Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care.

BACKGROUND: The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care. METHODS: In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges. RESULTS: The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression. CONCLUSION: The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.

What can patients do to facilitate shared decision making? A qualitative study of patients with depression or schizophrenia and psychiatrists.

PURPOSE: Patient involvement in decision making is endorsed by patients and professionals. While research has recently been conducted on how professionals can promote shared decision making (SDM), little is known about how patients can also facilitate SDM. METHODS: Seven focus groups were conducted: 3 with psychiatrists and 4 with patients with schizophrenia or depression. The focus groups were transcribed and independently coded line by line by 2 researchers. Data were analyzed using content analysis. RESULTS: Seven themes related to patient attitudes and behaviors were identified: honesty and openness with one's psychiatrist and oneself, trust in one's psychiatrist and patience with the treatment, respect and politeness, informing the psychiatrist and giving feedback, engagement/active participation during the consultation, gathering information/preparing for the consultation and implementing decisions. Barriers (e.g., avolition, lack of decisional capacity, powerlessness during involuntary treatment) and facilitators of active patient behavior were also identified. CONCLUSIONS: There are various ways in which patients can facilitate SDM/play a more active role in decision making, with patients emphasizing being open and honest and psychiatrists emphasizing being active in the consultation. Interventions to increase active patient behavior may enhance SDM in mental health care.

Managers' reactions towards employees' disclosure of psychiatric or somatic diagnoses.

AIMS: To study whether employees who disclose a psychiatric diagnosis, such as depression risk stigmatisation and discrimination at the workplace. METHODS: Randomised experimental study with 748 managers from German companies incorporating four case vignettes displaying an employee with different 'diagnoses' (depression, burnout, private crisis and thyroid dysfunction), but identical unspecific complaints. Main outcome measures were the managers' attitudes and their impact on stigmatisation with respect to job performance. RESULTS: In nearly all aspects of job performance, the diagnosis depression (psychiatric disorder) was seen as more critical than the diagnosis of a thyroid dysfunction (somatic disease). The diagnosis 'burnout' did not prove to be less stigmatising than 'depression'. Likewise 'private crisis' was rated less favourably than thyroid dysfunction. CONCLUSIONS: Therefore, employees have to evaluate if they disclose their psychiatric disorder or if they conceal it as a somatic illness.

[Understanding the term burnout in psychiatry and psychotherapy]. / Verständnis des Begriffs Burnout in Psychiatrie und Psychotherapie.

BACKGROUND: Currently there is much debate about the concept of burnout and its use as a diagnostic entity. The aim of the present survey was to present the view of mental health professionals towards the concept of burnout. METHODS: A total of 300 mental health professionals were surveyed using a structured questionnaire. RESULTS: The majority of participants see burnout as a state of exhaustion which constitutes a risk factor for later developing a mental disorder. Participants reported that from their point of view typical triggers for burnout exist while symptoms overlap to a great extent with depression. Psychotherapy as well as interventions at the workplace are regarded as promising interventions; however, in the clinical routine only a minority of participants actually contacted the patients' workplace. In the participants workplace settings most Burnout-Patients suffered from a diagnosis defined in ICD 10 but judged themselves to be suffering from burnout. DISCUSSION: Burnout-Patients in mental health settings differ from the picture currently drawn in the media, probably because Burnout-Patients reach the mental health sector only after already having developed a manifest psychiatric disorder.

[Treadmill therapy in patients after ischaemic stroke]. / Laufbandtherapie bei Patienten nach ischämischem Hirninfarkt.

Treadmill training with body weight support was applied in 30 patients who had suffered an ischaemic stroke, with the goal of improving their independence in the activities of daily living (ADL). The following inclusion criteria were used: inability to walk (FAC-score 0 - 2); motor abilities (the ability to sit without support, a palpable muscle function of the hip extensors, abductors and the knee extensors in the affected leg); adequate cooperation, motivation and vigility; absence of muscle contractures which would affect gait; onset of therapy no later than one year after the incident. The average duration of treadmill training was 6,6 weeks. The patients' age was an average 68 years (48 - 82). 87 % of the patients were able to improve their gait within the Functional Ambulation Categories (FAC) scale. 60 % of the patients achieved the ability to walk independently without technical aid. Apart from improving their gait, the patients also attained significantly increased scores in the motor scale of the Rivermead Motor Assessment (gross function) and the motor part of the ADL scale of the Barthel Index (items 2 - 4) and the Functional Independence Measure (items 3 and 4). Treadmill training is establishing itself as an important therapeutic approach in gait rehabilitation with patients with acquired brain damage.

Attributions of depressed persons: how consistent are they with the covariation principle?

The sensitivity of depressives' and nondepressives' attributions to covariation information is investigated. Individuals differing in depression made attributions in response to descriptions of negative situations, either without or with additional covariation information designed to lead to external and specific (Studies 1, 2, and 3) or to internal, stable, and global attributions, or to both (Studies 2 and 3). Covariation information modified attributions in the expected directions equally strongly for both mood groups. In Study 4, covariation information was assessed rather than provided. Depressives were more prone than nondepressives to assume low consensus, low distinctiveness, and high consistency for negative events. Depressives' causal conclusions from the self-perceived covariation information were more negative but correlated more strongly with self-perceived covariation than did nondepressives' attributions.

[Sarcoidosis. Case report of a patient with isolated sarcoidosis of the breast]. / Sarkoidose der Mamma. Fallbericht einer Patientin mit isolierter Sarkoidose der Mamma.

The case of a 41-year-old woman with sarcoidosis of the breast without evidence of disease elsewhere is reported. The diagnosis was established histologically, and other causes of the sarcoid-like granulomatous lesions could be excluded.

[Immunocytochemical detection of tumor cells in bone marrow as a prognostic factor in breast carcinoma]. / Immunzytochemischer Nachweis von Tumorzellen im Knochenmark als Prognosefaktor beim Mammakarzinom.

In a prospective study at the University of Erlangen, Dept. Gynaecol, and Obstet., 228 patients with breast cancer during their primary surgery and 20 patients during their metastatic surgery, underwent bone marrow punctions at six punction sides, which were twice at the sternum and twice at both iliac crest. The control group was 20 patients without an invasive carcinoma. Aim of the study was to detect or exclude tumour cells in the bone marrow via examination of the biopsies with monoclonal antibodies EMA and cytokeratin and consequently to find out the meaning of the results as prognostic criteria by statistical measurements. Tumour cells in the bone marrow were detected in 46.5% (106/228) of the patients, who underwent a bone marrow biopsy during primary surgery. 21% (23/106) of the patients who were bone marrow positive, but only 5.75% (7/122) of the patients, who were bone marrow negative, developed metastases during a median follow-up of 20 months. This difference is statistically significant. 17 of the 30 patients with recurrences developed bone metastases; 16 of them were EMA-positive. The median recurrence-free interval was 5 months in the bone marrow positive group and therefore noticeably shorter, than in the bone marrow negative patient group with 11 months. Of the nodal negative patients, 2 bone marrow positive patients developed distant metastases. With the knowledge of the nodal status and bone marrow biopsy result, it was possible to predict 28 of the 30 patients correctly in respect of their risk to metastasize. The result of the bone marrow puncture was proved in a multivariate analysis to be an independent prognostic factor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Indications, technique and results of ultrasound guided punch biopsy in breast diagnosis (n=307)]. / Indikationen, Technik und Ergebnisse der sonographisch gezielten Stanzbiopsie in der Mammadiagnostik (n = 307).

From May 1, 1992, to April 30, 1993, we performed 307 ultrasonic guided high-speed punch biopsies. In 119 of the 307 women, we dispensed with further surgical and histological procedures when the tentative diagnosis from complementary mammary diagnostic procedures revealed no pathological findings and concurred with the histological results of the punch biopsy. In 188 women, the biopsy was followed by surgical intervention and correlation of the histological findings. This group of patients showed a sensitivity of 98%, a specificity and positive prognostic value of 100%, and a negative prognostic value of 91%. If we combine the results of the complementary mammary diagnostic (including the punch biopsy), then the sensitivity, specificity, and positive and negative prognostic values for this surgically and histologically confirmed group of patients all reach 100%. In trained hands, the ultrasonic guided high-speed punch is a reliable means of determining the histological nature of lesions detected in ultrasonic scans. This technique has been perfected in our facility. Along with preoperative carcinoma detection, it permits us to avoid unnecessary operations when under defined conditions there are no pathological findings.

[Breast cancer: breast saving therapy]. / Mammakarzinom: brusterhaltende Therapie.

Breast preservation has become an important option in the treatment of breast cancer patients. The selection of patients should be based upon history, actual clinical situation, mammographic and morphologic parameters. After careful evaluation of all those factors the surgical treatment and eventually an adjuvant postsurgical irradiation can be tailormade according to the associated individual risk-profile.

Prevention of chemotherapy-induced nausea and emesis in patients responding poorly to previous antiemetic therapy. Comparing tropisetron with optimised standard antiemetic therapy.

In a multicentre trial, 78 patients with a variety of malignancies, who had experienced insufficient control of emesis (greater than or equal to 3 episodes within 24 hours) while receiving standard antiemetics during previous chemotherapy, were randomly assigned to receive tropisetron 5mg once daily for 5 days or conventional antiemetic drugs. No attempt was made to standardise the conventional antiemetic treatment, which was given according to the usual practice of the participating institutions. Emesis was evaluated by counting emetic episodes and nausea by asking the patients to record on a diary chart the duration and severity of the nausea. Emesis was much better controlled with tropisetron than with standard drugs, complete control during the first 24 hours being achieved in 42% and 8% of patients, respectively, (p less than 0.001). Nausea was of significantly shorter duration (6.9 vs 10.3 hours; p less than 0.01) and was less severe (p less than 0.005) in the tropisetron group. The patients' overall assessment of treatment outcome was markedly better for tropisetron than for the standard antiemetic therapy. The superior efficacy of tropisetron was especially marked during the first 24 hours. For delayed nausea, no significant difference between treatments was seen. No serious adverse effects were observed.