[Differential Provision of Care for Patients with Mental Disorders by Different Care Providers. An Analysis of Reimbursement Claims in Mecklenburg-West Pomerania in 2010]. / Differentielle Versorgung von Patienten mit psychischen Störungen. Analyse von Abrechnungsdaten der Kassenärztlichen Vereinigung Mecklenburg-Vorpommern aus dem Jahr 2010.

Aim of this study was to use reimbursement claims to analyse in how far the heterogeneous spectrum of mental disorders is reflected by the provision of care by different providers. Of the 728 542 reimbursement claims from the last quarter in 2010, most claims were billed for depressive (22.0%), somatoform (16.8%) and anxiety disorders (7.6%). Most claims were billed by general (50.7%), neurological/psychiatric (16.0%) or practices for internal medicine (10.6%). Claims from most providers reflected the expected spectrum of disorders per specialisation. General practices covered nearly the whole spectrum of disorders. Neurological/psychiatric practices billed more claims for depressive (26.6%) and, anxiety disorders (10.0%) or dementia (4.9%), practices for internal medicine billed more claims for somatoform (18.6%) or tobacco related disorders (13.5%). In the outpatient provision of care, a broad spectrum of disorders is cared for by a broad spectrum of providers. Outpatient practices, independently from their specialisation provide care for all kinds of disorders. At the same time, a focus of disorders along the spectrum of specialisation is observable.

[On the stability and modifiability of the sense of coherence in active seniors]. / Zur Stabilität und Modifizierbarkeit des Kohärenzgefühls aktiver älterer Menschen.

According to Antonovsky, the sense of coherence (SOC) determines health and wellbeing. This life orientation is shaped up to the age of 30 and is supposed to remain constant up to senior age. In a field study, in which the SOC, psycho-social resources and subjective health were assessed at three points in time, it could be shown for the first time that the SOC in old age can be malleable and expanding. The master sample (time t(1)) consisted of N = 58 active and "healthy" seniors at the mean age of 66.3 years (65.5% female), who decided to take part in a 14-week program focusing on physical activity and/or self-reflection (endurance training, strength training, yoga, or meditation), respectively. One year before, 90% of them had participated in the Greifswald Aging Study (t0). The intervention study was attended regularly by n = 42 persons (t1 and t2). The SOC and associated health appraisals remained constant over a period of one year (t0-t1); re-test reliabilities varied from satisfactory to very good. Overall, the current SOC (t1) was more important than the past SOC (t0) in accounting for current well-being (t1). The intervention (t1-t2) revealed that the elderly's SOC was significantly strengthened-independently of the program they took part in. Correspondingly, participants' wellbeing, subjective health and psycho-social resources were enhanced. Taking part in a systematic, age-based and group-oriented program that encourages an active and productive every-day life brings about coherence-promoting and health-promoting life experiences in old age.

[The desire for a child in a socio-structural context]. / Der Kinderwunsch im soziostrukturellen Kontext.

In the EU, Germany is one of the countries showing the lowest birth rate and the highest childlessness rate. The desire for a child competes with a variety of life goals that are propagated as valuable in an achievement-centered society. Psychologically speaking, it can be conceived of as a complex and highly ambivalent conflict between options. In view of adverse societal conditions, women and men at a fertile age face the problems of arbitration and of action insecurity, both of which are associated with the delay of the desire for a child and with abandonment of offspring, respectively. In this article, the socio-structural conditions of the desire for a child and of childlessness are specified, referring to relevant representative surveys, and important steps for overcoming this crisis are suggested.

[Salutogenesis in old age]. / Salutogenese im Alter.

In this contribution, the significance of the salutogenic model (Antonovsky) and its core concept-the sense of coherence-for research into "successful aging" is explicated on the background of a gerodynamic perspective (Schroots). Common to both approaches is the idea that the basic principle of life is based on imbalance, disease, and suffering (heterostasis). According to this pessimistic view, aging is considered as the individual time dimension on which these inevitable impairments in biological, behavioral, and social respects take place. The continuous increase in entropy (disorder) will finally result in the death of the organism. In the face of gerontological research showing variability and individual plasticity in aging processes-especially for the third age-, the salutogenic question is why some people generally become (very) old and stay healthy. According to the salutogenic model, the sense of coherence determines the (re-)production of order over the life span and mediates the relationship between resources/stressors and health outcome. Considering activity/disengagement theory and the selective optimization with compensation model as an example, the integrative potential of the salutogenic model is shown. Finally, the value of the salutogenic model for the fourth age is discussed. Healthy aging is one chance of human existence, but in no way a collective duty that should be imposed on the individual.

[Motor competence and quality of life in elderly active persons]. / Motorische Handlungskompetenz und Lebensqualität älterer aktiver Menschen.

Physical activity is a vital pre-condition for healthy aging and well-being. While the association between objective and subjective health in old age has extensively been investigated, the relationship between objective motor competence-the capability of mastering motor demands in everyday life adequately by using motor resources optimally-and subjective health-related quality of life has not been studied yet. In an interdisciplinary study, 168 active seniors (36 men) at the mean age of 67 (range: 59-89) underwent a test battery assessing motor resources and two objective domains of everyday life motor competence-"Perceiving and Reacting" and "Mastering Complex Situations". Subsequently, participants rated their mental, physical, social, functional health and life satisfaction by questionnaire. Motor competence domains were age-dependent; the strongest decrease was found for "Mastering Complex Situations". Only "Mastering Complex Situations" was predicted by motor resources: competent seniors in this domain were faster in motor activity, simple reactions, body movements following acoustic and optic signals, and showed a stronger handcraft and a higher mobility. Overall, health-related quality of life was contingent upon motor competence: physical and functional health and-to a lesser extent-mental health and life satisfaction showed a systematic but moderate relationship to both motor competence domains. The results emphasize the significance of age-compatible and everyday life-adjusted physical activity for the well-being of elderly persons. Even active elderly persons show deficits in motor competence and should be trained, taking into account individual resources and flaws.

Biofeedback as a supportive method in weaning long-term ventilated critically ill patients.

Weaning a patient from mechanical ventilation is occasionally a difficult process complicated by the patient's emotional state. Anxiety, agitation, depression and other emotional disturbances can start a vicious circle between fear of losing breath and dyspnea that impairs the process of withdrawing ventilatory support. A biocybernetic loop model is suggested that integrates psychological variables (e.g., capacity of self-control, self-confidence, sense of self-efficacy) as important factors for a successful weaning. The paradigm of biofeedback is regarded as a suited approach to strengthen these psychological factors. It means the externalization of physiological functions especially of those from the autonomous nervous system so that a patient becomes aware of them. In the case of the ventilated patient, it is assumed that the transformation of the respiratory activities into perceptible (acoustic and visual) signals supports the patient's self-controlling behaviour during the weaning process. He gets positive reinforcement for his efforts to influence his breathing intentionally and, by continuous and immediate information, he regains self-confidence to control his somatic functions effectively. The application of biofeedback is mainly described in single case studies. They all report a decrease in the respiratory rate and an increase in the tidal volume. The need for a controlled study is suggested that would answer the question of whether biofeedback is an appropriate psychological tool to facilitate the weaning process in mechanically ventilated patients.

[Incidence and prevalence of postoperative acute confusion in heart surgery patients after coronary artery bypass and heart valve replacement surgeries]. / Inzidenz und Prävalenz postoperativer akuter Verwirrtheit kardiochirurgischer Patienten nach Bypassoperationen sowie Herzklappenersatz.

Compared to foreign countries, Germany does not have data about the occurrence of acute confusion following heart-surgery. However, the occurrence of acute confusion does extend the hospital length of stay for up to 13 days. Thus, this phenomenon is of high relevance to nursing. This prevalence/incidence study was implemented with the goal of obtaining exact information on the incidence rate of acute postoperative confusion after a heart surgery through a multicenter evaluation. The data evaluation took place in the form of a convenience sample survey in three different German clinics specializing on heart surgeries. The observation period lasted from the day of the surgery up to the fifth postoperative day. In the context of this prospective Cohort-study all patients aged 18 and older who had heart surgery between February 1st and April 30th, 2000, were considered suitable as participants in the study. In the end, 860 patients were included in this study. 152 patients (17.4%) showed symptoms of acute confusion (confidence interval 14-20%). Certain circumstances seemed to predispose patients to acute confusion. A widespread occurrence could be observed particularly at night. Patients aged 81-91 were mainly affected. A confusion rate of 43.5% could be determined for this group. These results confirm the clinical importance and suggest interdisciplinary approaches for solution.

Impact of a cancer education multimedia device on public knowledge, attitudes, and behaviors: a controlled intervention study in Southern Sweden.

BACKGROUND: The objective was to determine the impact of a multimedia device offering information about malignant melanoma on public knowledge, attitudes, and behaviors. METHODS: Two municipalities in Sweden, Dalby and S Sandby, were chosen. The population of Dalby was exposed to the multimedia program during 1994-97, whereas the S Sandby population was not. A questionnaire was sent to random samples of the populations (10% of those aged 20-59 years) before (1994, n = 373 and n = 409, respectively) and after the intervention (1996, n = 375 and n = 418, respectively). Response rates were 74-89%. RESULTS: The groups were well balanced at baseline. In both areas women scored higher both at baseline and in 1996. Dalby women showed less fear of skin cancer in 1996 than in 1994 (2.13 vs 2.27, p < 0.01). This was not so in the controls. There was no major change in "sun behavior" in Dalby, whereas there was a negative change in S Sandby. After the intervention Dalby men had more "knowledge" (from 2.64 to 2.70, p < 0.05) and a tendency to better "sun behavior" (from 1.77 to 1.85, p = 0.076). There was no significant change over time in the S Sandby men. CONCLUSIONS: The multimedia program had a modest effect. The population in Dalby had more knowledge and changed its attitudes in a sun-protective direction. In the control area, the two-year follow-up sun behavior score was lower than at baseline. There was also significantly less fear of skin cancer after the intervention.

[Family emotional climate of pain patients]. / Familienklima chronischer Schmerzpatienten.

Personal clinical experiences in an interdisciplinary pain clinic and their integration into family interaction theories led to a concept of an explorative study of chronic pain patients. Therefore 32 patients and their spouses were investigated with the "family-environment-scale" (by Moos and Moos 1981, adapted by Schneewind et al. 1985). Most of the couples showed agreement with regard to familial solidarity, combined with few expressions of anger and conflict and low achievement orientation. The typical profile of these factors led to one group with the "positive-emotional family climate", in contrast to one group with the "normative-authoritative family climate". In addition, a potentially new factor was described as a so-called "symbiotic family climate". The latter constellation was on the one hand quite similar compared to the "positive-emotional climate", but differed on the other hand because of the small amount of structural control. The interference of these family climate profiles with the process of chronification for pain patients is discussed.

[The clinical picture of the chronic pain patient-Analysis of a pain outpatient clinic using headache as an example.]. / Das klinische Bild des chronifizierten Schmerzpatienten : Analyse einer Schmerzambulanz am Beispiel des Kopfschmerzes.

INTRODUCTION: Patients with chronic headache are seen in an interdisciplinary pain clinic after many years of treatment. Compared with other pain syndromes, the standards for diagnosis and treatment are widely accepted according to the guidelines of the International Headache Society. Nevertheless, many patients continue to suffer. Analysis of their special clinical features may help to clarify what kind of conditions potentially cause chronicity. PATIENTS AND METHODS: A total of 193 patients were seen in 1992-1993 in our pain clinic. Epidemiological, medical and psychological data were analyzed retrospectively. Classification of headache syndromes and pain behavior was based on the criteria of the International Headache Society, taxonomy of the Multiaxial Pain Classification System for Somatic Dimensions (MASK-S) and "Stages of Chronicity". Important psychodynamic factors were taken from standardized psychological interviews. RESULTS: The patients had a mean age of 46 years; 67 % of them were female. Fifty-three percent of the patients suffered from chronic tension headache; a high percentage was suspected to be caused by analgesic intake. Because of their pain behavior, 68 % were classified as being in an advanced chronic stage with a poor prognosis. The most important findings of the psychological diagnosis was that 40 % of patients had a depressive style of conflict solving. CONCLUSIONS: The results are discussed with respect to their relevance in explaining development of chronic pain, as seen in selected headache patients in an interdisciplinary pain clinic.

[Conversation during regional anesthesia]. / Das Gespräch während der Regionalanaesthesie.

From the psychological point of view, regional anesthesia is something special because the patient experiences his operation consciously. This means that the anesthetist is required not only to guarantee a safe anesthetic, but also to recognize the special needs of the patients, to enter into them adequately, and thus to support the patient's own strategies for coping with his situation. The question arises as to what extent the anesthetist's behavior meets the patient's psychological requirements. For this reason, the conversation between patient and anesthetist was monitored during 17 operations under regional anesthesia and investigated by means of a quantitative speech analysis. It was shown that the anesthetist clearly predominated in the course of the conversation: particularly during the time when the patient was preparing himself for the operation, it was the anesthetist who actively framed the communication by numerous questions and conversational activities while the patient responsively remains passive. The anesthetist spoke simply and clearly to the patient. Prime consideration was given to explaining the anesthetic procedure and the operation. There were not many attempts by the physician to also deal with the patient's psychic state. On the while, communication was concerned with the quick and easy performance of anesthesia. This was also demonstrated by the fact that conversation between the anesthetist and the patient was nearly absent during the operation.

[Psychophysiologic reaction patterns in coping with events by intensive care patients]. / Psychophysiologische Reaktionsmuster bei der Ereignisbewältigung von Intensivpatienten.

The aim of this study was to demonstrate the clear relations between psychological and physiological parameters determined in intensive care patients. For this purpose, heart rate, salivary-cortisol secretion and blood pressure were measured as physiological stress indicators; psychological parameters were covered by examining the patients' way of coping, that is to contrast emotional with rational coping. By comparison, the equivalent parameters were determined in a group of healthy patients. When comparing both groups, we found a higher salivary-cortisol secretion and an increased heart rate in the group of intensive care patients, with the circadian rhythm of the cortisol-secretion remaining almost stable. When examining the patients' group according to the way of coping, we found a higher activation of the sympathetic nervous system in those patients who coped with their situation emotionally than in those who faced their problems rationally. The level of physiological excitation significantly decreased after the patients had been transferred from the ICU to the normal ward. The increased physiological excitation of ICU patients serves to release energies that help them to cope with their situation and can likewise be associated with emotional reactions such as being extremely watchful and in a state of mobilization as well as feeling particularly helpless. The extent of physiological irritation is modified by the way of intrapsychical coping.

[The situation on relatives in the intensive care unit]. / Die Situation von Angehörigen auf der Intensivstation.

Up to now there are almost no investigations on the situation of relatives of ICU patients. Therefore a study was designed into the impressions left on relatives by intensive care treatment in their next of kin. A questionnaire including 46 items was developed which mainly refers to the following topics: first contact with the ICU, experience with the situation in the ICU, information given on the patient's state, psychosocial assistance, evaluation of experiences made in the ICU. The questionnaire was sent to 210 relatives of former long-term intensive care patients; 57 completed forms could be evaluated. It can be demonstrated that the first contact with the ICU is characterised by the concern for the patient's actual state of disease so that previous information about the ICU and on the patient's condition are considered helpful. The contact with the intensive care patient seems to be most impressive for all relatives. It creates feelings of uneasiness, compassion and despair. The relatives of moribund patients additionally show feelings of mourning. The request for information mainly refers to the patient's present state. The technical equipment of the ICU represents a reassuring factor to most of the relatives; likewise the smallest number of them feels disturbed by witnessing therapeutical measures. The relation to the medical and nursing staff is described as positive, especially by relatives of surviving patients. In retrospect the relatives--like the former ICU patients--hold a positive view of the intensive care unit. The reasons are discussed.

[Recent studies on the mental state of ventilated patients in intensive care units]. / Erfassung aktueller Erlebnisinhalte von beatmeten Patienten auf der Intensivstation.

Studies which retrospectively deal with the psychic situation of the intensive care patient are criticised and a methodological approach is introduced to describe the actual psychic state of these patients. As an appropriate method of research we suggest to collect written pronouncements, to categorize them and to evaluate them by means of content analysis. Thus, in a first step, 470 written pronouncements of ICU patients are collected and rated. Afterwards emotional expressions are analysed by means of a procedure measuring the degree of anxiety and aggression. The results permit a description of the actual psychic situation of the ventilated patient. They reveal that the patient is primarily concentrated on his own physical condition. Likewise there is an extended need for communication and information. Aggressive impulses are mostly directed against the own self as evidenced by self-reproaches and self-criticism. Anxieties mainly include diffuse fears, fears of being injured and fears of dying. Like the disturbance of self-confidence they can be considered as a psychic reaction to the life-threatening disease. The reactions of ventilated patients are similar to those of critically ill but not ventilated patients. Specific reactions due to ventilation cannot be observed in this group of patients.

[Assessment of the value of sedation and mobilization in the therapy concept of mechanically ventilated patients]. / Der Stellenwert von Sedierung und Mobilisation im Therapiekonzept beatmeter Patienten.

Continuous improvements in intubation technology have caused a substantial change in the treatment of intubated patients. Whereas, until a few years ago, patients requiring intubation were sedated and treated by muscular relaxation for technical reasons, today sedation is no longer technically indicated. The patient is sedated so that he may be spared the potentially traumatizing psychic experience of machine ventilation. Recent investigations have shown, however, that the emotional strain to which intubated patients are subjected cannot be specifically attributed to artificial ventilation, but rather that it may occur in any severe physical illness. This strain may be eased by a positive relationship between the patient and the ICU staff. Routine sedation of intubated patients thus seems unnecessary. Nevertheless, there are some indisputable medical and psychological arguments in favour of sedation of intubated patients, including insufficiently stabilized fractures, states of restlessness, tetanus, intentional reduction of oxygen consumption, etc. Among the objectives to be achieved by mobilizing intubated patients are the following: restoration of the patient's autonomy, prevention of impaired consciousness, improved oxygenation. A meaningful performance of mobilization under both medical and psychological aspects is also described.