Screening for depression: Psychometric properties of the German version of the Glasgow depression scale for people with a learning disability (individual and carer version).

BACKGROUND: Adults with intellectual disabilities should participate in the diagnostics of their mental health. The Glasgow Depression Scale for people with a Learning Disability (GDS-LD) and its Carer Supplement (GDS-CS) were translated into German and tested. METHODS: Internal consistency, criterion validity and inter-test reliability were tested in 64 adults with borderline, mild or moderate intellectual disabilities and their carers. Convergent validity was analysed in 57 adults without intellectual disabilities. RESULTS: Internal consistency was good (α = 0.81) for GDS-LD and acceptable (α = 0.72) for GDS-CS. The GDS-LD did not differentiate between groups with and without depression. The GDS-CS significantly differentiated between these groups. Convergent validity of the GDS-LD was high. The correlation of GDS-LD and GDS-CS was non-significant. CONCLUSIONS: In its present form the German version of the GDS-LD does not meet the psychometric properties to be used in clinical practice. This leads to the broader question, how to measure depression in people with learning disabilities with the knowledge of the fallibility of existing measures when utilised with this clinical cohort. Also, future studies need to investigate the role of self-rating.

[Psychotherapy in disorders of intellectual development-Current evidence and practical implementation]. / Psychotherapie bei Störungen der Intelligenzentwicklung ­ aktuelle Evidenz und praktische Umsetzung.

People with a disorder of intellectual development (German draft of the ICD-11, which came into force on 1 January 2022) suffer more frequently from mental illnesses. According to the international treatment guidelines multimodal approaches should include not only psychopharmacological treatment, but also disorder-specific psychotherapeutic methods. These psychotherapeutic interventions have to be adapted to the communicative and cognitive abilities (performance diagnostics with IQ tests) as well as the emotional developmental stage (developmental diagnostics, e.g., with the scale of emotional development, short version, SED-S 2; [1]). To ensure this, the rules of simple language should be observed and when appropriate relatives or caregivers should be involved in the therapeutic process. The effectiveness of cognitive behavioral therapy has received most scientific attention, especially for affective disorders. Posttraumatic stress disorders can be validly treated with eye movement desensitization and reprocessing (EMDR). There is also good evidence for exposure therapy with reinforcement in the treatment of anxiety disorders.

[Psychological Care for a High Risk Group of Refugees - Concept of Care for the Yazidi Women and Children of the Sonderkontingent Baden-Württemberg in Freiburg]. / Psychologische Versorgung einer besonders vulnerablen Flüchtlingsgruppe.

After the genocide of Shingal in August 2014 in Northern Iraq, the humanitarian admissions program Sonderkontingent Baden-Württemberg "Schutzbedürftiger Frauen und Kinder aus dem Nordirak" was implemented. 1100 persons, most of them Yazidis, were hosted by different municipalities in Germany. The target group is a particularly vulnerable group of persons with a high risk for developing post-traumatic stress disorder. We present the concept of care in Freiburg for 205 Yazidi women and children in Freiburg. A stepped-care approach was developed for the psychological care to introduce the Yazidi people to the daily life and to the health care system in Germany. An outreach of psychological services and an interdisciplinary and multidisciplinary cooperation of all services involved were crucial.

Cognitive behavioral group therapy for patients with physical diseases and comorbid depressive or adjustment disorders on a waiting list for individual therapy: results from a randomized controlled trial.

BACKGROUND: Depressive and adjustment disorders are highly prevalent in patients with physical diseases and are associated with poorer quality of life, increased morbidity and mortality, as well as higher healthcare costs. Access to mental health care holds strong importance for these patients, although waiting times for outpatient individual psychotherapy in Germany are often long. Attending an intervention while waiting for individual therapy could improve this problem. For this purpose, we developed an eight-session cognitive behavioral group therapy (STEpS) and tested its efficacy in a randomized controlled trial. METHODS: Seventy-six patients with chronic physical diseases and comorbid depressive or adjustment disorders were randomized to either STEpS or a waiting list control group. The primary outcome was self-reported depression measured by the Hospital Anxiety and Depression Scale (HADS-D), while the secondary outcomes included global psychological distress and health-related quality of life. Data was assessed at baseline, post-treatment and 2-month follow-up and was analyzed based on intention-to-treat. RESULTS: Compared to the control group, the STEpS group showed significantly less depression (d = 0.37; p = .009) and significantly higher quality of life (mental: d = 0.47; p = .030; physical: d = 0.70; p = .001) at post-treatment. The groups did not differ in global psychological distress. At 2-month follow-up, the STEpS group indicated significantly higher subjective physical health (d = 0.43; p = .046), but did not differ from the control group in the remaining outcomes. CONCLUSIONS: STEpS proved effective in improving depression and health-related quality of life in the short term but did not reveal effects on mental outcomes at 2-month follow-up. Nonetheless, the implementation of STEpS as a waiting list intervention prior to individual therapy could help patients to handle long waiting periods in outpatient care. TRIAL REGISTRATION: German Clinical Trials Register DRKS00005140 (27 August 2013).

Immediate help through group therapy for patients with somatic diseases and depressive or adjustment disorders in outpatient care: study protocol for a randomized controlled trial.

BACKGROUND: One in three people with a chronic somatic disease suffer from a comorbid mental disorder. Most common comorbidities are depressive, anxiety and adjustment disorders. These lead to an increase in morbidity and mortality, and a deterioration of quality of life and healthcare costs. Treatment of mental disorders is of great importance, but the waiting time for outpatient individual psychotherapy can be up to six months in Germany. Group therapy has comparable treatment effects and is considerably more economic than individual therapy; however, it is still almost unused in the outpatient care system. The introduction of a stepped care approach, such as attending a group program before individual therapy, could improve this issue. For this purpose we developed a group program (STEpS), and its efficacy will be evaluated in this study. METHODS/DESIGN: A randomized controlled trial will be conducted to evaluate the efficacy of a cognitive behavioral therapy (CBT) group program for patients with somatic diseases and depressive or adjustment disorders, compared to a wait-list control group. A total of 128 adults with any chronic somatic disease and comorbid depression or adjustment disorder will be recruited in our outpatient clinic, and will be randomly assigned to participate in the group program immediately after contacting the clinic (intervention group) or after a waiting period of four months (wait-list control group). Primary outcomes will be self-reported depressive and anxiety symptoms. Secondary outcomes will be self-reported psychological distress, changes in experience and behavior, health-related quality of life, state of self-esteem and subjective need for therapy. Assessments will take place at baseline, 10 weeks (post-treatment) and 18 weeks (follow-up) after randomization. Additionally, treatment acceptance and psychotherapeutic process will be assessed after each session. DISCUSSION: This study investigates whether the CBT group program is an effective treatment to reduce depressive and anxiety symptoms and psychological distress in these patients. If the group program is effective, it could be implemented as a treatment option prior to individual outpatient therapy. These results will contribute to improving outpatient care for mental disorders in patients with somatic diseases. TRIAL REGISTRATION: German Clinical Trials Register DRKS00005140 (27 August 2013).

Correlates of reduced exercise behaviour in depression: the role of motivational and volitional deficits.

OBJECTIVE: The study aimed at uncovering the correlates of reduced exercise in depressive patients. On the basis of the Health Action Process Approach (Schwarzer, 2011 ), we hypothesised that reduced exercise in depressive patients can be explained by motivational deficits and volitional deficits. DESIGN: A longitudinal sample of 56 clinically depressive outpatients was compared to a sample of 56 parallelised non-depressive controls. MAIN OUTCOME MEASURES: Self-reported intention, exercise, and motivational and volitional HAPA variables were measured with self-report questionnaires at baseline and four-week follow-up. RESULTS: Depressive patients showed a motivational deficit: they had significantly reduced intentions to exercise compared to non-depressive participants, and they suffered from reduced self-efficacy and increased negative outcome expectations. No differences were found with regard to positive outcome expectations. Depressive patients also showed a volitional deficit: depressive high-intenders were less capable of transforming their intention into action than non-depressive high-intenders. They produced less action plans, had less maintenance self-efficacy and were more easily distracted by barriers. CONCLUSION: The lower level of exercise among depressive patients is partly due to motivational, partly to volitional deficits. Interventions should be stage-matched and should focus on pessimistic beliefs (negative outcome expectations, self-efficacy) and planning deficits in depression.

[Dance/movement therapy in oncological rehabilitation]. / Tanztherapie in der stationären onkologischen Rehabilitation.

BACKGROUND: Dance/movement therapy may be defined as a psychosocial and body-oriented art therapy, which uses dance for the expression of emotional and cognitive issues. Dance/movement therapy is an important intervention for cancer patients to enhance coping strategies. There are only few studies investigating dance therapy with cancer patients. METHODS: The present study investigates effects of dance/movement therapy (n = 115) in the setting of inpatient rehabilitation based on a pre-post design with a control group as well as a follow-up 3 months later. Standardized questionnaires measuring quality of life, anxiety and depression, and self-concept (EORTC QLQ-C30, HADS, FSKN) were used. In addition, at the end of the inpatient rehabilitation program subjective expectations of the dance/movement therapy and the patients' subjective evaluation of the benefits of the intervention were measured by a new developed questionnaire. RESULTS: As process factors of dance/movement therapy, expression of emotions, enhancement of self-esteem, development of the personality, vitality, getting inner balance, and getting in touch with the body have been identified. In terms of quality of life and psychological well-being, the results showed significant improvements with medium to large effect sizes. CONCLUSIONS: Even though those effects may not be attributed to the intervention alone, the analysis of the data and the patients' subjective statements help to reveal therapeutic factors and process characteristics of dance/movement therapy within inpatient rehabilitation.

Coping in long-term survivors of childhood cancer: relations to psychological distress.

OBJECTIVE: The goal of this study was to describe coping strategies and their associations with psychological distress in young adult survivors of childhood cancer. METHODS: One hundred and sixty-four childhood cancer survivors, at least 7 years after diagnosis, completed questionnaires assessing demographics, health information, psychological distress, and different ways of coping (return rate: 61%). The Brief Symptom Inventory-18 (BSI-18) and the Post-traumatic Diagnostic Scale's (PDS) eight-item short form were used to measure psychological distress. Coping was assessed with the Cognitive Control Strategies Scale (CCSS), the Illness Perception Questionnaire-Revised (IPQ-R), and the White Bear Suppression Inventory (WBSI). RESULTS: Higher levels of distress were associated with the female sex, not being in a relationship, and with the presence of medical late effects. These predictors explained 12% of the variance in psychological distress. When coping variables were also entered into the equation, the amount of explained variance increased to 50%. The most important determinants of psychological distress in our sample were a tendency to suppress negative thoughts and a low level of optimism. CONCLUSION: These results contribute to a better understanding of the correlates of difficulties in long-term psychological adjustment after childhood cancer. Cognitive strategies, which are associated with or may increase the risk for concurrent psychological distress, in specific, avoidance of negative thoughts and a lack of positive future expectations, should be addressed in psychological counseling with survivors suffering from symptoms of distress.

Are depression and anxiety determinants or indicators of quality of life in breast cancer patients?

Depression and anxiety are associated with a decline of health-related quality of life (QoL) in breast cancer patients, and the present study aims to investigate the longitudinal relationship of depression and anxiety with QoL in breast cancer patients. Depression and anxiety (HADS) as well as QoL (EORTC QLQ-C30) were assessed at baseline and six-month follow-up in 118 breast cancer patients and analysed using cross-lagged partial correlation analysis (CLPC). There were significant partial correlations between depression and anxiety at baseline and physical functioning, emotional functioning and "global health and QoL" at six-month follow-up (range of pr = -0.197 and -0.392; p < 0.05). "Global health and QoL" at baseline was significantly correlated with depression and anxiety at follow-up (pr = -0.207 and -0.327; p < 0.05). Cognitive functioning at baseline was significantly associated with anxiety at follow-up (pr = -0.248; p < 0.01). CLPC analysis of two models (depression and anxiety determining QoL vs. QoL determining depression and anxiety) did not show significant results. Hence, in breast cancer patients, depression and anxiety are closely related to QoL and the observed correlations suggest a complex interrelation in which depression and anxiety have to be regarded as indicators of QoL rather than determinants.

Development and evaluation of a checklist assessing communication skills of oncologists: the COM-ON-Checklist.

OBJECTIVES: Communication skills training (CST) has to be proven effective, and therefore reliable instruments to evaluate CST are required. Most instruments assessing medical consultations do not take individual aspects of CST into consideration. Such assessment tools should naturally also be closely associated with the communication skills taught to the participants. Thus, we developed a new instrument which evaluates the effects of specific CST. DEVELOPMENT: Based on a literature review, we developed a checklist with questions ('items') which assess the behaviour of a doctor in a special doctor-patient consultation (The COM-ON-Checklist, COM-ON = communication in oncology). First, we developed items for general communication skills that are a requirement of every doctor-patient consultation, and in addition to this, we developed items for specific situations which present a particular challenge for doctors in terms of communication skills, namely: the situation in which the doctor is required to discuss the shift from curative to palliative care, and the disclosure of information about clinical trials. For assessment, a 5-point rating scale with anchor points was used. EVALUATION: Blinded raters were trained to use the COM-ON-Checklist. The intra-class correlation (ICC) was used to calculate the agreement between raters. RESULTS: The COM-ON-Checklist consists of two parts: the first part evaluates general communication skills; the second part evaluates content-specific aspects of the consultation. The ICC ranged from 0.5 to 0.8, which demonstrates moderate to very good results of inter-rater reliability. DISCUSSION: The COM-ON-Checklist can be used to evaluate specific CST. It is also a feedback source for clinicians because it assesses their personal communication skills in different settings. In conclusion, the COM-ON-Checklist provides a reliable, structured method for assessing communication skills in oncological settings.

Patients' needs and experiences at breast cancer diagnosis: how perceived threat influences the physician-patient interaction.

Physician-patient interaction at breast cancer diagnosis can only succeed if physicians know what patients want. To investigate patients' needs and experiences we conducted semistructured interviews with eight patients. Verbatim transcripts were analyzed according to grounded theory and a typological approach. Patients' needs and experiences concurred with a patient-centered approach in many aspects. The threat perceived by patients following diagnosis strongly influenced their needs and experiences. Three different types of patients were identified: emotionally needy, active, and trustful, adaptive. The typology identified in this study may help physicians to adequately adapt their behavior.

Communication matters: the impact of communication and participation in decision making on breast cancer patients' depression and quality of life.

OBJECTIVE: This study explored the impact of breast cancer patients' experiences of physician-patient communication and participation in decision making on patient depression and quality of life three and six months after primary treatment. METHODS: Participants were 135 German breast cancer patients, recruited within a week after the beginning of treatment. Women were asked to complete a self-administered questionnaire at baseline and three and six months later. RESULTS: Patients who rated their level of information at baseline as high were less depressed after three (p=.010) and six months (p<.001) and experienced higher quality of life after three (p<.001) and six months (p=.049). Patients who participated as much as they had wanted were more satisfied with the decision making process (p<.001) and had lower depression scores three months later (p=.005). The level of participation itself (passive, collaborative, active) and the treatment type had no impact. CONCLUSION: The findings reveal the significance of physician-patient communication and stress the meaning of baseline depression for later adjustment. PRACTICE IMPLICATIONS: A high level of information and tailoring the involvement in decision making to patients' desired level can help patients to better cope with their illness. Physicians should assess and treat depression early in cancer treatment.

Information and decision making: patients' needs and experiences in the course of breast cancer treatment.

OBJECTIVE: This study explored breast cancer patients' preferences and experiences in receiving information and decision making in the course of the first 6 months of cancer treatment. METHODS: Participants were 135 German breast cancer patients, recruited within a week of either surgery or the beginning of neo-adjuvant chemotherapy. Women were asked to complete a self-explanatory questionnaire at baseline and 3 and 6 months later. RESULTS: There was a significant decrease in the importance of specific information needs. The quality of received information through the physician was rated significantly better at baseline than 6 months later. Nearly half of all patients changed their decision making preference at least at one assessment point. Shared decision making rarely took place in the first 6 months of treatment. CONCLUSION: Breast cancer patients' information needs and decision making preferences can change during treatment. Future research should analyse which patients change their decision making preference under which circumstances. PRACTICE IMPLICATIONS: Physicians need to investigate the decision making preferences and information needs of their patients in the course of treatment. Patient oriented communication skills might be helpful to meet patients' preferences and needs.

Concordance between patients' desired and actual decision-making roles in breast cancer care.

This study explored breast cancer patients' preferences and experiences for participation in treatment decision making as well as the concordance between patients' actual and desired decision making. The interplay between depression, anxiety and decision-making preferences was also examined.A consecutive sample of primary breast cancer patients was recruited within a week of either surgery or the beginning of neo-adjuvant chemotherapy in two breast cancer centres in Germany. Women were asked to complete a self-explanatory questionnaire. Most patients (40.2%) of the 137 participants preferred the physician to make the treatment decision. A total of 63.4% were able to fulfil their preferred decision-making role. Breast cancer patients who wanted the physician to make the decision and patients who wanted to make the decision on their own were more likely to have their preferences met than patients who wished to share the decision (p < 0.01). Availability of treatment choice and the level of depression influenced the preferred decision-making preference. Limited concordance between desired and actual decision making of patients with collaborative decision-making preferences suggests the need for better communication and physician training on shared decision making.

Results of a randomized study of telephone versus in-person breast cancer risk counseling.

OBJECTIVE: Women of all risk levels have reported high interest in obtaining genetic testing for breast cancer risk. Breast cancer risk counseling may help women to learn about their risk and appropriate options of testing. This study measured the effects of an intervention in-person and by telephone, compared to a control group. METHODS: Participants were 340 women, recruited through a network of primary care physicians. They received a baseline questionnaire in the mail, were randomized to one of the three study arms, and completed a follow-up survey 3 months later. RESULTS: Both types of counseling were very well received. The counseling decreased women's cancer worry, risk perceptions, and intentions to pursue genetic testing. There were similar effects for both in-person and telephone counseling. CONCLUSION: Genetic counseling can be used to inform women at all risk levels about their breast cancer risk. PRACTICE IMPLICATIONS: Breast cancer risk counseling can be done in-person and by telephone--thereby reaching women in remote areas.

[On past practices and future directions of informed consent in (radiation) oncology]. / Qui nescit simulare nescit curare--Wer nicht täuschen kann, kann nicht heilen. Anmerkungen zur Aufklärung von Patienten in der (Radio-)Onkologie.

BACKGROUND AND PURPOSE: Informed consent, especially in oncology, is predominantly seen from a legal point of view. Such a limited perspective runs the risk of reducing informed consent to some tiresome formalism. The present article highlights how the relationship between patient and physician might be enriched by a comprehensive historicocultural understanding of informed consent. The authors show in which future directions the practice of informed consent might develop. MATERIAL AND METHODS: Analysis of historical and forensic literature regarding informed consent. RESULTS: With the terms "information" and "consent" the last 2500 years of medical history can schematically be divided in three epochs: the first epoch started around 500 years BC, lasted until the 19th century AC and was dominated by the principle of "salus aegroti suprema lex". The patient's benefit was exclusively defined by the treating physician. Formal consent was not required in those times. The era of enlightment brought new ideas to Europe, especially the principle of individual autonomy. In 1894, the Supreme Court of the German Reich decided that any medical intervention without the patient's consent was regarded as physical injury and was thus illegal. Systematic requirements regarding patient information on planned medical interventions were not known. The beginning of the third epoch is marked by the introduction of the term "informed consent" in modern medicine in 1957. Since then, a comprehensive information of the patient is seen as a prerequisite for consent. The patient's right of self-determination is attributed a higher legal and moral value than the physician's concept of the proposed treatment. Nowadays, the debate regarding informed consent is dominated by the continuing differentiation of modern medicine, the development of medical practice as part of the service sector, and the changing ways how patients see themselves. CONCLUSIONS: Social and legal developments have strongly influenced medical practice in the past. The importance of informed consent will continue to rise in the future, while the emphasis of the physician's task will shift from information to counseling. Informed consent will be increasingly established as independent service.

Application of the protection motivation theory to genetic testing for breast cancer risk.

BACKGROUND: Many women, even women at low risk, are interested in genetic testing for breast cancer risk. However, the test has little to offer for women at low to moderate risk. We applied the Protection Motivation Theory (PMT) to investigate predictors of women's motivation to obtain such a test. METHODS: Women at low to moderate risk (n = 330) were recruited through a physician network. They received an informational letter by mail and completed a telephone survey and a written baseline questionnaire. RESULTS: Structural equation analyses with motivation to test as the outcome variable showed that the full model was not supported by the data. However, modifications to the model resulted in good model fit and explained 51% of the variance. Women with increased breast cancer worries, which were influenced by perceived risk, and women who saw more disadvantages of not getting tested showed more motivation to pursue testing. Women who saw more advantages of not getting tested showed less motivation. CONCLUSIONS: Applying the PMT was helpful in determining factors that play a role in women's intentions to obtain genetic testing. Counseling should aim at decreasing perceived risk and breast cancer worries and include a discussion of the consequences of not getting tested.

Patient preferences of decision-making in the context of genetic testing for breast cancer risk.

PURPOSE: We conducted a study on women's preferred physician involvement in the decision to obtain genetic testing for breast cancer risk. METHODS: Women from a primary care physician network completed a telephone survey and a written baseline questionnaire. RESULTS: The majority preferred to make up their own minds. Predictors of leaving the decision to providers were less education, less knowledge, and higher external health locus of control. Trust in one's physician mediated the effect of health locus of control on decision method. CONCLUSION: Physicians will face requests from low-risk women and will need effective communication skills to inform women about the test.