Do patients' symptoms and interpersonal problems improve in psychotherapeutic hospital treatment in Germany? A systematic review and meta-analysis

Predicting treatment response using machine learning: A registered report

OBJECTIVE

Previous research on psychotherapy treatment response has mainly focused on outpatients or clinical trial data which may have low ecological validity regarding naturalistic inpatient samples. To reduce treatment failures by proactively screening for patients at risk of low treatment response, gain more knowledge about risk factors and to evaluate treatments, accurate insights about predictors of treatment response in naturalistic inpatient samples are needed.

METHODS

We compared the performance of different machine learning algorithms in predicting treatment response, operationalized as a substantial reduction in symptom severity as expressed in the Patient Health Questionnaire Anxiety and Depression Scale. To achieve this goal, we used different sets of variables-(a) demographics, (b) physical indicators, (c) psychological indicators and (d) treatment-related variables-in a naturalistic inpatient sample (N = 723) to specify their joint and unique contribution to treatment success.

RESULTS

There was a strong link between symptom severity at baseline and post-treatment (R2 = .32). When using all available variables, both machine learning algorithms outperformed the linear regressions and led to an increment in predictive performance of R2 = .12. Treatment-related variables were the most predictive, followed psychological indicators. Physical indicators and demographics were negligible.

CONCLUSIONS

Treatment response in naturalistic inpatient settings can be predicted to a considerable degree by using baseline indicators. Regularization via machine learning algorithms leads to higher predictive performances as opposed to including nonlinear and interaction effects. Heterogenous aspects of mental health have incremental predictive value and should be considered as prognostic markers when modelling treatment processes.

Do Patient's Interpersonal Problems Improve Following Metacognitive Therapy? A Systematic Review and Meta-Analysis

Metacognitive therapy (MCT) aims to modify dysfunctional metacognitions that are thought to be universal determinants of emotional distress and psychological dysfunction more generally. MCT is an effective treatment for emotional distress symptoms, but less is known about its effect for other types of psychological problems. Interpersonal problems are common in psychological disorders and should be improved following psychotherapy. Therefore, we conducted a systematic review and meta-analysis of trials on the effects associated with MCT for interpersonal problems among adults with mental health disorders published until 15 November 2023 using PubMed, Cochrane Library and PsycNet. Trials with a minimum of 10 participants were included. A total of six studies based on five trials reported on the effectiveness of MCT for interpersonal problems and met our inclusion criteria. Two trials evaluated MCT for patients with major depressive disorders, two for patients with anxiety disorders and one for borderline personality disorder. Three of the trials were randomized controlled trials. Four of the trials reported follow-up data but varied in their time-points. The within-group effect size estimate from pretreatment to posttreatment across five trials was large (g = 0.865, 95% CI [0.512-1.218]). Our results indicate that MCT is an effective treatment for improving interpersonal problems in individuals with common mental disorders, even though the treatment is short and primarily concern improving mental regulation through modifying metacognitions. While this finding is in line with metacognitive theory, more trials evaluating personality and interpersonal functioning are needed to draw firm conclusions.

[The relationship of functional and symptomatic changes after multimodal psychodynamic treatment]

Objectives: Personality organization or functioning describes biographically acquired characteristics for the regulation of psychological processes. Limitations correlate with symptom load. This study examines whether significant improvement in personality functioning can be achieved in the framework of a multimodal psychodynamic treatment and its influence on the psychological symptoms. Methods: In this naturalistic study design (N = 318) personality organization was measured with the OPD-SQS and the symptoms were obtained using PHQ-9, GAD-7, SCL-9 and mini- Spin. Changes in the functioning levels were calculated using a t-test. The associations between the functional and symptom improvements were calculated using hierarchical regressionmodels. ANOVAs for dependent samples were used to calculate the association of the personality organization changes on symptom reduction Results: Treatment resulted in significant improvement in personality structure.The greater the changes, the lower the symptom burden at the end of treatment. Patients with lower personality structure benefited equally well from treatment. Conclusions: Personality functioning improves with multimodal psychodynamic therapy and is accompanied by reduction of psychological symptoms. Structural changes proceed equally in high and low structured patients.

Symptom Change during Waitlist for Medicated and Nonmedicated Patients with Chronic Depression

INTRODUCTION

Patients seeking psychotherapy often spend time on waitlist (WL), the effect of which is largely unknown. WL patients may forego alternative non-psychotherapeutic assistance and thus do more poorly than had they not been placed on a WL. The course of symptoms might also be influenced by use of antidepressant medication (ADM), an issue that remains unexplored in the literature.

OBJECTIVE

In a naturalistic setting, WL symptom change before inpatient psychotherapy (mean weeks of waiting = 22.6) was assessed in a sample (N = 313) of chronically depressed patients.

METHODS

Using the Beck Depression Inventory-II, patients' symptoms were tracked at assessment, when admitted to treatment (i.e., after WL), at posttreatment and 1-year follow-up. Multilevel growth curve analysis was used to examine waitlist change for the whole sample as well as for ADM users and nonmedicated patients.

RESULTS

Symptoms were reduced significantly from assessment to admittance (Cohen's d = 0.47). Symptoms reduced less for ADM users (d = 0.39) than for nonmedicated patients (d = 0.65).

CONCLUSION

The findings indicate that chronically depressed patients experience a decrease in symptoms during WL, quite likely due to treatment expectations. We discuss whether less symptom improvement for ADM users could be attributed to iatrogenic comorbidity and a higher degree of demoralization in this group.

The multicenter effectiveness study of inpatient and day hospital treatment in departments of psychosomatic medicine and psychotherapy in Germany

Background

Reliable outcome data of psychosomatic inpatient and day hospital treatment with a focus on psychotherapy are important to strengthen ecological validity by assessing the reality of mental health care in the field. This study aims to evaluate the effectiveness of inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy in a prospective, naturalistic, multicenter design including structured assessments.

Methods

Structured interviews were used to diagnose mental disorders according to ICD-10 and DSM-IV at baseline. Depression, anxiety, somatization, eating disorder and posttraumatic stress disorder (PTSD) symptoms, as well as personality functioning were assessed by means of questionnaires on admission and at discharge.

Results

2,094 patients recruited by 19 participating university hospitals consented to participation in the study. Effect sizes for each of the outcome criteria were calculated for 4-5 sub-groups per outcome domain with differing severity at baseline. Pre-post effect sizes for patients with moderate and high symptom severity at baseline ranged from d = 0.78 to d = 3.61 with symptoms of PTSD, depression, and anxiety showing the largest and somatization as well as personality functioning showing somewhat smaller effects.

Conclusions

Inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy is effective under field conditions.

Clinical trial registration

https://drks.de/search/de/trial/DRKS00016412, identifier: DRKS00016412.

Seeing the past in a new light: change in reports of childhood abuse and neglect before and after inpatient psychotherapy and its relevance for change in depression symptoms

OBJECTIVE

As changes in mental representations have been discussed as mechanisms of change in psychotherapy, the question arises whether recollections of childhood abuse and neglect are altered as well and how they relate to symptom changes.

METHOD

Individuals in psychosomatic inpatient treatment (N = 488, 60.5% women) filled out the Childhood Trauma Questionnaire (CTQ) and Patient Health Questionnaire (PHQ-9). Changes in both were investigated with correlations and t-tests. Linear regression analysis was used to test whether CTQ changes predicted symptom changes. Network analysis was performed to ascertain structural connections between somatic and emotional-cognitive depression symptoms and CTQ subscales before and after treatment.

RESULTS

After treatment (duration in days: M = 52.83, SD = 20.94), patients reported fewer depression symptoms (d = 0.84), while CTQ scores increased slightly (d = 0.11). Changes in the CTQ predicted recovery from depression symptoms in a statistically significant way (β = .133, p = .001). We did not observe changes in the overall network structure between baseline assessment and discharge.

CONCLUSION

The findings suggest that the evaluation of past experiences can change over multiple weeks of psychotherapy. Further, these updated mental representations, indicating a greater recognition of past adversity, may contribute to symptom relief.

Changes in treatment outcomes in patients undergoing an integrated psychosomatic inpatient treatment: Results from a cohort study

Objective

In Germany, multimodal psychosomatic inpatient treatment can be initiated for patients with substantial mental disorders (e.g., depression, anxiety, somatoform disorders) and comorbid physical disease. However, studies investigating changes in psychological and functional treatment outcomes, and predictors of long-term treatment effects in patients undergoing psychosomatic inpatient treatment are needed.

Methods

This cohort study analyzed 160 patients aged ≥18 who were treated on an integrated psychosomatic inpatient unit at the University of Göttingen Medical Center. Its aim was to analyze changes in psychological and functional outcomes, and to identify predictors of long-term improvements in health-related quality of life (HRQoL) in patients with comorbid mental and physical illness who were undergoing integrated inpatient psychosomatic treatment. Assessments were completed at admission, discharge, and 12- or 24-month follow-up. Outcomes included physical complaints [Giessen Subjective Complaints List (GBB-24)], psychological symptoms [Brief Symptom Inventory (BSI)], and HRQoL [European Quality of Life Questionnaire (EQ-5D)].

Results

One-hundred sixty inpatients were included (mean age = 53.1 ± 12.6; 53.8% female). There were significant, medium- to large-sized improvements in psychological symptoms (BSI-Global Severity Index; d = -0.83, p < 0.001), physical symptom burden (d = -0.94, p < 0.001), and HRQoL (d = 0.65, p < 0.001) from admission to discharge, and significant, small- to medium-sized greater improvements in all psychological outcomes from admission to follow-up (BSI-GSI: d = -0.54, p < 0.001; GBB-24 total symptom burden: d = -0.39, p < 0.001; EQ-5D: d = 0.52, p < 0.001). Furthermore, better improvement in HRQoL during hospitalization (partial η2 = 0.386; p < 0.001) was associated with higher HRQoL at follow-up. Finally, intake of antidepressant at discharge was associated with impaired HRQoL at follow-up (η2 = 0.053; p = 0.03).

Conclusion

There were significant short- and long-term improvements in psychological symptoms, physical complaints, and HRQoL after treatment on an integrated psychosomatic inpatient unit in patients with mental disorders and a comorbid physical disease.

Specialized Biopsychosocial Care in Inpatient Somatic Medicine Units-A Pilot Study

Introduction

Specialized biopsychosocial care concepts are necessary to overcome the dualism between physical and psychosocial treatment in acute care hospitals. For patients with complex and chronic comorbid physical and mental health problems, neither standardized psychiatric/psychosomatic nor somatic care units alone are appropriate to their needs. The “Nuremberg Integrated Psychosomatic Acute Unit” (NIPA) has been developed to integrate treatment of both, psychosocial and physical impairments, in an acute somatic care setting.

Method

NIPA has been established in inpatient internal medical wards for respiratory medicine, oncology and gastroenterology. One to two patients per ward are regularly enrolled in the NIPA treatment while remaining in the same inpatient bed after completion of the somatic care. In a naturalistic study design, we evaluated treatment effects by assessment of symptom load at admission and at discharge using the Patient Health Questionnaire (PHQ) and the Generalized Anxiety Disorder Scale-7 (GAD-7). Furthermore, we assessed the severity of morbidity using diagnosis data during treatment. At discharge, we measured satisfaction with treatment through the Patient Satisfaction Questionnaire (ZUF-8).

Results

Data from 41 NIPA patients were analyzed (18–87 years, 76% female). Seventy-eight percent suffered from at least moderate depression and 49% from anxiety disorders. Other diagnoses were somatoform pain disorder, somatoform autonomic dysfunction, eating disorder and posttraumatic stress disorder. Hypertension, chronic lung diseases and musculoskeletal disorders as well as chronic oncological and cardiac diseases were the most common somatic comorbidities. Treatment resulted in a significant reduction of depressive mood (admission: M = 10.9, SD = 6.1, discharge: M = 7.6, SD = 5.3, d = 0.58, p = 0.001), anxiety (admission: M = 10.6, SD = 4.9, discharge: M = 7.3, SD = 4.1, d = 0.65, p< 0.001) and stress (admission: M = 6.0, SD = 3.6, discharge: M = 4.1, SD = 2.5, d = 0.70, p< 0.001). Somatic symptom burden was reduced by NIPA treatment (admission: M = 10.9, SD = 5.8, discharge: M = 9.6, SD = 5.5, d = 0.30), albeit not statistically significant (p = 0.073) ZUF-8 revealed that 89% reported large or full satisfaction and 11% partial dissatisfaction with treatment.

Discussion

NIPA acute care is bridging the gap for patients in need of psychosocial treatment with complex somatic comorbidity. Further long-term evaluation will show whether psychosocial NIPA care is able to reduce the course of physical illness and hospital costs by preventing hospitalization and short-term inpatient re-admissions.

Meta-Analysis of the Effect of Psychotherapy in an Inpatient Setting: Examining the Moderating Role of Diagnosis and Therapeutic Approach

OBJECTIVE

The current meta-analysis investigates the efficacy of psychotherapy during psychiatric hospitalization and examines the moderating role of diagnosis and therapeutic approach.

METHODS

We conducted systematic searches in literature databases, including PubMed, PsycInfo, and Google Scholar. In total, 37 samples were included for the meta-analysis with a total of 4,443 patients. The primary outcome was the standardized mean differences in clinical status measured by symptomatic and functional measures.

RESULTS

The meta-analysis of 22 samples without a control group resulted in the upper end of the medium effect size for the overall effect of treatment during psychiatric hospitalization that included psychotherapy (k = 22, Cohen's d = 0.70, and 95% Cl 0.36 to 1.04). The meta-analysis of 15 samples with a control group resulted in the upper end of the low effect size for the contribution of psychotherapy to the improvement of patients' clinical status measured by symptomatic and functional measures (k = 15, Cohen's d = 0.43, and 95% CI 0.06 to 0.81). No significant effects were uncovered for psychotherapy orientation. Diagnosis was found to moderate the contribution of psychotherapy in an inpatient setting to the improvement of patients' clinical condition.

CONCLUSION

Psychotherapy during psychiatric hospitalization may be an effective treatment. Across the various samples, psychotherapy has a moderate effect on the reduction of psychiatric symptoms beyond the overall effect of ward treatment.

[Effectivity of Inpatient and Day-clinic Psychosomatic-Psychotherapeutic Treatment]

AIM

(Partial) inpatient psychotherapy is well implemented in Germany. To better understand efficacy factors and effects, efficacy studies are necessary. This naturalistic study investigates the effectiveness of inpatient and day clinic psychotherapy as well as patient-and disorder-related factors influencing individual symptom improvements.

METHODS

Patients at a psychosomatic-psychotherapeutic university hospital treated from 2015 to 2019 who completed the BSI-18 either at admission and discharge (n=1366) or at admission and three-month catamnesis (n=497) were included in the analysis.

RESULTS

Improvements in global symptom severity showed moderate effect sizes. Descriptively, these were larger for day clinic patients than for those receiving treatment as inpatients-especially in the follow-up comparison (immediately after discharge: dinpatient=0.401, dday clinic=0.482; three months after discharge: dinpatient=0.403, dday clinical=0.807). Day hospitalized patients differed significantly from inpatients-slightly in age, employment status, ability to work and initial symptom burden, moderately in the number of mental comorbidities and strongly in their main diagnoses. Socio-demographic factors showed no positive influence on symptom improvement, initial symptom severity a moderate positive influence and the number of mental comorbidities a complex influence.

DISCUSSION

In general, this study confirms the effectiveness of (partial) inpatient psychosomatic therapy. The relevance of day clinic offers is emphasised in the context of cost efficiency and good integration into everyday life, but under consideration of individual treatment indications.

Predictors for successful psychotherapy: Does migration status matter?

Background

We investigated, if migration status, and additional sociodemographic and clinical factors, are associated with somatization and depressiveness at admission and with remission after inpatient psychotherapy.

Methods

Multiple linear and binary logistic regression analyses were used to identify predictors for severity of somatoform and depressive symptoms at admission of inpatient psychotherapy (T0), and for remission after inpatient psychotherapy (T1). We tested the association between symptoms concerning somatization (PHQ-15: Patient-Health-Questionnaire Somatization Module) and depression (PHQ-9: Patient-Health-Questionnaire Depression Module) and several sociodemographic and clinical factors in 263 patients at admission. For remission after treatment, we additionally included severity of symptoms at admission, number of diagnoses and duration of treatment in the regression models. Remission after treatment was defined as response plus a post value of less than 10 points in the respective questionnaire. Clinical relevance was interpreted using effect sizes (regression coefficients, Odds Ratio (OR)) and Confidence Intervals (CI).

Findings

Significant and clinically relevant predictors for high symptom severity at T0 were lower education (β = -0.13, p = 0.04), pretreatment(s) (β = 0.205, p = 0.002) and migration status (β = 0.139, p = 0.023) for somatization, and potential clinically relevant predictors (|β|>0.1) for depression were living alone (β = -0.116, p = 0.083), pretreatment(s) (β = 0.118, p = 0.071) and migration status (β = 0.113, p = 0.069). At T1 patients with pretreatment(s) (OR = 0.284 [95% CI: 0.144, 0.560], p<0.001) and multiple diagnoses (OR = 0.678 [95% CI: 0.472, 0.973], p = 0.035) were significantly and clinically relevant less likely to show a remission of depressive symptoms. In addition, a potentially clinically meaningful effect of migration status on remission of depressive symptoms (OR = 0.562 [95% CI: 0.264, 1.198], p = 0.136) cannot be ruled out. For somatoform symptoms pretreatment(s) (OR = 0.403, [95% CI: 0.156, 1.041], p = 0.061) and education (OR = 1.603, [95% CI: 0.670, 3.839], p = 0.289) may be regarded as clinically relevant predictors for remission.

Conclusion

The results of our study suggest that migration status has a clinically relevant influence on severity of somatoform and depressive symptoms at admission. Clinical relevance of migration status can also be assumed regarding the remission of depression. Migration status and further factors affecting the effectiveness of the treatment should be analyzed in future research among larger samples with sufficient power to replicate these findings.

Implementing Digital Trainings within Medical Rehabilitations: Improvement of Mental Health and Synergetic Outcomes with Healthcare Service

The need for new technologies in healthcare services has been stressed. However, little is known about the effectiveness of digital interventions integrated in psychosomatic rehabilitation processes. Data from 724 patients from psychosomatic rehabilitation clinics were analyzed with regard to the effectiveness of digital trainings indicated by a change in symptoms related to depression, anxiety, stress, and loneliness from pre– to post–rehabilitation. Rehabilitation satisfaction was examined in association with reaching rehabilitation goals and satisfaction with communication. A mixed repeated measures analyses of covariance, analyses of covariance, and hierarchical stepwise regression analyses were performed. Results indicated a superior effectiveness for the intervention group receiving all offered digital treatments in addition to the regular face-to-face rehabilitation program with regard to symptoms of depression (F (2674) = 3.93, p < 0.05, η_p² = 0.01), anxiety (F (2678) = 3.68, p < 0.05, η_p² = 0.01) post-rehabilitation, with large effect sizes for both depression (d = 1.28) and anxiety (d = 1.08). In addition, rehabilitation satisfaction was positively associated with reaching rehabilitation goals and perceived communication with healthcare workers. Digital interventions appeared effective in supporting mental health of psychosomatic rehabilitation patients’ post-rehabilitation. These findings support the inclusion of multidisciplinary and interdisciplinary digital and face-to-face treatment programs and call for more implementations of new technologies in a context of complexity to improve health and healthcare service.

[Clinical courses of depressive and anxiety disorders over 1 year : Direct comparison of four treatment settings in psychiatry and psychosomatic medicine-results of the PfAD study]

BACKGROUND

Inpatient care for patients with depressive and anxiety disorders (ICD-10 F3/F4 diagnoses) is provided in Germany in different settings of psychiatry and psychosomatic medicine.

OBJECTIVE

Apart from the question of the effectiveness of treatment, it is of interest whether the course of the disease differs between four different settings up to a period of 1 year after discharge.

MATERIAL AND METHODS

A total of 320 patients with main clinical diagnoses from the ICD-10 F3/F4 spectrum were recruited and interviewed consecutively in four treatment settings (psychiatric depression unit, psychiatric crisis intervention unit, psychiatric day hospital, psychosomatic acute hospital). The interviews were conducted after admission, before discharge and 6 and 12 months after discharge.

RESULTS

Overall, treatment in all four settings was shown to be highly effective. The slight increase in symptoms in the postinpatient phase described in the literature was observed across all settings. In terms of treatment intensity, those treated in the crisis intervention unit received the most services after index treatment; however, this group was also the one with the most pronounced symptom burden at admission. Patients treated in the psychosomatic department had the lowest symptom burden at admission and overall received the least inpatient services over the observation period; however, outpatient follow-up treatment was apparently used most by those patients.

CONCLUSION

The treatments proved to be effective in the long-term in both psychiatric and psychosomatic units. The different settings seem to be successful in adapting the treatments to the respective patient groups.

[Measurement of Change with the Short Form of the OPD Structure Questionnaire (OPD-SQS)]

The transdiagnostic concept of personality structure plays a key role in psychodynamic nosology, since many mental and psychosocial disorders are considered mainfestations of structural vulnerabilities and deficits. Therefore, structural diagnostics is of particular importance, especially with respect to the planning of tailor-made psychotherapeutic interventions. Because changes in personality structure are increasingly being considered as a relevant therapeutic goal, any measures employed towards achieving this goal should be sensitive enough to capture these changes appropriately. Although the short form of the OPD Structure Questionnaire (OPD-SQS) can easily be administered and is therefore frequently used in clinical and research settings, its sensitivity to change has not yet been analyzed. Two large, independent and diagnostically heterogeneous samples of inpatient psychotherapy patients (n=1183 and n=967, respectively) completed the OPD-SQS both at admission and before discharge. Standardized Effect Size (SES), Standardized Response Mean (SRM) and Smallest Real Difference (SRD) were computed as indicators of the measure's ability to capture change. For the OPD-SQS and its subscales, low effect sizes were found in both samples (SES between 0.23 and 0.48; SRM between 0.27 and 0.53). Additionally, it was demonstrated that greater changes among patients with structural deficits were detectable with the OPD-SQS compared to those without structural deficits, and that these group differences were significant. By means of the SRD, we determined a proportion of about 22% of patients with significantly structurally improved changes in both samples. Despite some methodological issues, our findings suggest that the OPD-SQS is suitable for measuring changes in personality structure in inpatients between the beginning and the end of treatment. Since studies on the sensitivity to change of similar assessment tools are still pending, it is not yet possible to formulate any empirically validated recommendations as to which of the measure best captures therapeutically induced changes in personality structure.

[Effectiveness of in-patient internal-psychosomatic hospital treatment: Evaluation of a treatment-concept in Lower Austria]

Effectiveness of in-patient internal-psychosomatic hospital treatment: Evaluation of a treatment-concept in Lower Austria Background: Medical care for psychosomatic patients in Austria differs from Germany. Besides treatment in psychiatric wards, there are also inpatient programs for psychosomatic patients integrated in internal medical departments. Such an integrated ward in Lower Austria operates for more than 35 years and treats internal-psychosomatic and gastroenterological patients. However, its effectiveness was not yet evaluated. Objective: The aim of the current study was to evaluate the effectiveness of an inpatient program for psychosomatic patients. Method: In total, 184 patients participated in the naturalistic study and filled in questionnaires at admission and discharge from inpatient treatment. Primary endpoint was the difference in global symptom burden, as well as symptom burden in the areas of somatization, anxiety, and depression as measured with the Brief Symptom Inventory (BSI) between admission and discharge. Secondary endpoints were body image (FKB-20) and subjective therapeutic success (BVB-2000). The predictive power of the Structure of Personality (OPD-SF) and adverse childhood experiences (ACE-D) was also investigated. A smaller sample of 59 patients also participated in a four-month follow up assessment. Results: The inpatient treatment was associated with improvement in the primary endpoints that can be interpreted as large effects. The effects were also small to large for the secondary endpoints, however, the improvement was smaller at the follow up time point. Patients with deficits in the dimensions regulation of relationships and internal emotional communication showed less improvement. Discussion: Symptoms improve over the course of the evaluated inpatient treatment program. Specific dimension of the structure of personality predict treatment response and should be considered in treatment planning. Conclusion: This study provides initial evidence for the presented internal-psychosomatic inpatient program. The program might act as model for psychosomatic medical care in Austrian hospitals.

Increasing Mentalization to Reduce Maladaptive Defense in Patients With Mental Disorders

Background: There are indications of associations between the ability to mentalize and psychological defense mechanisms. However, only a few studies have focused on these associations, and even fewer have included empirical analyses. In the present study, we aimed to fill this research gap by analyzing the link between the ability to mentalize and psychological defense mechanisms in patients with mental disorders. We examined whether changes in defense mechanisms are predicted by an increase in mentalization or whether such changes are only related to reductions in psychopathology and interpersonal problems. Methods: A clinical sample of N = 89 patients was studied during and after inpatient psychiatric rehabilitation. Repeated-measures analyses of variance were performed to determine changes in mentalization, psychological defense, psychopathology, and interpersonal problems over the course of therapy and post-treatment. Linear regression analyses were used to predict the change in defense patterns based on an increase in mentalization. Results: Maladaptive defense mechanisms were significantly reduced during inpatient therapy and remained low until follow-up, whereas neurotic and adaptive defense mechanisms did not change significantly. The results of the regression analyses indicated that mentalization played an important role in the reduction in maladaptive defense during and after inpatient rehabilitation for mental disorders, whereas reductions in psychopathology and interpersonal distress were only partially associated with a reduction in maladaptive defense. Conclusion: We conclude that mentalization is vital for reducing maladaptive defense mechanisms, which are commonly associated with mental disorders. In therapy, an increase in patients' capacity to mentalize may be a practicable approach to diminish maladaptive defense mechanisms.

Multimodal Psychotherapeutic Inpatient Therapy of Depression Is Successful in Patients With High Cytokine Production

Objective: In experimental settings, systemically elevated inflammation markers interfere with major depression treatment. In German healthcare, compulsory national health insurance covers treatment of a wide variety of depressive disorders, if it follows evidence-based medicine guidelines combining recommended therapies. To date, little is known about the relevance of immune system cytokine production with regard to real-world clinical care for patients with moderate depression. Methods: Seventy three patients with moderate depression subjected to multimodal psychotherapeutic inpatient therapy (mPT) following a psychodynamic concept at a German university hospital were included. As a primary outcome, mPT success, evidenced by delta HADS "depression," was analyzed according to tumor necrosis factor alpha (TNFα) production by peripheral blood mononuclear cells (PBMC) after phytohemagglutinin (PHA) challenge at baseline. Secondary outcomes addressed the inflammatory response and mental health comparing high and low TNFα-producers. Results: First, higher PBMC TNFα production at baseline predicted a better mPT-outcome (R ² 0.162, p = 0.014). Second, patients with high TNFα (hTNF) at baseline produced significantly more acute inflammatory cytokines [interleukin (IL)1β, IL6), TH1/TH2 cytokines [interferon gamma (IFNγ), IL4] as well as eotaxin and IL2 compared to low TNFα producers (lTNF) (Cohen's ds between -0.532 and -1.013). Demographic data, diagnosis subtype-distribution, medication, systemic inflammation markers [C-reactive protein (CRP), high mobility group box 1 (HMGB1), leptin], anxiety and depression (HADS) did not differ. From baseline to mPT-discharge, HADS "depression" decreased in both hTNF (11.31 to 5.47, p = 0.001, d = 1.184) and lTNF patients (11.50-7.92, p = 0.001, d = -0.765), while PBMC cytokine production decreased significantly in hTNF (Cohen's ds between -0.304 and -0.345) with a significant group by time interaction for TH1/TH2 ratio. At the end of therapy, comparison of TNF groups revealed significantly lower depression-scores in hTNF compared to lTNF patients (5.47 compared to 7.92, p = 0.035, d = 0.504). Conclusions: Our study demonstrates successful treatment of depression in a clinical care setting using multimodal psychotherapy based on a psychodynamic concept following guideline recommendation. The greatest improvement in patient depression was linked to the highest production of TNFα by PBMCs at baseline. Our study contributes to the definition of patient subpopulations with differing cytokine responses that are related to succesful treatment of depression.

Effectiveness of Inpatient Psychotherapy for Patients With and Without Migratory Background: Do They Benefit Equally?

BACKGROUND

Research on the effectiveness of inpatient psychotherapy for migrant patients predominantly concludes that they have greater symptom severity at admission and benefit less from psychotherapy. This study aims to compare symptom severity and effects of psychotherapy regarding depression, somatoform disorders, anxiety disorders, and posttraumatic stress disorder (PTSD) in a sample of patients with and without migratory background (MB).

METHODS

Symptom severity of 263 patients (T0, pretreatment) and 256 patients (T1, posttreatment) was assessed using the Patient Health Questionnaire somatization module (PHQ-15), depression module (PHQ-9), and general anxiety disorder module (GAD-7), and the PTSD Checklist (PCL-5). Calculations were made for a completer sample and an intention-to-treat (ITT) sample. To investigate the effectiveness of psychotherapy, we calculated effect sizes (Cohen's d) and clinically significant changes using the reliable change index (RCI).

RESULTS

Patients with MB showed significantly higher symptom burden at admission for somatization (p = 0.025, d = 0.345) and posttraumatic symptoms (p = 0.008, d = 0.424) than patients without MB. At discharge, patients with MB reported significantly higher severity regarding all assessed symptoms (somatization: p = 0.001, d = 0.507; depression: p = 0.045, d = 0.313; anxiety: p = 0.012, d = 0.428; traumatization: p = 0.040, d = 0.329) compared with non-migrant patients. Patients without MB improved significantly regarding all assessed symptoms (somatization: p < 0.001, d = -0.304; depression: p < 0.001, d = -0.692; anxiety: p < 0.001, d = -0.605; posttraumatic symptoms: p < 0.001, d = -0.204). Patients with MB improved significantly concerning depression (p < 0.001, d = -0.649) and anxiety (p = 0.002, d = -0.441). Occurrence of comorbidity was high (87.1% had more than one psychiatric diagnosis). Neurotic, stress-related, and somatoform disorders (F4) and personality disorders (F6) were more frequent among patients with MB.

CONCLUSIONS

Patients with MB showed higher symptom severity at admission. Our study demonstrated a significant reduction of depressive and anxiety symptoms among patients with MB receiving psychotherapy. Further research is needed to identify interventions that effectively improve somatization and posttraumatic stress for patients with MB, since these symptoms were not significantly reduced.

Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial

Background

We recently showed in a randomized controlled trial that Web-based self-help as an adjunct improved the effectiveness of multimodal inpatient psychotherapy for depression.

Objective

The aims of this study were (1) to determine whether a Web-based self-help adjunctive to multimodal inpatient psychotherapeutic treatment could also improve the course of depressive symptoms and (2) to identify predictors of residual depressive symptoms at follow-up.

Methods

Overall, 229 patients were randomized either to the Web-based self-help intervention group (Deprexis) or an active control group (Web-based information about depression and depressive symptoms) in addition to multimodal inpatient psychotherapy. Participants in both groups were able to access their respective Web-based programs for 12 weeks, which meant that they typically had access after discharge from the inpatient unit (mean hospitalization duration: 40 days, T1). Follow-up was performed 6 months after study intake (T3).

Results

At follow-up, participants of the Web-based self-help group had considerably lower symptom load regarding depressive symptoms (d=0.58) and anxiety (d=0.46) as well as a better quality of life (d=0.43) and self-esteem (d=0.31) than participants of the control group. Nearly 3 times as many participants of the intervention group compared with the control group achieved remission in accordance with less deterioration. The number needed to treat based on the Beck Depression Inventory-II (BDI-II) improved over time (T1: 7.84, T2: 7.09, and T3: 5.12). Significant outcome predictors were BDI at discharge and treatment group.

Conclusions

Web-based self-help as an add-on to multimodal inpatient psychotherapy improved the short-term course of depressive symptoms beyond termination. Residual symptoms at discharge from inpatient treatment and utilization of the Web-based self-help were the major predictors of depressive symptoms at follow-up. Challenges and barriers (eg, costs, therapists’ concerns, or technical barriers) of adding Web-based interventions to inpatient treatment have to be addressed.

Trial Registration

ClinicalTrials.gov NCT02196896; https://clinicaltrials.gov/ct2/show/NCT02196896.

Psychosomatic inpatient treatment: Real-world effectiveness, response rates and the helping alliance

OBJECTIVE

While inpatient mental health treatments in real-world settings have shown to be generally effective with moderate to large pre-post effects, little is known about rates of response in inpatients.

METHODS

Inpatients routinely treated at a university hospital for psychosomatics and psychotherapy in Germany were assessed before and after receiving a psychodynamically oriented multimodal treatment. As primary outcome response rates based on the Symptom Checklist-90-Revised (SCL-90-R) were used. As secondary outcomes, pre-post effect sizes on measures of symptoms and stress (SCL-90-R, Hospital anxiety and depression scale, Perceived stress questionnaire) as well as interpersonal problems (IIP) were determined. Additionally, the relationship of the helping alliance to outcome was examined.

RESULTS

A total of 709 patients with various primary diagnoses and high mental (72.4%) and physical (61%) comorbidity, receiving on average 7.9 weeks of treatment, were included. The response rate based on the SCL-90-R global severity index was 62.9% at posttreatment and 60.4% at short-term follow up. Pre-post effect sizes on symptom and stress measures were large (Cohen's d ≥ 1.0) while change regarding interpersonal problems was small (d = 0.34). For patients responding to treatment a significantly better helping alliance was found, corresponding to a large effect (d = 0.84).

CONCLUSIONS

A majority of patients benefitted considerably from a psychosomatic inpatient treatment in terms of response and pre-post effects. Response was significantly related to the quality of the therapeutic alliance. Monitoring and improving alliance may enhance treatment outcome.

Online Self-Help as an Add-On to Inpatient Psychotherapy: Efficacy of a New Blended Treatment Approach

BACKGROUND

Depression is one of the most frequent and costly mental disorders. While there is increasing evidence for the efficacy of online self-help to improve depression or prevent relapse, there is little evidence in blended care settings, especially combined with inpatient face-to-face psychotherapy. Therefore, we evaluated whether an evidence-based online self-help program improves the efficacy of inpatient psychotherapy.

METHODS

A total of 229 depressed patients were randomly allocated either to an online self-help program (intervention group [IG]; Deprexis) or an active control group (CG; weekly online information on depression) in addition to inpatient psychodynamic psychotherapy. Both groups had access to their respective experimental intervention for 12 weeks, regardless of inpatient treatment duration. Reduction of depressive symptoms, as measured with the Beck Depression Inventory-II, was the primary outcome at the end of the intervention (T2).

RESULTS

Depressive symptoms were statistically significantly lower in the IG compared to the active CG at T2 with a moderate between-group effect size of d = 0.44. The same applied to anxiety (d = 0.33), quality of life (d = 0.34), and self-esteem (d = 0.38) at discharge from inpatient treatment (T1). No statistically significant differences were found regarding dysfunctional attitudes (d = 0.14) and work ability (d = 0.08) at T1.

CONCLUSIONS

This is the first evidence for blended treatment combining online self-help with inpatient psychotherapy. The study opens new and promising avenues for increasing the efficacy of inpatient psychotherapy. Future studies should determine how integration of online self-help into the therapeutic process can be developed further.

Patterns of symptom change in major depression: Classification and clustering of long term courses

To evaluate treatment effects in depression, it is important to monitor change during treatment and also to follow up for a reasonably long time. Describing the variability of symptom change trajectories is useful to better predict long-term status and to improve interventions. Outcome data (N__complete = 518, 4 time points, 1 year of observation time) from a large naturalistic multi-center study on the effects of inpatient and day hospital treatment of unipolar depression were used to identify clusters of symptom trajectories. Common outcome classifications and statistical methods of longitudinal cluster analysis were applied. However, common outcome classifications (in terms of e.g. remission, relapse or recurrence) were not exhaustive, as 49.3% of the trajectories could not be allocated to its classes. Longitudinal cluster analysis reveals 7 clusters (fast response, slow response, retarded response, temporary or persistent relapse, recurrence, and nonresponse). Nonresponse at the end of treatment was a predictor of poor outcome at long term follow up. The classification of patterns of symptom change in depression should be extended. Longitudinal cluster analysis seems a valid option to analyze outcome trajectories over time if a limited number of time points of measurement are available.

Metacognitive Therapy for Depression Reduces Interpersonal Problems: Results From a Randomized Controlled Trial

Interpersonal problems are significantly elevated in patients with depression. Metacognitive therapy (MCT) for depression does not address interpersonal problems but is associated with large reduction in depressive symptoms. The main aim of the current study was to explore whether MCT leads to improvements in interpersonal problems in patients with depression. The study was a waitlist controlled trial and assessments took place at pre- and post-treatment as well as 6-month follow-up. At pre-treatment, the sample had more interpersonal problems compared to samples from other studies of psychiatric outpatients. MCT was associated with large reductions in interpersonal problems. Level of interpersonal problems were not related to poorer treatment response. MCT, which does not directly target interpersonal problems, worked well for patients with depression and interpersonal problems. Future research should compare MCT with other evidence-based treatments for patients with depression and interpersonal problems.

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

BACKGROUND

Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions.

AIMS

The current study examined the assumption of iatrogenic effects among BPD adults.

METHODS

Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization.

RESULTS

Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity.

CONCLUSIONS

Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

Improvements in mentalization predict improvements in interpersonal distress in patients with mental disorders

Objectives

Associations between interpersonal problems and mentalization have rarely been investigated. In this study, we explored patterns of interpersonal problems, mentalization, symptom severity, and attachment during inpatient treatment and at follow‐up. Additionally, we investigated whether mentalization predicts a decrease in interpersonal distress.

Method

 We analyzed time‐series data from patients with mental disorders. Data were collected at the beginning and at the end of inpatient treatment, and approximately 6 months after discharge from hospital.

Results

Patterns of correlations were stable from admission to the hospital until follow‐up. Treatment significantly increased the levels of mentalization and decreased the levels of interpersonal problems and symptom severity, whereas attachment was only partially targeted. Improvements in mentalization significantly predicted reduction in interpersonal distress at each point in time.

Conclusion

Results revealed characteristic patterns of interpersonal problems, mentalization, symptom severity, and attachment. Mentalization was found to play a key role in the reduction of interpersonal distress.

Past, Present, and Future of Psychosomatic Movements in an Ever-Changing World: Presidential Address

OBJECTIVE

The American Psychosomatic Society was founded in 1942 and is celebrating its 75th anniversary in 2017. In recognizing the society's anniversary, this article provides a historical perspective on its history, the field of psychosomatic medicine in general, and anticipated future directions.

METHODS

Essay and narrative review of the literature on the historic development of psychosomatic concepts and their impact on medicine over time.

RESULTS

Mind-body associations have been described in the medical literature for more than 3500 years. Early concepts of mind-body dualism and attempts to overcome them are found in classical Greek medicine. Psychosomatic thinking can be observed ever since, but only in the 20th century, a "psychosomatic movement" emerged in Europe and North America, aiming at humanizing medicine by introducing a holistic understanding of man into what was considered a widely reductionistic practice of medicine. This movement led to the inauguration of the American Psychosomatic Society during World War II and of national and international societies of psychosomatic medicine and its subspecializations thereafter.

CONCLUSIONS

Psychosomatic medicine has its roots in the beginnings of medicine. During the past 75 years, it has made substantial contributions to the science and practice of medicine. The field has also changed in response to developments in medicine, technology, and society and is facing new challenges and opportunities that may require further adaptation of its concepts and practice.

Factors influencing the length of hospital stay of patients with anorexia nervosa - results of a prospective multi-center study

BACKGROUND

The length of stay (LOS) strongly influences anorexia nervosa (AN) inpatient weight outcomes. Hence, understanding the predictors of LOS is highly relevant. However, the existing evidence is inconsistent and to draw conclusions, additional evidence is required.

METHODS

We conducted a prospective, multi-center study including adult female inpatients with AN. Using stepwise linear regression, the following demographic and clinical variables were examined as potential predictors for LOS: admission BMI, AN-subtype, age, age of onset, living situation, partnership status, education, previous hospitalization, self-rated depression, anxiety and somatic symptoms (PHQ-9, PHQ-15, GAD-7), self-rated therapy motivation (FEVER) and eating disorder psychopathology (EDI-2 subscale scores).

RESULTS

The average LOS of the sample (n = 176) was 11.8 weeks (SD = 5.2). Longer LOS was associated with lower admission BMI (ß = -1.66; p < .001), purging AN-subtype (ß = 1.91; p = .013) and higher EDI-2 asceticism (ß = 0.12; p = .030). Furthermore, differences between treatment sites were evident.

CONCLUSIONS

BMI at admission and AN-subtype are routinely assessed variables, which are robust and clinically meaningful predictors of LOS. Health care policies might consider these variables. In light of the differences between treatment sites future research on geographical variations in mental health care seems recommended.

Information and decision-making needs of psychiatric patients: the perspective of relatives

Background

Mental illness may strongly affect relatives’ lives. Therefore, it is important to empower relatives by providing health information according to their preferences.

Methods

An online cross-sectional survey was conducted using a purpose-designed questionnaire on online health information and decision-support needs.

Results

Prevalent reasons for online health information search of the 185 participating relatives were the need for general information and the insufficiency of the information given by the health care provider. The most difficult treatment decisions concerned the treatment setting (inpatient or outpatient) as well as the psychopharmacological treatment.

Discussion

Since psychiatric patients’ relatives report extensive information and decision-support needs, it is essential to address their needs in health information material. Assessment of relatives’ needs when developing health information materials is recommended.

Does migration affect the outcome of inpatient psychotherapy? Results from a retrospective cohort study

OBJECTIVE

Reliable data to determine whether migrant patients benefit sufficiently from evidence-based mental health interventions are scarce. Our aim was to examine the effect of migration on the outcome of inpatient psychotherapy.

METHODS

We conducted a retrospective cohort study and predicted the course of the global severity index of the Symptom Checklist 90 during therapy based on data from our routine clinical practice (N=542). We used mixed models for our analysis and included relevant clinical characteristics.

RESULTS

One hundred and twenty-one patients of our sample had a history of migration which was consistently associated with more symptoms at baseline assessment. Patients with direct experiences of migration had the highest level of symptoms before therapy but also showed the largest decrease of symptoms during therapy (B=-0.09, SD=0.04, p=0.030). This interaction effect could be accounted for by our clinical variables. Patients with indirect experiences of migration did not differ from other patients in their level of improvement (B=-0.05, SD=0.04, p=0.149).

CONCLUSION

According to our preliminary data, migration does not seem to negatively affect the outcome of inpatient psychotherapy. Limitations of these promising findings are discussed together with the strong need for more advanced studies in this area of research.

Prognostic and prescriptive predictors of improvement in a naturalistic study on inpatient and day hospital treatment of depression

BACKGROUND

The study aimed to identify prognostic (associated with general outcome) and prescriptive (associated with differential outcome in two different settings) predictors of improvement in a naturalistic multi-center study on inpatient and day hospital treatment in major depressive disorder (MDD).

METHODS

250 inpatients and 250 day hospital patients of eight psychosomatic hospitals were assessed at admission, discharge and a 3-months follow-up. Primary outcome was defined as a reduction of depressive symptomatology from admission to discharge and from discharge to follow-up (QIDS-C, total score). Percent improvement scores at discharge and at follow-up were entered as dependent variables into two General Linear Models with a set of predictor variables and the respective interaction terms with treatment setting. The selection of predictor sets was guided by statistical methods of variable preselection (LASSO).

RESULTS

Three variables were associated with less improvement from admission to discharge: the number of additional axis-I diagnoses, axis-II co-morbidity (SCID) and lower motivation (expert assessment). Social support (F-SozU) predicted symptom course between discharge and 3-month follow-up. Patients with no absent / sick days prior to admission showed a less favorable symptom course after discharge when treated as inpatients.

CONCLUSIONS

Patients with co-morbidity show less improvement during the active treatment phase. Motivation can be considered a prerequisite for symptom reduction, whereas social support seems to be an important factor for the maintenance of treatment gains. The lack in prescriptive predictors found may point to the fact that inpatient and day hospital treatment have comparable effects for most subgroups of patients with MDD.

Day clinic and inpatient psychotherapy of depression (DIP-D): qualitative results from a randomized controlled study

OBJECTIVE

Depressive disorders are among the most common psychiatric disorders. For severely depressed patients, day clinic and inpatient settings represent important treatment options. However, little is known about patients' perceptions of the different levels of care. This study aimed to obtain an in-depth analysis of depressive patients' experiences of day clinic and inpatient treatment in a combined clinical setting.

METHODS

Following a randomized controlled trial comparing day clinic and inpatient psychotherapy for depression (Dinger et al. in Psychother Psychosom 83:194-195, 2014), a sample of depressive patients (n = 35) was invited to participate in a semi-structured interview during an early follow up 4 weeks after discharge. A qualitative analysis of interview transcripts was performed following the principles of constructivist thematic analysis.

RESULTS

Following analysis, 1355 single codes were identified from which five main categories and 26 themes were derived for both groups. In regard to patient group integration and skill transfer to everyday life, distinct differences could be observed between the day clinic and inpatient group.

CONCLUSION

While adjustment to therapeutic setting and patient group integration seem to be facilitated by inpatient treatment, the day clinical setting appears to promote treatment integration into patients' everyday contexts, aiding treatment-related skill transfer to everyday life as well as alleviating discharge from clinic treatment. Further studies on depressive subject groups in day clinic and inpatient treatment should investigate aspects of group cohesion and treatment integration in relation to therapeutic outcome.

Symptom course in inpatient and day clinic treatment of depression: Results from the INDDEP-Study

BACKGROUND

In major depression (MDD), hospital treatment is an option in more severe cases or if outpatient treatment failed. Psychosomatic hospitals in Germany provide treatment programs with multimodal psychotherapy, either in an inpatient or a day hospital setting. In the context of health care research, this study aimed (1) to compare characteristics of patients treated in psychosomatic day hospitals and inpatient units, (2) to compare the effectiveness of both treatment modalities.

METHODS

A naturalistic design was chosen to achieve external validity. 604 consecutive patients were assessed at admission, discharge and a 3-month follow-up. Primary outcome was defined as a reduction of depressive symptomatology (QIDS-C), secondary outcomes comprise overall functioning and quality of life. For a comparison of effectiveness, inpatient and day hospital samples were matched according to known predictors of outcome.

RESULTS

The few differences found between the inpatient and day hospital sample were related to severity of depression and physical impairment. Inpatients more often got antidepressant medication. Additionally, inpatients were treated significantly longer, due to a subgroup of patients with somatic co-morbidity. There were no differences when comparing effectiveness.

LIMITATIONS

When comparing treatment effectiveness, possible bias cannot be ruled out. There was no randomization or untreated control group.

CONCLUSIONS

In patients with a more severe depression and somatic co-morbidity, inpatient treatment might be preferred as compared to day hospital treatment. However, most patients can be treated in both settings.