Prevention of depression in adults with long-term physical conditions.

BACKGROUND: Major depression is one of the world's leading causes of disability in adults with long-term physical conditions compared to those without physical illness. This co-morbidity is associated with a negative prognosis in terms of increased morbidity and mortality rates, increased healthcare costs, decreased adherence to treatment regimens, and a substantial decline in quality of life. Therefore, preventing the onset of depressive episodes in adults with long-term physical conditions should be a global healthcare aim. In this review, primary or tertiary (in cases of preventing recurrences in those with a history of depression) prevention are the focus. While primary prevention aims at preventing the onset of depression, tertiary prevention comprises both preventing recurrences and prohibiting relapses. Tertiary prevention aims to address a depressive episode that might still be present, is about to subside, or has recently resolved. We included tertiary prevention in the case where the focus was preventing the onset of depression in those with a history of depression (preventing recurrences) but excluded it if it specifically focused on maintaining an condition or implementing rehabilitation services (relapse prevention). Secondary prevention of depression seeks to prevent the progression of depressive symptoms by early detection and treatment and may therefore be considered a 'treatment,' rather than prevention. We therefore exclude the whole spectrum of secondary prevention. OBJECTIVES: To assess the effectiveness, acceptability and tolerability of psychological or pharmacological interventions, in comparison to control conditions, in preventing depression in adults with long-term physical conditions; either before first ever onset of depressive symptoms (i.e. primary prevention) or before first onset of depressive symptoms in patients with a history of depression (i.e. tertiary prevention). SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registries, up to 6 February 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of preventive psychological or pharmacological interventions, specifically targeting incidence of depression in comparison to treatment as usual (TAU), waiting list, attention/psychological placebo, or placebo. Participants had to be age 18 years or older, with at least one long-term physical condition, and no diagnosis of major depression at baseline (primary prevention). In addition, we included studies comprising mixed samples of patients with and without a history of depression, which explored tertiary prevention of recurrent depression. We excluded other tertiary prevention studies. We also excluded secondary preventive interventions. Primary outcomes included incidence of depression, tolerability, and acceptability. Secondary outcomes included severity of depression, cost-effectiveness and cost-utility. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 11 RCTs, with one trial on psychological interventions, and 10 trials on pharmacological interventions. Data analyses on the psychological intervention (problem-solving therapy compared to TAU) included 194 participants with age-related macular degeneration. Data analyses on pharmacological interventions included 837 participants comparing citalopram (one trial), escitalopram (three trials), a mixed sample of fluoxetine/nortriptyline (one trial), melatonin (one trial), milnacipran (one trial), and sertraline (three trials), each to placebo. Included types of long-term physical conditions were acute coronary syndrome (one trial), breast cancer (one trial), head and neck cancer (two trials), stroke (five trials), and traumatic brain injury (one trial). Psychological interventions Very low-certainty evidence of one study suggests that problem solving therapy may be slightly more effective than TAU in preventing the incidence of depression, immediately post-intervention (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.20 to 0.95; 194 participants). However, there may be little to no difference between groups at six months follow-up (OR 0.71, 95% CI 0.36 to 1.38; 190 participants; one study; very low-certainty evidence). No data were available regarding incidence of depression after six months. Regarding acceptability (drop-outs due to any cause), slightly fewer drop-outs occurred in the TAU group immediately post-intervention (OR 5.21, 95% CI 1.11 to 24.40; 206 participants; low-certainty evidence). After six months, however, the groups did not differ (OR 1.67, 95% CI 0.58 to 4.77; 206 participants; low-certainty evidence). This study did not measure tolerability. Pharmacological interventions Post-intervention, compared to placebo, antidepressants may be beneficial in preventing depression in adults with different types of long-term physical conditions, but the evidence is very uncertain (OR 0.31, 95% CI 0.20 to 0.49; 814 participants; nine studies; I2 =0%; very low-certainty evidence). There may be little to no difference between groups both immediately and at six months follow-up (OR 0.44, 95% CI 0.08 to 2.46; 23 participants; one study; very low-certainty evidence) as well as at six to 12 months follow-up (OR 0.81, 95% CI 0.23 to 2.82; 233 participants; three studies; I2 = 49%; very low-certainty evidence). There was very low-certainty evidence from five studies regarding the tolerability of the pharmacological intervention. A total of 669 adverse events were observed in 316 participants from the pharmacological intervention group, and 610 adverse events from 311 participants in the placebo group. There was very low-certainty evidence that drop-outs due to adverse events may be less frequent in the placebo group (OR 2.05, 95% CI 1.07 to 3.89; 561 participants; five studies; I2 = 0%). There was also very low-certainty evidence that drop-outs due to any cause may not differ between groups either post-intervention (OR 1.13, 95% CI 0.73 to 1.73; 962 participants; nine studies; I2 = 28%), or at six to 12 months (OR 1.13, 95% CI 0.69 to 1.86; 327 participants; three studies; I2 = 0%). AUTHORS' CONCLUSIONS: Based on evidence of very low certainty, our results may indicate the benefit of pharmacological interventions, during or directly after preventive treatment. Few trials examined short-term outcomes up to six months, nor the follow-up effects at six to 12 months, with studies suffering from great numbers of drop-outs and inconclusive results. Generalisation of results is limited as study populations and treatment regimes were very heterogeneous. Based on the results of this review, we conclude that for adults with long-term physical conditions, there is only very uncertain evidence regarding the implementation of any primary preventive interventions (psychological/pharmacological) for depression.

[Online Rehab-Need Test (OREST): Effectiveness of an Invitation to Proactive Screening (self-test) for the Need for Medical Rehabilitation Among Individuals Covered by the German Statutory Pension Insurance Agencies in Baden-Württemberg and the Rhine Region]. / Online-Rehabedarfstest (OREST): Wirksamkeit einer Einladung zu einem proaktiven Screening (Selbsttest) auf Bedarf an medizinischen Rehabilitationsmaßnahmen bei Versicherten der Deutschen Rentenversicherung Baden-Württemberg und Rheinland.

PURPOSE: Up to now, there has been a lack of proactive approaches on the part of the rehabilitation providers, while simultaneously a suspected unmet rehabilitation need exists in some groups of insured persons. Therefore, the effectiveness of the invitation to a web-based self-test for rehabilitation needs as a new access route to medical rehabilitation was evaluated. The main question was whether the intervention leads to more approved rehabilitation applications in the follow-up period of 22 months and whether this effect is also apparent after controlling other influencing variables. METHODS: A randomized, controlled study with N=8000 insured persons of two regional statutory pension insurance agencies was conducted to check the effectiveness of the intervention. Insured persons of the intervention group (IG; n=4000) were informed by mail about the web-based self-test and received individual access data for it (user ID and PIN). The control group (CG; n=4000) received no information about the self-test. The primary outcome was the rate of approved rehabilitation applications, the secondary outcome was the application rate regardless of approval. RESULTS: Groups do not differ significantly in terms of primary or secondary outcomes. Even after controlling for other influencing factors, the intervention does not contribute to the prediction of outcomes, but some control variables, such as previous rehabilitation experience, prove to be important predictors for the application. CONCLUSION: The mere offer of a self-test for rehabilitation need by the pension insurance institution has no effect on the application process. Hence a letter from the pension insurance institution as the sole means of access does not appear suitable for increasing the rate of meaningful rehabilitation applications.

Systematic development of practice guidelines for psychological interventions in stroke rehabilitation.

Purpose: We aimed to develop evidence-based practice guidelines that can support decision-making in individual cases and be used by a multidisciplinary team in stroke rehabilitation.Materials and methods: We conducted a literature search (step 1), and a survey of all neurological rehabilitation facilities in Germany concerning their structural working conditions and current practices (step 2). Based on this information, we drafted a first version of the practice guidelines, and discussed them with a group of experts (step 3). We also consulted concurrently with senior psychologists, head physicians (step 4), and patients after stroke (step 5). We revised the guidelines until consensus on the final version was reached (step 6).Results: Referring to the ICF for guidance, the practice guidelines comprise of psychological recommendations in five problem areas ("Participation - Major Aims of Rehabilitation", "Cognition", "Affect & Behavior", "Risk Factors", and "Specific Problems & Aspects"), and provide preliminary remarks on general frame conditions and procedural requirements. The practice guidelines were widely accepted by head psychologists and physicians of in- and outpatient neurological rehabilitation with an average agreement of 97% (range: 88-100%).Conclusions: Our practice guidelines include detailed recommendations for psychological interventions that can guide individual decision-making by a multidisciplinary team. Specific aspects to foster implementation were considered, and attempts were made to promote their dissemination.Implications for RehabilitationWe developed practice guidelines for psychological interventions in rehabilitation after stroke based on the best available evidence.The practice guidelines include detailed recommendations for psychological interventions that can guide individual decisions by a multidisciplinary team.The practice guidelines are highly specific, and have been widely agreed upon by a group of experts from different professions as well as by researchers, patients, and clinicians (average agreement: 97%).The practice guidelines offer knowledge on different areas of psychological impairment, can help guide diagnostic and therapeutic procedures for individual patients, and thus, improve standard care in neurological rehabilitation.

(Neuro)Psychological Interventions for Non-Motor Symptoms in the Treatment of Patients with Parkinson's Disease: a Systematic Umbrella Review.

Conducted in a multidisciplinary and multimodal setting, the main objectives of neuropsychological treatment are to improve cognition, alleviate affective disorders, and to promote activities and participation. This article reviews the evidence on therapeutic or educative interventions based on psychological principles for patients with Parkinson's disease. The electronic bibliographic databases MEDLINE, PsycINFO, PSYNDEX, and CINAHL were systematically searched for meta-analyses on psychological interventions for patients with Parkinson's disease, published from January 2000 to June 2018. We extracted psychological interventions, non-motor outcomes, effect sizes, confidence intervals, and I2 heterogeneity statistics. In addition, we rated the level of evidence on an intervention's effectiveness regarding a specific outcome. We identified 15 meta-analyses out of 1084 search results and identified a broad variety of psychological interventions for non-motor symptoms in patients with Parkinson's disease. In total, 48 outcome-intervention-pairs were extracted. Psychotherapy, mind and body interventions, and cognitive training are promising treatment approaches when addressing cognition, depression, and QoL in patients with Parkinson's disease. The available evidence on the effectiveness of psychological interventions in the treatment of symptoms in patients with Parkinson's disease is very heterogeneous. Still, our review reveals that some interventions are appropriate and effective for a variety of symptoms. Primary studies are not considered in this review, resulting in the omission of potentially relevant findings. Further high-quality research is needed to confirm the existing evidence and to explore the potential of psychological interventions for patients with Parkinson's disease.

Intervention policies and social security in case of reduced working capacity in the Netherlands, Finland and Germany: a comparative analysis.

OBJECTIVES: Working age disability is a major challenge for policymakers in European countries. This pertains to both occupational reintegration and social benefits for work incapacity. In many states reforms have been initiated aimed at reducing disability scheme inflow and fostering return to work. Our study was motivated by the question as to which aspects of these reforms seem to have been effective. METHODS: Three different approaches were utilized: case vignettes, interviews and expert workshops in the respective countries (Netherlands and Germany in 2012; Finland in 2015), and a systematic search for relevant studies on occupational reintegration was performed. RESULTS: We found considerable differences as to the assessment of work incapacity and resulting monetary benefits in the three countries. Also, organisation and practices of occupational reintegration vary from one country to another. Major differences concern (1) the timing of interventions, (2) employer responsibility and workplace involvement, (3) incentives and sanctions and (4) organisational and procedural issues. CONCLUSIONS: Our results may partly explain why some reform strategies have been more successful than others, and thus contribute to the further development of social and labour policies in Europe.

Telephone-delivered lifestyle support with action planning and motivational interviewing techniques to improve rehabilitation outcomes.

OBJECTIVE: In this randomized controlled trial, we evaluated the effectiveness of a telephone-delivered intervention based on the Health Action Process Approach (HAPA) after discharge from inpatient rehabilitation to address behavior change, emotional status, and glycemic control in patients with Type 2 diabetes. DESIGN: In a German rehabilitation center, 249 patients with Type 2 diabetes were separated into randomized groups, either a 12-month telephone follow-up support group or the usual care group. The counselor identified personal target areas and intervention modules and developed with the patient an individualized action plan for the telephone support. To enhance motivational processes, they used motivational interviewing techniques. Counselors called patients monthly to support the implementation of the personal plans into the patients' daily routines and to screen for emotional problems. Assessments measured exercise, diet, medication adherence, psychological variables, body mass index, HbA1c, and cardiovascular risk. RESULTS: Twelve months after inpatient rehabilitation, the telephone group's rate of physical activity rose by 26% compared with the usual care group's 10%. Patients in the intervention group exhibited greater improvements in terms of their illness burden, psychological well-being, and depression. HbA1c fell in the telephone group but increased in the usual care group (-0.68% vs. 0.12%). The intervention group's cardiovascular risk fell, whereas the usual care group's rose (-0.57 vs. 0.23). CONCLUSION: A theory-based telephone-delivered follow-up intervention utilizing motivational interviewing techniques and focusing on personalized action planning demonstrated improvements in patients' level of activity and health status 12-months postrehabilitation discharge and may be a beneficial supplement to rehabilitation programs. (PsycINFO Database Record

Can trajectories of glycemic control be predicted by depression, anxiety, or diabetes-related distress in a prospective cohort of adults with newly diagnosed type 1 diabetes? Results of a five-year follow-up from the German multicenter diabetes cohort study (GMDC-Study).

AIMS: The longitudinal association between glycemic control with depression, anxiety or diabetes-related distress in type 1 diabetes is poorly understood. Therefore, we examined long-term trajectories of HbA1c in a new-onset cohort of adults with type 1 diabetes, and analyzed associations with depression, anxiety, and diabetes-related distress. METHODS: We included 313 newly diagnosed adults with type 1 diabetes in a prospective multicenter cohort study. Depression, anxiety, and diabetes-related distress were assessed starting with the diabetes diagnosis and at five annual surveys. HbA1c-measurements started with the one-year follow-up. HbA1c trajectories were analyzed applying Growth mixture modeling, while prediction of membership in the trajectories classes was analyzed using multiple regression, and one-way ANOVA/Chi2 to identify differences between classes. RESULTS: Average HbA1c increased constantly: follow-up at 1-year 6.5% (48 mmol/mol), 2-years 6.9% (52 mmol/mol), 3-years 7.1% (54 mmol/mol), 4-years 7.1% (54 mmol/mol), and 5-years 7.4% (57 mmol/mol). HbA1c trajectories included one 'good control' and three 'poor control' (52% of patients) classes. At the five-year follow-up, mean HbA1c was 6.3% (45 mmol/mol) in the 'good control' class, and ranging from 7.9% (63 mmol/mol) to 9.0% (75 mmol/mol) in the three 'poor control' classes. Classes were neither predicable, nor differentiated by depression, anxiety, or diabetes-related distress. CONCLUSIONS: We identified distinct trajectories of glycemic control. Depression and anxiety were highly prevalent but they neither predicted 'poor'/'good' glycemic control trajectories nor were they associated with glycemic control at any assessment point.

Effectiveness and cost-effectiveness of a guided internet- and mobile-based depression intervention for individuals with chronic back pain: protocol of a multi-centre randomised controlled trial.

INTRODUCTION: Depression often co-occurs with chronic back pain (CBP). Internet and mobile-based interventions (IMIs) might be a promising approach for effectively treating depression in this patient group. In the present study, we will evaluate the effectiveness and cost-effectiveness of a guided depression IMI for individuals with CBP (eSano BackCare-D) integrated into orthopaedic healthcare. METHODS AND ANALYSIS: In this multicentre randomised controlled trial of parallel design, the groups eSano BackCare-D versus treatment as usual will be compared. 210 participants with CBP and diagnosed depression will be recruited subsequent to orthopaedic rehabilitation care. Assessments will be conducted prior to randomisation and 9 weeks (post-treatment) and 6 months after randomisation. The primary outcome is depression severity (Hamilton Rating Scale for Depression-17). Secondary outcomes are depression remission and response, health-related quality of life, pain intensity, pain-related disability, self-efficacy and work capacity. Demographic and medical variables as well as internet affinity, intervention adherence, intervention satisfaction and negative effects will also be assessed. Data will be analysed on an intention-to-treat basis with additional per-protocol analyses. Moreover, a cost-effectiveness and cost-utility analysis will be conducted from a societal perspective after 6 months. ETHICS AND DISSEMINATION: All procedures are approved by the ethics committee of the Albert-Ludwigs-University of Freiburg and the data security committee of the German Pension Insurance (Deutsche Rentenversicherung). The results will be published in peer-reviewed journals and presented on international conferences. TRIAL REGISTRATION NUMBER: DRKS00009272; Pre-results.

[Comparison of medical rehabilitation in various European countries and the impact of European law on rehabilitation practice in Germany]. / Medizinische Rehabilitation im europäischen Vergleich und Auswirkungen des europäischen Rechts auf die deutsche Rehabilitation.

Medical rehabilitation practice differs substantially among European countries. In most countries, rehabilitation is predominantly carried out on an outpatient basis. It is funded by health care, and rehabilitation facilities are not very specialized in terms of specific indications. In contrast, medical rehabilitation in Germany is mostly carried out on an in-patient basis as a contained 3­week treatment. European law and European policies merely have an indirect impact on rehabilitation practice in Germany. In this article, the advantages and disadvantages of the various forms of rehabilitation services are discussed.

Development of practice guidelines for psychological interventions in the rehabilitation of patients with oncological disease (breast, prostate, or colorectal cancer): Methods and results.

OBJECTIVE: The goal of this project was to develop evidence- and consensus-based practice guidelines for psychological interventions in the rehabilitation of patients with oncological disease (breast, prostate, or colorectal cancer). METHODS: First of all, we conducted a literature search and survey of all oncological rehabilitation centers in Germany (N = 145) to obtain a thorough perspective of the recent evidence, guidelines, the structural framework, and practice of psychological services in oncological rehabilitation. Next, an expert workshop was held with national experts from scientific departments, clinicians from rehabilitation centers, and patients. In this workshop, we drafted and agreed upon an initial version of the practice guidelines. Afterwards, the practice guidelines were sent to all head physicians and senior psychologists at oncological rehabilitation centers in Germany for approval (N = 280 questionnaires). In addition, key recommendations were discussed with a group of rehabilitation patients. Finally, the practice guidelines were revised by the expert panel and made available online to the public. RESULTS: The practice guidelines have been widely accepted by both the expert panel and the surveyed clinicians and patients. They include recommendations for psycho-oncological interventions that should be offered to all rehabilitation patients with breast, prostate, or colorectal cancer. They also comprise recommendations for specific problem areas concerning psychological functions, body functions, and environmental and personal factors. CONCLUSIONS: The practice guidelines provide detailed recommendations for high-quality psychosocial care in an oncological rehabilitation context. It is their aim to guide the multidisciplinary team, especially psychologists and physicians, in their daily practice.

Trajectories of depression in adults with newly diagnosed type 1 diabetes: results from the German Multicenter Diabetes Cohort Study.

AIMS/HYPOTHESIS: There is a paucity of longitudinal data on type 1 diabetes and depression, especially in adults. The present study prospectively analysed trajectories of depressive symptoms in adults during the first 5 years of living with type 1 diabetes. We aimed to identify distinct trajectories of depressive symptoms and to examine how they affect diabetes outcome. METHODS: We reanalysed data from a prospective multicentre observational cohort study including 313 adults with newly diagnosed type 1 diabetes. At baseline and in annual postal surveys over 5 consecutive years, we gathered patient characteristics and behavioural and psychosocial data (e.g. Symptom Checklist-90-R [SCL-90-R]). Medical data (e.g. HbA1c levels) was obtained from the treating physicians. We applied growth mixture modelling (GMM) to identify distinct trajectories of depression over time. RESULTS: Five years after diagnosis, 7.8% (n = 20) of patients were moderately depressed and 10.2% (n = 26) were severely depressed. GMM statistics identified three possible models of trajectories (class 1, 'no depressive symptoms'; class 2, 'worsening depressive symptoms that improve after 2 years'; class 3, 'worsening depressive symptoms'). Severity of depression symptoms at baseline (subscale of the SCL-90-R questionnaire) significantly predicted membership of classes 2 and 3 vs class 1. After 5 years, higher HbA1c values were detected in class 3 patients (mean = 8.2%, 66 mmol/mol) compared with class 1 and class 2 (both: mean = 7.2%, 55 mmol/mol). CONCLUSIONS/INTERPRETATION: We identified distinct trajectories of depressive symptoms that are also relevant for diabetes outcome. Patients with worsening depressive symptoms over time exhibited poor glycaemic control after the first 5 years of living with diabetes. They also exhibited a reduced quality of life and increased diabetes-related distress.

Trajectories of depressive symptoms after a major cardiac event.

Depression is a common comorbidity in cardiac patients. This study sought to document fluctuations of depressive symptoms in the 12 months after a first major cardiac event. In all, 310 patients completed a battery of psychosocial measures including the depression subscale of the Symptom Check List-90-Revised. A total of 252 of them also completed follow-up measures at 3 and 12 months. Trajectories of depressive symptoms were classified as none, worsening symptoms, sustained remission, and persistent symptoms. Although the prevalence of depressive symptoms was consistent at each assessment, there was considerable fluctuation between symptom classes. Regression analyses were performed to identify predictors of different trajectories.

Effects of a hospital-based education programme on self-care behaviour, care dependency and quality of life in patients with heart failure--a randomised controlled trial.

AIMS AND OBJECTIVES: To evaluate the effects of a nurse-led, hospital-based heart failure specific education session with a three-month telephone follow-up on self-care behaviour, care dependency and quality of life for patients with chronic heart failure. BACKGROUND: Patient education in patients with heart failure is able to promote heart failure-specific self-care, to reduce mortality, morbidity and rehospitalisation rates and to enhance quality of life, especially if heart failure education is embedded in a multidisciplinary approach. Evidence of the effect of a nurse-led self-care education, quality of life and care dependency in addition to standard medical treatment in Germany is lacking. DESIGN: Nonblinded, prospective, single-centre, randomised controlled trial. METHOD: Sixty-four patients were allocated either to the intervention group or to the control group. Patients in the intervention group received education about heart failure self-care with a consecutive telephone follow-up over three months in addition to standard medical treatment. Patients in the control group received standard medical treatment only. RESULTS: Data of 110 patients (58 in the intervention group and 52 in the control group) with a mean age of 62 years and mean left ventricular ejection fraction of 28·2% could be analysed. Self-care education had a significant influence on overall heart failure self-care but not on quality of life and care dependency. CONCLUSION: A single education session with a consecutive telephone follow-up is able to improve overall self-care behaviours but not quality of life. Care dependency was not influenced by the education session. RELEVANCE TO CLINICAL PRACTICE: The easy to implement and short educational intervention has a positive effect on self-care behaviour for patients with heart failure. However, there was no effect on quality of life and care dependency. To improve quality of life and to influence care dependency, different measures have to be applied.

Web-based interventions for comorbid depression and chronic illness: a systematic review.

Web-based interventions offer potential benefits for managing and treating depression in the context of chronic physical illness, however their use with this population has yet to be quantitatively assessed. The present systematic review examined the biopsychosocial data from 11 independent studies (N = 1348 participants), including randomised controlled and quasi-experimental designs most commonly performed with diabetes and multiple sclerosis. Study quality was evaluated using the Downs and Black (1998) index, with most studies being statistically underpowered although internal validity was demonstrated. Treatment outcomes were quantified using Cohen's d effect sizes. Results indicated significant short-term improvements in depression severity (d w = 0.36, CI = 0.20-0.52, p < 0.01), in addition to quality of life, problem-solving skills, functional ability, anxiety and pain-related cognitions (d range = 0.23 to 1.10). Longer-term outcomes could not be determined based on the limited data. Further robust studies are required before wider adoption of web techniques takes place.

Psychological interventions in the rehabilitation of patients with chronic low back pain: evidence and recommendations from systematic reviews and guidelines.

The purpose of the article is to summarize evidence and recommendations for psychological interventions in the rehabilitation of patients with chronic low back pain. We carried out a systematic literature search in several databases and on the websites of professional associations to identify relevant reviews and guidelines. In addition to the electronic search, a handsearch was carried out. Eligible publications were selected. We extracted and summarized both evidence for psychological interventions and recommendations on psychological diagnostics and interventions. Six systematic reviews and 14 guidelines were included. We collected recommendations and partially restricted evidence on the following psychological interventions: behavioural therapy, fear-avoidance training, stress management, relaxation therapy, patient education and back school. Most available evidence for psychological interventions in the rehabilitation of patients with chronic low back pain is of moderate to low quality. In addition, some of the older evidence is inapplicable to modern interventions using a biopsychosocial approach. Thus, high quality and current evidence is needed. The summary of guidelines shows that multimodal, multidisciplinary programmes including psychological interventions have become standard in the rehabilitation of patients with chronic low back pain. In most guidelines, however, there are no recommendations on which (psychological) intervention should be considered for which specific problem (problem-treatment pairs). Suggestions for future research and future guidelines are made.

The association of depressive symptoms and ischemic heart disease in older adults is not moderated by gender, marital status or education.

OBJECTIVES: To investigate whether the association of depression and ischemic heart disease (IHD) is moderated by gender, marital status or education. METHODS: Data from the 1998 Medicare Health Outcome Survey (HOS) with a 2 year follow-up were re-analyzed. 63,965 older adults who had not reported IHD at baseline were included. Logistic regression analysis modelled the effects of depression, somatic risk factors, and demographic variables on IHD after 2 years. RESULTS: Two year reported incidence of IHD was 6.2%. Depression was associated with a 1.53-fold risk of developing IHD after controlling for somatic risk factors and demographic variables. Male gender, lower than high-school education, and being married were associated with IHD. Neither of these variables yielded significant interactions with depression, nor did any of the higher-order interaction terms. CONCLUSIONS: The association of depression and IHD seems independent from pivotal demographic variables. Possibly the impact of psychosocial factors in this sample of older people is weak compared to medical conditions and age. Also the possibility exists that a common factor such as a shared genetic vulnerability contributes to both depressive symptoms and IHD.

Medium-term effects of cardiac rehabilitation in Germany: systematic review and meta-analysis of results from national and international trials.

BACKGROUND: Contrary to international practice, cardiac rehabilitation (CR) in Germany is predominantly offered as comprehensive inpatient treatment lasting for 3 weeks. Evidence for this kind of health care is poor, comprising observational cohort studies only. METHODS: We conducted a systematic search for relevant German studies (1990-2004). International studies were selected from recent meta-analyses. Medium-term (12 month) results for blood lipids, blood pressure, functional capacity and psychological wellbeing, as well as cardiac morbidity and mortality are reported. RESULTS: For most outcomes, effect sizes in national studies are poorer than those from international interventions or, in the case of blood pressure and depression, even poorer than international controls. CONCLUSIONS: Altogether, our analysis does not suggest that comprehensive inpatient rehabilitation treatment is superior to international practice of long-term outpatient rehabilitation.

Gender-specific issues in cardiac rehabilitation: do women with ischaemic heart disease need specially tailored programmes?

Ischaemic heart disease (IHD) has changed from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s. Most clinical studies during the past three decades have been conducted with men. Cardiac rehabilitation programmes were also developed with special regard to improving the rate of return to work in middle-aged men. The rehabilitation needs of older patients and women in particular have been largely neglected. The aim of this review is briefly to outline our present knowledge on gender issues in cardiac rehabilitation, and to specify barriers with regard to physical activities especially in (older) women. Coping with a cardiac event, women tend to minimize or play down the impact of their health situation and avoid burdening their social contacts. After a first cardiac event, women report greater psychological distress and lower self-efficacy and self-esteem. In addition, older age, lower exercise levels and reduced functional capacity or co-morbid conditions such as osteoporosis and urinary incontinence are barriers to physical activities in women with IHD. Recent studies on psychosocial intervention revealed less favourable results in women compared with men. These findings have not yet been well explained. This emphasizes our current lack of knowledge about the processes and determinants of successful psychosocial interventions in men and women with IHD. A large (European) trial on gender-specific coping styles, needs, and preferences of older women, and the effects of psychosocial intervention is proposed.

Outcomes of cardiac rehabilitation with versus without a follow-up intervention rendered by telephone (Luebeck follow-up trial): overall and gender-specific effects.

The effects of a nurse-managed secondary prevention program for patients after acute cardiac events were examined. Special interest was given to gender-specific results. The design was a prospective, randomized, controlled trial involving 343 patients following 3 weeks of inpatient cardiac rehabilitation, randomly assigned to either of two study groups. Patients in the treatment group were contacted monthly by phone over 1 year. The main goals of the intervention were the reduction of behavioural coronary risk factors and enhancing quality of life. The program was conducted by specially trained nurses. The control group received written information only. Primary outcome was the Framingham risk score. Follow-up examination after 12 months was completed by 297 patients. Patients in the intervention group showed lower Framingham risk scores as compared to controls. Separate analyses by sex revealed that this was mostly due to the men in the sample. Women, on the other hand, showed a significant rise of clinically relevant anxiety/depressiveness in the control but not in the intervention group; in males there were no differences between study conditions. In conclusion, telephone counselling by specially trained nurses seems a cost-effective way to achieve a lasting reduction in cardiac risk factors and to maintain the effects of cardiac rehabilitation.