[Drug and psychological therapies in chronic subjective tinnitus. Meta-analysis of therapeutic effectiveness]

A metaanalysis on pharmacological and psychological treatment reports was conducted in order to evaluate the overall effectiveness of these treatment conditions in chronic tinnitus. A totality of 109 treatment studies published between 1976 and 3/1995 and meeting minimal inclusion criteria was located, but only 24 studies reporting sufficient information could be analyzed. The methodological quality of the studies was evaluated by a coding scheme, and the resulting index of effectiveness has been weighted by this standard as well as by sample size. Effect sizes of pharmacological studies were ES = 1.27 and by this higher than the ones for psychological studies with ES = 0.88. This finding is attenuated by high (unspecific) placebo effects of ES = 0.65 in pharmacological studies compared to ES = 0.10 in psychological studies. In general, patients from psychological studies further improve after treatment in cases where catamnestic measurements have been conducted.

[Indirect costs and time costs of (ambulatory) rehabilitation of mothers with psychosomatic disorders who have preschool children]

Ambulatory rehabilitation concepts for women with psychosomatic disorders and with pre-school children are rare and moreover not yet assessed. An economic concept for the evaluation of indirect costs and (patient) time costs is being developed in this article and applied to an ongoing ambulatory rehabilitation programme for mothers at the Hanover Medical School. In health economic evaluations time cost is expressed by loss and reduction of working time, time for housework, and leisure time. These are indirect cost items (working time) and direct non-medical costs (housework and leisure time). To estimate the loss of working time (and hence production loss) the human capital approach and the frictional cost approach can be applied. Loss of time due to housework can be estimated either by the production of goods and services or by the opportunity costs of the equivalent working time. Loss of leisure time can be partial or total whereas a total loss and a loss of working time are considered to be analogous. The health economic evaluation of the ambulatory rehabilitation programme for mothers is designed as a randomised controlled study with repeated data collection. The parameters of indirect and direct non-medical costs are measured at the beginning of the rehabilitation programme and until twelve months later by means of questionnaires, face-to-face and telephone interviews. So far, results of the evaluation show that the actual time cost of the rehabilitation programme is DM 6,162 for each mother and the time cost because of the utilisation of the health care system is DM 996 per four weeks. Therefore, the patient costs are obviously higher than the direct medical costs for the programme which makes it clear that taking into account the costs of the patient (especially the time costs) can make a decisive difference in the evaluation of alternative treatment programmes and may possibly reverse the advantages of an alternative.

[Illness-related stress in psoriasis vulgaris. Validation of the "Psoriasis Daily Stress Inventory"]

BACKGROUND AND OBJECTIVE

Illness specific stress plays an important part in the daily life of psoriatic patients. Until now for the measurement of relevant aspects of daily stress only the "Psoriasis Life Stress Inventory" (PLSI) of Gupta & Gupta exists; with the "Psoriasis-Alltagsstress-Inventar" (PAI), a German version of the PLSI is presented and its psychometric properties are discussed.

PATIENTS/METHODS

385 in-patients completed the PAI. The internal validity was examined by factor analysis. Moreover, the correlations between the PAI total score and sociodemographic parameters (ANOVA) and extent of skin involvement (multiple regression) were determined.

RESULTS

The PLSI score proves to be sufficiently independent of age, sex, age at onset, and general extent of skin involvement. However, affections of the hands, the lower abdomen and the genitals show a strong influence on the total score. We found marked interrelations with the stigmatization feeling ("Questionnaire on Experience with Skin Complaints" QES, Schmid-Ott et al. 1998).

CONCLUSIONS

The results suggest that the PAI is a useful and psychologically relevant questionnaire for psoriatic patients.

[Concept for a health care economic evaluation of short- and long-term costs and effectiveness parameters of an expanded ambulatory psychosomatic rehabilitation program]

There are only few ambulatory rehabilitation concepts for mothers with psychosomatic disorders (prevalence 5%). Also, only little is known about the evaluation of these programmes. This study compares the socioeconomic evaluations of an ambulatory rehabilitation programme with a post-assistance programme and one without a post-assistance programme. The superior programme should be determined by weighing all relevant costs and benefits. The intensive phase of the ambulatory rehabilitation programme consists of an eight-week treatment with group, single, body and art therapy. The post-assistance programme spans a period of nine-months with 36 sessions of psychoanalytic group therapy. The evaluation of both programme alternatives is made by with the evaluation tool of socioeconomic analyses. For consideration and pricing of costs all direct medical costs, direct non-medical costs and indirect costs are being monitored. Outcomes assessment is realised by cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis. Utilisation of the health care system is being assessed with questionnaires. Measurements are being performed at the beginning and the end of the rehabilitation programme and three, six, nine and twelve months later. Mothers with children aged six years and younger and suffering from various psychosomatic disorders were included in this study. The costs identified for the rehabilitation programme are DM 5571.10 (intensive care and post-assistance programme) and DM 1512.40 (intensive care) per patient. Further progress of the study will show if future cost will differ between the two alternatives. For the comparison of both alternatives all costs will be linked with outcomes. It remains to be seen that additional costs of the post-assistance programme will be compensated with positive outcomes. A sensitivity analysis will show if variation of assumptions will influence the cost-benefit-ratio of the different alternatives.

Validity study for the stigmatization experience in atopic dermatitis and psoriatic patients

A central experience of patients with atopic dermatitis and psoriasis is the feeling of stigmatization. This can be estimated by the "Questionnaire on Experience with Skin Complaints" (QES), based on the "Feelings of Stigmatization Questionnaire" by Ginsburg & Link. This study was designed to evaluate the psychometric properties of the QES, especially the validity of this questionnaire, and to supply more information about the stigmatization experiences of patients with atopic dermatitis and psoriasis. Three groups of patients were analysed: 76 with atopic dermatitis, 81 and 217 with psoriasis, respectively. The comparison of subgroups with different affected regions revealed that the genital region is especially relevant for the stigmatization experience in these patients. In addition, the feeling of stigmatization (estimated by the QES) is relatively independent of the different dimensions of the "Trier Scales of Coping with Diseases", except for the depressive coping style "Rumination" measuring a high amount of inner concern with the afflicting disease. It can be concluded that the QES is a valid and reliable instrument for examining the stigmatization experience of patients with atopic dermatitis and psoriasis.

[Results of a 1-year follow-up study of neighborhood ambulatory aftercare after inpatient psychosomatic rehabilitation]

Attention has been repeatedly drawn to the necessity to support patients after psychosomatic rehabilitation with their transfer of skills acquired during their stay at the interface between their inpatient treatment and their reintegration into everyday life. The authors' concept of the outpatient aftercare was already introduced in an earlier paper. This article presents the results of the one-year follow-up. A comparison with a control group revealed a further reduction of patients' depression. In contrast to the control group, the reduction in fear and discomfort already achieved during inpatient rehabilitation remained stable. At the same time the ability to cope with everyday life was expanded. Compared with the control group the participants of the aftercare could reduce the absence from work, days spent in hospital and visits to the doctor more than twice as much. Methodological problems of the design of the study are critically discussed.

[Psychotherapy research--how it should (not) be done. An expert reanalysis of comparative studies by Grawe et al. (1994)]

22 psychotherapy outcome studies used in the Bernese meta-analysis by Grawe, Donati and Bernauer (1994) for a treatment comparison between behavioural and psychoanalytic-psychodynamic treatment concepts were reanalysed by 12 expert psychotherapy researchers independent of each other. Three clinical criteria served as basic criteria for the assessment of the methodological quality of the 22 comparative studies: treatment dosage, therapists' competence or expertise, and an adequate realisation of the intended treatment concept. The expert ratings were then compared with an evaluation of an assessment of a research team from the University of Ulm and with the one from the Bernese research team. Contrary to the Bernese meta-analysis, both the experts and the Ulm research group conclude that only 5 or 8 of the 22 studies, respectively, could be accepted for a relatively fair comparison between the treatments under study. Out of the 5/8 studies, none could be considered fully suitable for a treatment comparison, at the most only moderately suitable. These remaining 5 or 8 studies, respectively, do not prove superiority of one treatment over the other. Hence, the "Dodo Bird Verdict" stands up under scrutiny.

[Medical and non-medical ambulatory psychotherapy in the Hannover area. A specialty, school and sex related comparison]

The result of an investigation of 128 from 283 (45.2%) medical and psychological psychotherapists established in the city of Hannover is presented. The aim of the study is to characterize the situation of psychotherapeutical care not only by the number of psychotherapists in relation to inhabitants but also by the working time spent for psychotherapy. Besides we found gender, school of psychotherapy and professional experience as factor influencing the patients waiting time for beginning a psychotherapy. In contrast to other studies, the number of medical and psychological psychotherapists is not different, nevertheless the psychotherapeutical care in Hannover is not ensured.

Psychosomatic medicine and primary care in Germany

The development and training in psychosomatic medicine in Germany are presented. This branch of medicine emphasizes the biopsychosocial understanding of disorders, and psychological, particularly psychoanalytic, methods are used. The outcome of treatment studies are awaited to clarify their role in the medical services of Germany.

[Inpatient treatment of a patient with large duodenal diverticulum and psychogenic vomiting--somatic and psychosomatic approach]

The inpatient psychotherapy of a female patient with a large duodenal divertivulum and psychogenic vomiting is described. The specifics of the inpatient treatment setting necessary for change are presented thereby demonstrating to be helpful for these kind of patients with previous negative experiences of somatic and psychotherapeutic treatment.

[Illness experience and treatment seeking behavior of psoriasis patients]

We analyzed how psoriasis patients sought professional help and correlated it to their illness attitudes and feeling of stigmatization. Semi-structured interviews of 400 patients were reanalyzed to identify homogeneous groups concerning initial reactions at first manifestations of the disease. Four groups ("isolated", "stigmatized", "socially supported" and "non-stigmatized" patients) were found and cross-tabulated with five resulting groups of a second cluster-analysis concerning the "style" of the seeking behaviour of professional and paraprofessional help and medical measures against the psoriasis ("multi-users", "arranged mini-users", "waiting-room patients", "optimists" and "self-therapists"). We were able to describe typical courses of illness behaviour depending on the initial reaction. The results are discussed with regard to the desirable identification of problematic patients within professional care units.

[Sense of coherence and psychosomatic treatment outcome. An empirical study of salutogenesis]

According to Aaron Antonovsky's model of salutogenesis health protective resources by him conceptualised as "sense of coherence" (SOC) determine decisively the ability to recuperate. We investigate the relationship between treatment outcome and the sense of coherence measured by the SOC questionnaire at the beginning (n = 81), during the inpatient treatment phase and 6 month later (n = 70). For testing the psychometric qualities we obtained additional data from the outpatient department (n = 461). SOC-Score increased significantly during inpatient treatment. Outcome of treatment could not be predicted by the initial SOC, but we found a highly significant relation between an increase in the SOC value and a decrease in complaints (SCL-90-R, r = .81). In our opinion, the application of the SOC in psychosomatic patients is restricted, because there is a high overlap with psychic complaints (i.e. anxiety, depression).

[Psychosomatic rehabilitation]

Containing 14,000 beds on wards, the psychosomatic rehabilitation in hospitals has a significant part in the treatment of psychosomatic and somato-psychological diseases where psycho-social parameters play an etiological role. This work may be aggravated by the fact that these diseases are often recognized too late and that the patients are admitted to specialized hospitals in a state of chronic illness. Nevertheless, these hospitals are working with great success especially regarding the reduction of costs in the period after discharge, reduction of the time being incapable to work, in patient days, medication, and medical attendance. Beside these parameters of cost reduction, the success in treatment also contains the improvement of subjective parameters such as satisfaction of living, relationships, and every day life. Psychodiagnostic hints are given for the on time diagnosis of the mentioned disturbances allow an early and adequate treatment.

[Patient-medical staff-consultant triad: conditions for satisfaction in psychosomatic consultation service]

In a large 1000 bed University Medical Center the psychosomatic consultation service (PCS) was evaluated by a two step investigation. 1. Housemen (interns) and senior staff members were asked by questionnaires about their previous experiences with psychological medicine and particularly about their satisfaction with the PCS and how they would estimate the need for additional psychosomatic treatment for the patients on their ward. A striking disproportion was found between actual requests (1.8%) for PCS and the estimated need (18%) for additional psychosomatic advice or treatment. 2. Questionnaires dealing with satisfaction were given to the consultant, the patient and the consultee. The satisfaction of the consulte was mainly determined by the promptness in answering his request and formal aspects of the exchange, the patient satisfaction was mainly determined by the way they viewed the help, the sense of importance of the consultation and by the feeling of being understood by the consultant. This seems to influence the future compliance. Surprisingly, a correlation between the patient satisfaction with the consultation and the quantitative and qualitative aspects of exchange between consultant and consultee was less clearly demonstrated. This could be seen as a hint of communication problems between the consultee and his patient, the improvement of which is one of the main concerns of psychosomatic consultation.

[Economic sequelae of failed treatments of psychosomatic and somato-psychic illnesses]

The search for biotechnical causes of diseases although very successful in many areas fail to account for wide variations of morbidity and mortality. Such search in the most common symptoms, for which our health care system is utilized, falls short of meeting the health needs of a vast number of patients, since only in 16% such causes can be found. This continuing misunderstanding contributes to the tremendous rise in healthcare expenditures without improving the delivered health care. Relatively short lasting psychosocial interventions are shown to have a significant effect in reducing health care seeking behaviour. This is particular demonstrated in somatization disorder. In the last section examples for cost offset effects in outpatient care and in psychosomatic inpatient treatment will be given with remarkable cost savings. Finally recommendations are listed to meet the health needs of the public more sufficiently. Psychosocial factors are shared determinants of health outcomes across diseases, therefore labeled as "Super highways for Disease", must be taken into account to reduce the number of unnecessary diagnostic examinations and unsuccessful treatments, to reduce the length of hospital stay, to increase the survival rate in cancer by increasing the self-management and self-competence, which will finally lead to a tremendous reduction in costs for our health care system.

Dimensions of stigmatization in patients with psoriasis in a "Questionnaire on Experience with Skin Complaints'

BACKGROUND

Stigmatization is a central experience of patients with psoriasis with a broad psychic and social impact.

OBJECTIVE

The purpose of this study is to identify the dimensions of stigma experience by a Questionnaire on Experience with Skin Complaints (QES; 'Fragebogen zum Erleben von Hautbeschwerden').

METHODS

187 in-patients with psoriasis were examined with the QES, an adopted and extended (German) version of the Feeling of Stigmatization Questionnaire by Ginsburg and Link. A factor analysis of the questionnaire was conducted and the construct validity was evaluated.

RESULTS

Five factors were found: 'self-esteem', 'retreat', 'rejection', 'composure' and 'concealment'. Self-esteem, retreat and rejection are mainly influenced by 'problematic regions' affected by psoriasis, rejection also by 'visible parts' and retreat also by 'invisible regions'. The influences of age, age at onset and sex on the stigma experience are small but significant.

CONCLUSIONS

The QES proved to be an economical and reliable psychometric instrument to differentiate the stigma experience of psoriasis patients.

[Study of the practicability of qualitative and quantitative documentation of outcome in inpatient psychotherapy]

The results of a study evaluating the practicability of two newly-developed documentation forms are presented (n = 336 inpatient psychosomatic-psychotherapeutic treatment episodes in 8 clinics). Parallel versions of the forms were completed by patients and therapists. The "ErgeDoku-A-Form" allows for the naming of up to five therapy goals determined at the beginning of therapy and evaluated in relation to their achieved quality at the end of therapy. The "ErgeDoku-B-Form" describes a variety of problem areas as well as questions related to medication and changes in data structure are presented. Results reveal high levels of acceptance in daily clinical practice (indicating clear and appropriate semantics) as well as highly significant relationships between patient and therapist evaluations.

[Evaluation of change by patients and staff and specialist physicians in psychosomatic rehabilitation--a catamnestic comparison]

Considering three single outcome criteria reflecting the change of a) physical state, b) general condition and c) ability to work catamnestic ratings of patients and of external doctors are compared. The ratings were assessed by questionnaires 12 months after the end of inpatient psychosomatic treatments ("direct measurement of change"). Mayor findings are: a) the judgements of both data sources indicated positive change or improvement for a majority of patients, b) the ratings of the external doctors were more favourable than the patients' self-ratings, c) moderate but statistically significant correlations between the ratings of the two groups of judges were to be observed. From a more methodological point of view it will be attempted to analyze the meaning of these correlations somewhat more in detail.

[Possibilities in clinical quality assurance founded on a basis documentation system and extended evaluation studies]

Although the topic of quality control (QC) has been under discussion at least since the "Health Reform Legislation" (GRG) in almost all areas of the public health system, there is quite often a lack of models for practicability. Even for inpatient medical rehabilitation--at least concerning empirically founded QC-measures suitable methods and instruments have still to be developed. These must be relatively simple and economical to be integrated in the daily routine within a special clinic, if quality control should function. Starting from a broad concept of evaluation, the authors present a practical empirical QC-model for clinics, specifically for psychosomatic rehabilitation, which has been developed and proven for more than five years. To investigate the "programme" of the clinic, or particular program components (e.g. patients, treatments, outcome criteria) with systematically obtained data and analysis, is the main goal of this model. Where statements are replaced by empirically proven data. Aspects of process and outcome quality are considered to be a main task, and transparency is a necessary supposition. This model is particularly based on questionnaire procedures, is two-tracked, e.g. it is composed by continuous data collection ("treatment documentation") on the one hand and by time-restricted and defined studies for programme evaluation on the other. The treatment results represent the true target variable.

[Satisfaction with inpatient management. Development of a questionnaire and initial validity studies]

In Germany methodologically reliable procedures to assess patients satisfaction with inpatient health care are almost totally missing. With reference to the well known American CSQ-Questionnaire (Attkisson et al.) a 17-items questionnaire (to assess satisfaction) was developed and presented to a sample of 300 patients undergoing inpatient treatment within a psychosomatic clinic (the rate of responding was about 80%). With a concise form of the questionnaire (Zuf-8, 8 items) an economical and reliable test-instrument is presented in this paper to measure general satisfaction, which also was investigated in regard to item- and factor analysis. This method seems suitable for measuring patient satisfaction with inpatient psychosomatic treatment. The investigated scales of satisfaction show a statistically significant correlation with additionally obtained patient characteristics. This inquiry also suggests that it might be rewarding to pursue the often neglected phenomenon of questionnaires filled out incomplete as an indicator of latent dissatisfaction.

[Immobilization stress and its significance for psychosomatic medicine]

Results from a variety of different experiments with immoblization stress, an operationally well defined stressor, are discussed with particular emphasis on gastric ulcers and hypertension. Finally an integrative model of hypertension is presented using dopamine-beta-hydroxylase as a marker of sympathetic nervous system activity and discussing the results in the context of giving up as the final common pathway to changes in health according to the concept developed by Schmale.