxiety and communication avoidance. Clinical cut-off at sum-score ≥6 was of high sensitivity (95%) and specificity (81%). Previous use of social support and readiness for ACP was related to higher chance of interest in ACP. CONCLUSION: Screening for need of ACP is possible with two objective items and one subjective item. Positive screening therefore indicates when to offer ACP discussions and provides routine estimation of ACP need in clinical practice.

Measuring personality functioning with the 12-item version of the OPD-Structure Questionnaire (OPD-SQS): reliability, factor structure, validity, and measurement invariance in the general population.

Background: The assessment of personality functioning is at the core of current dimensional models of personality disorders. A variety of measures from different clinical and research traditions aim to assess basic psychological capacities regarding the self and others. While some instruments have shown reliability and validity in clinical or other selected samples, much less is known about their performance in the general population. Methods: In three samples representative of the German adult population with a total of 7,256 participants, levels of personality functioning were measured with the short 12-item version of the Operationalized Psychodynamic Diagnosis - Structure Questionnaire (OPD-SQS). We addressed questions of factor structure, reliability, validity, factorial invariance, and provide norm values. Results: Confirmatory factor analysis indicated a satisfactory to good model fit. OPD-SQS models were mostly unaffected by variables such as gender, age, or measurement time. As expected, personality functioning was associated with general psychopathology as well as indices of occupational functioning. Conclusion: The OPD-SQS is a viable measure to assess personality functioning in the general population.

Validation of the irritation scale on a representative German sample: new normative data.

The irritation scale is a widely used and reliable self-report scale for measuring cognitive and emotional strain related to the work environment. It extends existing measures by providing a sensitive assessment for pre-clinical stress at work. Existing normative data are based on convenience samples and are therefore not representative. This study provides new normative data for the irritation scale based on a representative German sample (N = 1480). The new normative data indicate that the overall level of irritation in the German workforce is significantly lower compared to previously published data. Convergent and discriminant validity is confirmed by correlations with depression and anxiety (Patient Health Questionnaire-4 for Depression and Anxiety), somatic symptom scales (Bodily Distress Syndrome 25 checklist, Somatic Symptom Scale-8, Giessen Subjective Complaints List-8, comorbidity), psychological functioning (Mini-ICF rating for activity and participation disorders in mental illness), work-related stressors (overcommitment and bullying) and individual resources (self-efficacy). The results confirm the utility of the irritation scale and provide new benchmarks that avoid an underestimation of the levels of irritation in future studies.

The multicenter effectiveness study of inpatient and day hospital treatment in departments of psychosomatic medicine and psychotherapy in Germany.

Background: Reliable outcome data of psychosomatic inpatient and day hospital treatment with a focus on psychotherapy are important to strengthen ecological validity by assessing the reality of mental health care in the field. This study aims to evaluate the effectiveness of inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy in a prospective, naturalistic, multicenter design including structured assessments. Methods: Structured interviews were used to diagnose mental disorders according to ICD-10 and DSM-IV at baseline. Depression, anxiety, somatization, eating disorder and posttraumatic stress disorder (PTSD) symptoms, as well as personality functioning were assessed by means of questionnaires on admission and at discharge. Results: 2,094 patients recruited by 19 participating university hospitals consented to participation in the study. Effect sizes for each of the outcome criteria were calculated for 4-5 sub-groups per outcome domain with differing severity at baseline. Pre-post effect sizes for patients with moderate and high symptom severity at baseline ranged from d = 0.78 to d = 3.61 with symptoms of PTSD, depression, and anxiety showing the largest and somatization as well as personality functioning showing somewhat smaller effects. Conclusions: Inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy is effective under field conditions. Clinical trial registration: https://drks.de/search/de/trial/DRKS00016412, identifier: DRKS00016412.

Supplementary data analyses for the associations of child maltreatment and diabetes in adulthood and the mediating effect of personality functioning.

In this article, supplementary data analyses regarding the association between different types of child maltreatment (CM) and diabetes as well as mediation analyses examining the role of personality functioning are provided (original research article: 'Associations of different types of child maltreatment and diabetes in adulthood - the mediating effect of personality functioning: findings from a population-based representative German sample') (Zara et al., 2023). Analyses are based on a representative sample of the German population (N = 5,041). Data was acquired through a representative survey conducted by the independent research institute USUMA Berlin. CM, personality functioning, a diabetes diagnosis as well as symptoms of depression and anxiety were assessed using self-report questionnaires (CTQ, OPD-SQS, PHQ-4). Correlation analyses for all used variables were conducted. Independent t-tests were performed to examine whether symptoms of depression and anxiety are elevated in patients with diabetes and CM (compared to no CM). Regarding the odd ratios (ORs) calculated to examine the association between types of CM and diabetes as well as mediation analyses investigating the role of personality functioning in these associations, sensitivity analyses with persons ≥ 30 years are provided. The additional analyses are intended to add to the body of research showing that patients with diabetes experience symptoms of depression and anxiety more frequently compared to the general population (Kampling and Kruse, 2020; Chireh et al., 2019; Smith et al., 2018), examine the association between different types of CM and diabetes, and explore the role of personality functioning in the association between CM and diabetes.

Mentalizing and epistemic trust as critical success factors in psychosomatic rehabilitation: results of a single center longitudinal observational study.

Background: Inpatient psychosomatic rehabilitation is a key treatment for patients with mental health issues. However, knowledge about critical success factors for beneficial treatment outcomes is scarce. The aim of this study was to evaluate the association of mentalizing and epistemic trust with the improvement of psychological distress during rehabilitation. Methods: In this naturalistic longitudinal observational study, patients completed routine assessments of psychological distress (BSI), health-related quality of life (HRQOL; WHODAS), mentalizing (MZQ), and epistemic trust (ETMCQ) before (T1) and after (T2) psychosomatic rehabilitation. Repeated measures ANOVA (rANOVAs) and structural equation models (SEMs) were calculated to investigate the association of mentalizing and epistemic trust with the improvement in psychological distress. Results: A total sample of n = 249 patients were included in the study. Improvement in mentalizing was correlated with improvement in depression (r = 0.36), anxiety (r = 0.46), and somatization (r = 0.23), as well as improved cognition (r = 0.36), social functioning (r = 0.33), and social participation (r = 0.48; all p < 0.001). Mentalizing partially mediated changes in psychological distress between T1 and T2: the direct association decreased from ß = 0.69 to ß = 0.57 and the explained variance increased from 47 to 61%. Decreases in epistemic mistrust (ß = 0.42, 0.18-0.28; p < 0.001) and epistemic credulity (ß = 0.19, 0.29-0.38; p < 0.001) and increases in epistemic trust (ß = 0.42, 0.18-0.28; p < 0.001) significantly predicted improved mentalizing. A good model fit was found (χ2 = 3.248, p = 0.66; CFI = 0.99; TLI = 0.99; RMSEA = 0.000). Conclusion: Mentalizing was identified as a critical success factor in psychosomatic inpatient rehabilitation. A key component to increase mentalizing in this treatment context is the improvement of epistemic mistrust.

PHQ-9, CES-D, health insurance data-who is identified with depression? A Population-based study in persons with diabetes.

AIMS: Several instruments are used to identify depression among patients with diabetes and have been compared for their test criteria, but, not for the overlaps and differences, for example, in the sociodemographic and clinical characteristics of the individuals identified with different instruments. METHODS: We conducted a cross-sectional survey among a random sample of a statutory health insurance (SHI) (n = 1,579) with diabetes and linked it with longitudinal SHI data. Depression symptoms were identified using either the Centre for Epidemiological Studies Depression (CES-D) scale or the Patient Health Questionnaire-9 (PHQ-9), and a depressive disorder was identified with a diagnosis in SHI data, resulting in 8 possible groups. Groups were compared using a multinomial logistic model. RESULTS: In total 33·0% of our analysis sample were identified with depression by at least one method. 5·0% were identified with depression by all methods. Multinomial logistic analysis showed that identification through SHI data only compared to the group with no depression was associated with gender (women). Identification through at least SHI data was associated with taking antidepressants and previous depression. Health related quality of life, especially the mental summary score was associated with depression but not when identified through SHI data only. CONCLUSION: The methods overlapped less than expected. We did not find a clear pattern between methods used and characteristics of individuals identified. However, we found first indications that the choice of method is related to specific underlying characteristics in the identified population. These findings need to be confirmed by further studies with larger study samples.

The German version of the neurofibromatosis 2 impact on quality of life questionnaire correlates with severity of depression and physician-reported disease severity.

BACKGROUND: Neurofibromatosis type 2 (NF2) is a rare genetic disease that causes a wide range of disabilities leading to compromised quality of life (QOL). There is clear need for a validated disease-specific tool to assess quality of life among German-speaking patients with neurofibromatosis type 2 (NF2). The NFTI-QOL questionnaire has produced useful results in English-speaking cohorts. The aim of this study was to produce and validate a German version of the NFTI-QOL (NFTI-QOL-D) and to correlate QOL scores with a depression score (PHQ-9) and clinical disease severity. METHODS: The original English-language NFTI-QOL was translated into German and then back-translated in order to preserve the questionnaire's original concepts and intentions. A link to an online survey encompassing the NFTI-QOL-D and the PHQ-9 depression questionnaire was then sent to 97 patients with NF2 by email. The respondents' scores were compared to clinician-reported disease severity scores. RESULTS: 77 patients completed the online survey in full. Internal reliability among NFTI-QOL-D responses was strong (Cronbach's alpha: 0.74). Both PHQ-9 and clinician disease severity scores correlated with NFTI-QOL-D scores (Pearson's rho 0.63 and 0.62, respectively). CONCLUSIONS: The NFTI-QOL-D is a reliable and useful tool to assess patient-reported QOL in German-speaking patients with NF2. The correlation of QOL with both psychological and physical disease parameters underlines the importance of individualized interdisciplinary patient care for NF2 patients, with attention paid to mental well-being as well as to somatic disease manifestations.

Hair brain-derived neurotrophic factor (BDNF) as predictor of developing psychopathological symptoms in childhood.

BACKGROUND: Dysregulation in the expression of neurotrophins is implicated in the pathophysiology of several mental disorders. Peripheral brain-derived neurotrophic factor (BDNF) can be measured in hair and might represent a marker of adequate neuroplasticity regulation. In early developmental periods, neuroplasticity regulation might be particularly important, but BDNF markers have not yet been analyzed in this regard. We used the hair-BDNF concentration (HBC) to investigate the prediction of emerging symptoms of anxiety/depressive and attention-deficit hyperactivity disorder (ADHD) in the developmentally crucial period from preschool to school age. METHODS: 117 children (58 girls, 59 boys) participated in a longitudinal study at the ages of 4-5 (T1) and 8 (T2) years. At T1, HBC was measured in a 3 cm hair segment. At T1 and T2, symptom domains were assessed using a multi-method (clinical interview, questionnaire) and multi-informant approach. RESULTS: T1 HBC was significantly negatively associated with T1 anxiety/depressive symptoms (r = -0.27) and predicted T2 anxiety disorder symptoms (r = -0.34) after controlling for the T1 symptoms. T1 HBC also predicted T2 depressive disorder symptoms (r = -0.18) but was not associated with ADHD symptom development. LIMITATIONS: BDNF hair analysis is a new method with a not yet large number of studies on methodological issues. Our study adds evidence to the validity of the method. CONCLUSIONS: Prediction of anxiety/depressive symptom development by HBC was shown. As this study was the first to use HBC in this context, cross-validation is necessary and worthwhile. HBC might prove to constitute a useful, non-invasive early marker of risk for anxiety/depressive disorders in childhood.

Associations of different types of child maltreatment and diabetes in adulthood - the mediating effect of personality functioning: Findings from a population-based representative German sample.

PURPOSE: This study aimed to examine the role of personality functioning in the association between various types of child maltreatment (CM) (sexual, physical, and emotional abuse as well as physical and emotional neglect) and diabetes in adulthood. METHODS: Analyses are based on representative data of the German population (N = 5,041) from 2016 to 2019. Self-report questionnaires assessed diagnosis of diabetes, child maltreatment (CTQ), personality functioning (OPD-SQS), and symptoms of depression/anxiety (PHQ-4). Odd ratios were calculated to examine the association between CM and diabetes, and mediation analyses including PHQ-4 as covariate were conducted to examine the role of personality functioning. RESULTS: All CM types significantly elevated the odds of having diabetes in adulthood. Personality functioning mediated the association between abuse and diabetes (sexual: b = 0.012, 95% CI [.002, 0.022], PM = 25.0%, physical: b = 0.009, 95% CI [.001, 0.017], PM = 12.0%, and emotional: b = 0.013, 95% CI [.002, 0.024], PM = 59.8%), but not between neglect and diabetes. CONCLUSIONS: CM is associated with an increased risk of diabetes, with personality functioning being a relevant mediator for CM abuse types. Hence, by focusing on CM prevention and considering impaired personality functioning in diabetes treatment, diabetes self-management and health behavior could be improved.

What Kind of Patients Receive Inpatient and Day-Hospital Treatment in Departments of Psychosomatic Medicine and Psychotherapy in Germany?

INTRODUCTION: Germany is one of the few countries with a medical specialty of psychosomatic medicine and psychotherapy and many treatment resources of this kind. OBJECTIVE: This observational study describes the psychosomatic treatment programs as well as a large sample of day-hospital and inpatients in great detail using structured diagnostic interviews. METHODS: Mental disorders were diagnosed according to ICD-10 and DSM-IV by means of Mini-DIPS and SCID-II. In addition to the case records, a modified version of the CSSRI was employed to collect demographic data and service use. The PHQ-D was used to assess depression, anxiety, and somatization. RESULTS: 2,094 patients from 19 departments participated in the study after giving informed consent. The sample consisted of a high proportion of "complex patients" with high comorbidity of mental and somatic diseases, severe psychopathology, and considerable social and occupational dysfunction including more than 50 days of sick leave per year in half of the sample. The most frequent diagnoses were depression, somatoform and anxiety disorders, eating disorders, personality disorders, and somato-psychic conditions. CONCLUSIONS: Inpatient and day-hospital treatment in German university departments of psychosomatic medicine and psychotherapy is an intensive multimodal treatment for complex patients with high comorbidity and social as well as occupational dysfunction.

Epistemic Trust Is a Critical Success Factor in Psychosomatic Rehabilitation-Results from a Naturalistic Multi-Center Observational Study.

Knowledge about critical success factors underpinning beneficial treatment outcomes in psychosomatic inpatient rehabilitation is scarce. The aim of this study was to evaluate the influence of patients' epistemic stance in relation to the improvement of psychological distress during rehabilitation. In this naturalistic longitudinal observational study, n = 771 patients completed routine assessments for psychological distress (BSI-18), health-related quality of life (HRQOL; WHODAS), and epistemic trust (ETMCQ) before (T1) and after (T2) psychosomatic rehabilitation. Patients were grouped as best, average, and worst responders based on their mean BSI-18 changes during treatment, and their mean change in epistemic trust, mistrust, and credulity was compared using repeated measures analyses of variance (rANOVAs). No associations of performance with sex (p = 0.09), age (p = 0.11), or relationship status (p = 0.58) were found. Best responders reported significantly improved epistemic trust (p = 0.001) and reduced epistemic mistrust (p < 0.001), whereas worst responders reported a significant increase in epistemic mistrust (p < 0.001) and credulity (p < 0.001). Average responders did not change for either epistemic trust (p = 0.11), mistrust (p > 0.99), or credulity (p = 0.96). Our results underscore the role of the epistemic stance in psychosomatic and psychotherapeutic treatments. These results help to better understand what might determine psychosomatic rehabilitation outcomes and indicate the role of epistemic trust as a critical success factor.