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Abstract In western countries, men are increasingly using cosmetic surgery. However, despite this trend, there remains a dearth of information on the prevalence, acceptance, and motivations behind men’s use of cosmetic surgery. Furthermore, the potential association between men’s use of cosmetic surgery and in particular male-specific cosmetic surgery procedures such as head hair transplant or penis enlargement and traditional masculinity ideologies (TMI) has not been investigated so far. For this purpose, a cross-sectional anonymous online survey was conducted among 241 self-identifying men aged 18 years or older from the German-speaking part of Europe. Participants responded to questions about cosmetic surgery use and experiences, and completed the Conformity to Masculine Norms Inventory—Short Form (CMNI-SF) and the Male Role Norms Inventory—Short Form (MRNI-SF) questionnaires to assess conformity with and endorsement of TMI. Of the 241 men investigated, 47 (19.5%) had undergone cosmetic surgery. The most common types of cosmetic surgeries reported were wrinkle treatment, eyelid correction, and head-hair transplant. Penis enlargement procedures were reported by three (6.4%) of the 47 men who had undergone cosmetic surgery. The main reasons for undergoing surgery were to feel better (72.3%) and look better (55.3%), while to increase sexual success (17.0%) and to increase manliness (14.9%) were also reported. Logistic regression models showed that higher conformity to TMI (CMNI-SF) was associated with higher odds of having undergone cosmetic surgery. The results highlight the overall increase in men’s cosmetic surgery use and its specific characteristics. The significant positive association between conformity to TMI and men’s use of cosmetic surgery suggests that men increasingly use cosmetic surgery as a means to assert power, success, dominance, and sexual success.

Importance: Variables such as severe symptoms, comorbidity, and sociodemographic characteristics (eg, low educational attainment or unemployment) are associated with a poorer prognosis in adults treated for depressive symptoms. The exclusion of patients with a poor prognosis from RCTs is negatively associated with the generalizability of research findings., Objective: To compare the prognostic risk factors (PRFs) in patient samples of RCTs of face-to-face therapy (FTF) and internet-based therapy (IBT) for depression., Data Sources: PsycINFO, Cochrane CENTRAL, and reference lists of published meta-analyses were searched from January 1, 2000, to December 31, 2021., Study Selection: RCTs that compared FTF (individual or group therapy) and IBT (guided or self-guided interventions) against a control (waitlist or treatment as usual) in adults with symptoms of depression were included., Data Extraction and Synthesis: Data were extracted by 2 independent observers. The Cochrane revised risk-of-bias tool was used to assess the risk of bias. The study was preregistered with OSF Registries and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline., Main Outcomes and Measures: The primary outcome was the standardized mean difference (Hedges g effect size) in depressive symptoms at treatment termination (assessed with standard patient self-report questionnaires), with a positive standardized mean difference indicating larger improvements in the intervention compared with those in the control group. Meta-regression analyses were adjusted for the type of control group. Three preregistered and 2 exploratory sensitivity analyses were conducted. A prognostic risk index (PROG) was created that calculated the sum of 12 predefined individual indicators, with scores ranging from 0 to 12 and higher scores indicating that a sample comprised patients with poorer prognoses., Results: This systematic review and meta-regression analysis identified 105 eligible RCTs that comprised 18 363 patients. In total, 48 studies (46%) examined FTF, and 57 studies (54%) examined IBT. The PROG was significantly higher in the RCTs of FTF than in the RCTs of IBT (FTF: mean [SD], 3.55 [1.75]; median [IQR], 3.5 [2.0-4.5]; IBT: mean [SD], 2.27 [1.66]; median [IQR], 2.0 [1.0-3.5]; z = -3.68, P < .001; Hedges g = 0.75; 95% CI, 0.36-1.15). A random-effects meta-regression analysis found no association of the PROG with the effect size. Sensitivity analyses with outliers excluded and accounting for risk of bias or small-study effects yielded mixed results on the association between the PROG and effect size., Conclusions and Relevance: The findings of this systematic review and meta-regression analysis suggest that samples of RCTs of FTF vs IBT differ with regard to PRFs. These findings have implications for the generalizability of the current evidence on IBT for depression. More RCTs of internet-based interventions with clinically representative samples are needed, and the reporting of PRFs must be improved.

Background: Innovative moments (IMs), defined as moments in psychotherapy when patients' problematic patterns change toward more elaborated and adaptive patterns, have been shown to be associated with a clinical change in patients with depression. Thus, far IMs have been studied in face-to-face settings but not in telephone-based cognitive-behavioral therapy (t-CBT). This study investigates whether IMs occur in t-CBT and examines the association between IMs and symptom improvement, and reconceptualization and symptom improvement., Methods: The therapy transcripts of n  = 10 patients with mild to moderate depression (range: 7-11 sessions, in total 94 sessions) undergoing t-CBT were qualitatively and quantitatively analyzed. Symptom severity (Patient Health Questionnaire-9) and IMs (levels and proportions) were assessed for each therapy session. Hierarchical linear models were used to test the prediction models., Results: The rating of IMs was shown to be feasible and reliable using the Innovative Moments Coding System (IMCS) (84.04% agreement in words coded), which is indicative of the applicability of the concept of IMs in t-CBT. Only reconceptualization IMs were shown to have a predictive value for treatment success ( R 2  = 0.05, p  = 0.01)., Discussion: The results should be interpreted with caution due to the exploratory nature of this study. Due to the telephone setting, it was necessary to adapt the IMCS. Nonetheless, the extent of IMs identified in the low-intensity t-CBT investigated was comparable to IMs in face-to-face therapy. Further studies are needed to clarify the association between IMs and treatment success as a change process, especially for low-intensity treatments., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Drüge, Staeck, Haller, Seiler, Rohner and Watzke.)

Introduction: Internet-based self-help interventions have shown to be effective in the treatment of depression. Several meta-analyses indicated that human contact has a crucial impact on adherence and outcome. While most research focused on the role of guidance during interventions, a review by Andersson and Johansson (2012) suggested that contact before the intervention too may play an important role., Objective: We investigated the impact of the degree of contact in internet-based interventions (IBIs) for depression on outcome in adults suffering from elevated symptoms of depression., Methods: We conducted a preregistered meta-analysis (www.osf.io/4mzyd) and included trials comparing IBIs for depression against control conditions (treatment as usual [TAU] or waiting list [WL]) in patients with symptoms of unipolar depression searching the databases PsycINFO and Cochrane's Central Register of Controlled Trials (CENTRAL) limited to entries from EMBASE and PubMed. Following Andersson and Johansson (2012), contact before an intervention was defined as having had a diagnostic interview before the IBI, and contact during intervention was defined as having received guidance during the IBI. IBIs were grouped as providing (0) no contact, (1) contact before the IBI, (2) contact during the IBI, or (3) contact both before and during the IBI. The primary outcome was standardized mean difference (SMD) of the IBI and control in depressive symptoms at treatment termination. Secondary outcomes were study dropout and adherence to the IBI., Results: We included 56 eligible trials that randomized 13,335 patients to 75 internet-based intervention conditions and control groups (TAU in 23 trials, WL in 33 trials). In total, 44 trials (78.57 %) were judged to show some concerns or a high risk of bias. Overall heterogeneity was high regarding the primary outcome ( I 2 s < 66 %) and even higher for secondary outcomes ( I 2 s < 91 %). Degree of contact was a robust predictor of outcome and adherence in all pre-registered and exploratory analyses. We found the effect of the IBI to increase with higher degree of contact. However, in pair-wise contrasts, only IBIs offering both contact before and during the intervention (SMD = 0.573, 95 % CI: 0.437, 0.709) significantly outperformed interventions offering no contact (SMD = 0.224, 95 % CI: 0.090, 0.340)., Conclusions: The results suggest that contact before and during an intervention increases the effects of IBIs. The combination of contact before and during the intervention seems to a pivotal role regarding adherence as well as treatment outcome for patients suffering from depression., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Although E-mental health (EMH) interventions have been shown to be effective in the treatment of mental health problems and empirical knowledge regarding EMH acceptance for different occupations in health care is established, little is known regarding EMH and psychotherapists-in-training. This seems particularly relevant as psychotherapists-in-training will shape the future health care system since they are as being the next generation of psychotherapists. With social distancing measures in place, COVID-19 has led to an increased demand for EMH, which is broadening the way psychological treatments are delivered., Objective: The present study aims to assess the acceptance of EMH and its determinants among psychotherapists-in-training of different EMH modalities and to retrospectively compare current acceptance with pre-COVID-19 times., Methods: Altogether, 29 training institutions in Switzerland and 232 training institutions in Germany were contacted, resulting in a sample of N  = 216 psychotherapists-in-training (88.4 % female) who filled out the self-administered web-based questionnaire in summer 2020. The acceptance of EMH was assessed considering several different modalities (e.g., videoconference, guided self-help programs) as well as further possible predictors of EMH acceptance based on the Unified Theory of Acceptance and Use of Technology. Acceptance scores were categorized as low, moderate or high based on prior research and predicted using multiple regression., Results: Acceptance of EMH was moderate ( M  = 3.40, SD  = 1.11) and increased significantly ( t (215) = 12.03, p  < .01; d  = 0.88) compared to pre-COVID-19 ( M  = 2.67, SD  = 1.11); however, acceptance varied significantly between modalities (F(2.6, 561.7) = 62.93, p  < .01, partial η 2  = 0.23), with videoconferencing being the most accepted and unguided programs the least. Stepwise regression including three of 14 variables (R 2  = 0.55, F (14, 201) = 17.68, p  < .001) identified performance expectancy , social influence and concerns about the therapeutic alliance as significant determinants of EMH acceptance., Discussion: Acceptance by psychotherapists-in-training was moderate and in line with prior research and comparable with other clinicians' acceptance scores. Performance expectancy , social influence and concerns about the therapeutic alliance were predictive of EMH acceptance, indicating their significance in the implementation of EMH in health care., Conclusion: These findings underline the importance of the aforementioned determinants of EMH acceptance and the need for further studies investigating EMH acceptance in order to derive adequate educational programs and to facilitate dissemination among psychotherapists-in-training., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier B.V.)

Cognitive behavioral therapy is an effective treatment for body dysmorphic disorder (BDD), but many patients do not receive appropriate treatment due to several treatment barriers and psychosocial care structures. Low-threshold interventions, including those from the field of e-mental health, could improve access to psychotherapy. In addition to internet-administered therapy, telephone-administered therapy may reduce treatment barriers, especially during the COVID-19 pandemic. This article presents four case reports of the same treatment (12 weeks of telephone-administered cognitive behavioral therapy accompanied by a workbook) applied to patients with body dysmorphic disorder during the summer of 2020. Three patients who completed the treatment had clinically relevant reductions in body dysmorphic and depressive symptoms and improved insight. One patient did not complete the telephone-administered therapy because her symptoms worsened, and she needed a more intensive form of treatment. These findings encourage future studies on the efficacy and effectiveness of telephone-administered treatment for BDD and its role in stepped-care models.

Purpose: This work focuses on the experiences and practices of obstetrician-gynecologists (ob-gyns) with patients suffering from body dysmorphic disorder (BDD) and issues with their aesthetics, specifically focusing on female genitalia. Ob-gyns are likely to play an important role in the recognition and treatment of women facing such issues., Methods: This study took a qualitative, explorative approach. Semi-structured interviews were conducted with 11 ob-gyns about their experiences with patients who presented symptoms of BDD of female genitalia, their treatments, and interest in further education and supportive material. Interviews were analyzed through qualitative content analysis., Results: A categorization system was created. The results showed that the participating ob-gyns are often confronted with genital dissatisfaction of patients. The study sample demonstrated a lack of mental health literacy concerning BDD. The treatments that the ob-gyns of this sample suggested for BDD of female genitalia were not in line with what evidence suggests. Finally, interest in further education and supportive material for consultation was evidenced in this sample., Conclusions: The findings encourage further studies to identify the recognition of BDD concerning genitalia or etiological factors. Furthermore, practical implications (e.g., need of supportive material) can be derived from the results., (© 2021. The Author(s).)

Introduction: Treatment as usual (TAU) is the most frequently used control group in randomized trials of psychotherapy for depression. Concerns have been raised that the heterogeneity of treatments in TAU leads to biased estimates of psychotherapy efficacy and to an unclear difference between TAU and control groups like waiting list (WL)., Objective: We investigated the impact of control group intensity (i.e., amount and degree to which elements of common depression treatments are provided) on the effects of face-to-face and internet-based psychotherapy for depression., Methods: We conducted a preregistered meta-analysis (www.osf.io/4mzyd). We included trials comparing psychotherapy with TAU or WL in patients with symptoms of unipolar depression. Six indicators were used to assess control group intensity., Primary Outcome: Standardized mean difference (SMD) of psychotherapy and control in depressive symptoms at treatment termination., Results: We included 89 trials randomizing 14,474 patients to 113 psychotherapy conditions and 89 control groups (TAU in 42 trials, WL in 47 trials). Control group intensity predicted trial results in preregistered (one-sided ps < 0.042) and exploratory analyses. Psychotherapy effects were significantly smaller (one-sided p = 0.002) in trials with higher intensity TAU (SMD = 0.324, CI 0.209 to 0.439) than in trials with lower intensity TAU (SMD = 0.628, CI 0.455 to 0.801). Psychotherapy effects against lower intensity TAU did not differ from effects against WL (two-sided p = 0.663)., Conclusions: Our results suggest that variation in TAU intensity impacts the outcome of trials. More scrutiny in the design of control groups for clinical trials is recommended., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

People with mental illness often experience difficulties with reintegration into the workplace, although employment is known to assist these individuals in their recovery process. Traditional approaches of "first train, then place" have been recently replaced by supported employment (SE) methods that carry strategy of "first place, then train." Individual placement and support (IPS) is one of the best-studied methods of SE, which core principles are individualized assistance in rapid job search with consequent placement in a paid employment position. A considerable amount of high-quality evidence supported the superiority of IPS over conventional methods in providing improved employment rates, longer job tenure, as well as higher salaries in competitive job markets. Nonetheless, our knowledge about the IPS-mediated long-term effects is limited. This non-interventional follow-up study of a previously published randomized controlled trial (RCT) called ZhEPP aimed to understand the long-term impact of IPS after 6 years since the initial intervention. Participants from the ZhEPP trial, where 250 disability pensioners with mental illnesses were randomized into either IPS intervention group or treatment as usual group (TAU), were invited to face-to-face interviews, during which employment status, job tenure, workload, and salaries were assessed. One hundred and fourteen individuals agreed to participate in this follow-up study. Although during the first 2 years post-intervention, the IPS group had higher employment rates (40% (IPS) vs. 28% (TAU), p < 0.05 at 24 months), these differences disappeared by the time of follow-up assessments (72 months). The results indicated no substantial differences in primary outcome measures between IPS and TAU groups: employment rate (36 vs. 33%), workload (10.57 vs. 10.07 h per week), job tenure (29 vs. 28 months), and salary (20.21CHF vs. 25.02 CHF). These findings provide important insights regarding the long-term effects of IPS among individuals with mental health illnesses. Further research is required to advance the current knowledge about IPS intervention and its years-long impact., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Pichler, Stulz, Wyder, Heim, Watzke and Kawohl.)

Background: Body dysmorphic disorder (BDD), defined as the obsessive idea that some aspect of one's own body or appearance is severely flawed/deformed, is relatively common in the general population and has been shown to have strong associations with mood and anxiety disorders and substance abuse disorders. Furthermore, a previous study on symptoms of BDD among people in the military showed that muscles are an important area of preoccupation. Hence, this study aimed to 1. assess the prevalence of BDD symptoms in Swiss military recruits, 2. specify the areas of preoccupation, and 3. analyze associated features (depression and alcohol/drug abuse)., Method: A total of 126 Swiss male military recruits (age: M = 20.12, SD = 1.09, range: 18-24) were examined using self-report measurements to assess symptoms of BDD, depression, alcohol/drug abuse., Results: The results showed that symptoms of BDD were relatively common (9.5% reached the cutoff value for probable BDD, 84% reported some symptoms), with the muscles as the most common area of preoccupation. A positive correlation (r = .38, p < .001) between depressive symptoms and symptoms of BDD was found, thus no correlation between alcohol/drug abuse and symptoms of BDD., Conclusion: The results indicate a need to develop and implement measures for prevention (e.g. raising awareness among the military) and intervention in this specific population.

Background: We investigated the differential effectiveness of a stepped and collaborative care model (SCM) vs. treatment as usual (TAU) for primary care patients with various depression severity degrees and explored whether subgroups received distinct evidence-based treatments., Methods: Subgroup analyses of a RCT were calculated applying a multiple linear mixed model with the factors 1. group (SCM; TAU), 2. severity ((mild-moderate (MMD); severe depression (SD)) and their interaction, with PHQ-9 as primary outcome. Utilization of treatments was analyzed descriptively., Results: For the 737 participating patients (SCM: n = 569; TAU: n = 168), availability of data substantially varies between subgroups at 12-month follow-up ranging between 37% and 70%. ITT-analysis (Last-observation-carried-forward) revealed a significant interaction for group x severity [p = 0.036] and a significant difference between groups in symptom reduction for MMD (-3.9; [95% CI: -5.1 to -2.6, p < 0.001; d = 0.64] but not for SD (-1.6; [95% CI: -3.4 to 0.2, p = 0.093; d = 0.27]. Sensitivity analyses (multiple imputation, completer analysis, pattern mixture model) didn`t confirm the interaction effect and showed significant effects for both severity groups with slightly higher effect sizes for MMD. Differences between SCM and TAU in the percentage of patients utilizing depression-specific treatments are larger for MMD., Limitations: There was a high proportion of missing values among severely depressed patients, especially in SCM., Conclusion: SCM is effective for both MMD and SD. Utilization patterns might help explain the higher effects for MMD. Various strategies of replacement of missing values lead to slightly divergent results due to selective drop out between severity groups., (Copyright © 2020. Published by Elsevier B.V.)

Background: Depression is associated with major patient burden. Its treatment requires complex and collaborative approaches. A stepped care model based on the German National Clinical Practice Guideline "Unipolar Depression" has been shown to be effective. In this study we assess the cost-effectiveness of this guideline based stepped care model versus treatment as usual in depression., Methods: This prospective cluster-randomized controlled trial included 737 depressive adult patients. Primary care practices were randomized to an intervention (IG) or a control group (CG). The intervention consisted of a four-level stepped care model. The CG received treatment as usual. A cost-utility analysis from the societal perspective with a time horizon of 12 months was performed. We used quality-adjusted life years (QALY) based on the EQ-5D-3L as effect measure. Resource utilization was assessed by patient questionnaires. Missing values were imputed by 'multiple imputation using chained equations' based on predictive mean matching. We calculated adjusted group differences in costs and effects as well as incremental cost-effectiveness ratios. To describe the statistical and decision uncertainty cost-effectiveness acceptability curves were constructed based on net-benefit regressions with bootstrapped standard errors (1000 replications). The complete sample and subgroups based on depression severity were considered., Results: We found no statically significant differences in costs and effects between IG and CG. The incremental total societal costs (+€5016; 95%-CI: [-€259;€10,290) and effects (+ 0.008 QALY; 95%-CI: [- 0.030; 0.046]) were higher in the IG in comparison to the CG. Significantly higher costs were found in the IG for outpatient physician services and psychiatrist services in comparison to the CG. Significantly higher total costs and productivity losses in the IG in comparison to the CG were found in the group with severe depression. Incremental cost-effectiveness ratios for the IG in comparison to the CG were unfavourable (complete sample: €627.000/QALY gained; mild depression: dominated; moderately severe depression: €645.154/QALY gained; severe depression: €2082,714/QALY gained) and the probability of cost-effectiveness of the intervention was low, except for the group with moderate depression (ICER: dominance; 70% for willingness-to-pay threshold of €50,000/QALY gained)., Conclusions: We found no evidence for cost-effectiveness of the intervention in comparison to treatment as usual., Trial Registration: NCT, NCT01731717 . Registered 22 November 2012 - Retrospectively registered.

Background: More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care., Methods: An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10-15 min to complete. Spearman's correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data., Results: Eight hundred and sixty-seven (N = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers., Conclusions: Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.

Background: Telephone-administered cognitive-behavioral psychotherapy (T-CBT) can effectively treat patients with depressive symptoms. Introduction: We investigated whether adding letters (via postal mail) to T-CBT reduces depressive symptoms and increases response and remission. Additionally, we assessed whether T-CBT reduced all patients' symptoms in the first depression-specific T-CBT sample in German healthcare. Materials and Methods: Primary care patients were randomized to T-CBT with versus without letters. All received 1 face-to-face and 8-12 telephone-administered sessions. An intention-to-treat sample was analyzed. Between-groups differences in symptom change and the total sample's symptom change were computed using linear mixed models with group as fixed effect, referring general practice as random effect and several covariates. Differences in response and remission were assessed using logistic regressions. Results: Fifty-nine patients were referred to T-CBT and randomized. Twenty-six patients actually participated in T-CBT with letters and 21 without letters. The groups did not differ significantly regarding symptom change (Patient Health Questionnaire [PHQ-9]) from baseline to end: T-CBT without letters showed 1.05 points greater reduction (95% confidence interval: -4.72 to 2.62; p = 0.56; Cohen's d = -0.12) (adjusted mean change). The groups did not differ significantly regarding symptom change from baseline to 6-month follow-up nor odds of response or remission. The total sample's PHQ-9 showed significant adjusted mean reduction from baseline to end of T-CBT and to 6-month follow-up. Discussion: Additional letters did not lead to greater symptom reduction. Overall results for the first German T-CBT intervention for depression appear promising but require further assessment using a control condition. Conclusions: Additional letters do not appear to enhance the effectiveness of T-CBT.

Introduction: Advice literature on depression for patients and their relatives is a widespread and low-threshold source of information. In terms of empowerment of the patients it can contribute to the early detection and effective treatment of the disorder. An evaluation of its content quality, particularly its evidence base, is still missing. Considering this, the content of advice literature on depression is reviewed by comparing it systematically with content and recommendations from the German S3-/NV-guideline on unipolar depression., Methods: Based on a systematic search within the data base of the book trade, the 30 most widespread German advice books were analysed. For this purpose a rating instrument (RLP-D) with 54 items on diagnostics and treatment was derived from the current S3-/NV-guideline. With the help of the RLP-D one rater analysed both elaboration and accuracy of the 30 books' content., Results: Between 7.4 and 81.5% of the items i. e. of the guideline content, are missing in the analysed advice books (Mdn=25.9%, IQR=22.7%). On average a third of the 54 items is covered extensively as well as without contradictions to the guideline (Mdn=36.1%, IQR=17.1%, Range: 1.9-64.8%). A fifth of the covered items (Mdn=20.4%; IQR=19.0%, Range: 2.9-47.6%) shows clinically relevant contradictions to the guideline content. Information about psychotherapy and pharmacotherapy as treatment options is the content which is covered extensively and correctly most often: The information is given in more than 83% of the books., Discussion: There is a substantial variability concerning the elaboration and accuracy of the diagnostics and treatment content in advice literature. This also applies to the especially concerning erroneous content in advice literature. The further evaluation of the rating instrument RLP-D is a next important step. An application and reduction to the core contents of the guideline could facilitate the currently rather complex and laborious rating system., Conclusion: Although some basic information is given in almost all of the analysed books, advice literature on depression cannot be recommended per se due to the large differences in quality. Systematic evaluations of quality should be established in order to facilitate a well-grounded choice of literature in order to improve the information for patients., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Body Dysmorphic Disorder: Diagnosis, Treatment and Challenges in the General Practice Abstract. Body dysmorphic disorder (point prevalence: 1.7-2.4 %) is characterized by excessive preoccupation with one or more subjectively perceived blemishes of the appearance, as a result of which those affected show a high burden of disease due to avoidance behavior and time-consuming rituals, and often secondary problems (including depression, suicidal tendencies). The disorder is often accompanied by pronounced shame and is therefore associated with challenges in diagnostics, which is why the indication and specialist treatment (first-line treatment: cognitive-behavioural therapy) are usually only carried out with great latency. Family doctors can play a key role in diagnosis and treatment because of the often long-standing relationship of trust with their patients. Targeted screening, active and at the same time prudent discussion, as well as knowledge of treatment options and special features of the disease pattern (e.g. fluctuating understanding of the disease, desire for plastic surgery measures) are necessary. Against this background, the article provides an overview of the clinic, diagnostics and therapy and concludes with specific challenges and practical recommendations for family practice.

Background: Low-intensity treatments imply reduced therapist contact due to an emphasis on self-help and the use of technologies to deliver treatment. The role of the remoteness, the reduced therapist contact, and the interplay of these components has not been differentiated from a patients' perspective so far. This study's purpose is to capture patients' experiences with telephone-based self-help cognitive behavioural therapy (tel-CBT)., Methods: A subsample of mildly to moderately depressed patients (N = 13) who finished tel-CBT as part of a larger randomised controlled trial (RCT) in routine care were interviewed using a semi-structured questionnaire. Interviews were audiotaped, transcribed verbatim, and independently coded by two coders blind to treatment outcome. Using qualitative content analysis with deductive and inductive procedures, a two-level category system was established., Results: The category system contains four category clusters regarding expectations, self-help related aspects, telephone-related aspects, and implications for patients' treatment pathway, and subsumes a total of 15 categories. Self-help related aspects circulate around the interplay between written materials and professional input, trust and support in the therapeutic relationship and its relation to the initial personal contact, as well as CBT principles. Telephone-related aspects entail perceived advantages and disadvantages of the telephone on an organisational and content level as well as a discourse around distance and closeness in the interaction. Although patients raised doubts regarding the long-term effect of the intervention on symptomatology, patients expressed satisfaction with the treatment and reported an immediate as well as a longer lasting personal impact of the treatment. These results indicate user acceptance with tel-CBT., Conclusions: This qualitative analysis captures patients' experiences with tel-CBT and the perceived helpfulness of the diverse treatment components. This can facilitate refining aspects of low-intensity treatments and might improve dissemination., Trial Registration: ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Background: The aim of the study was to examine the prevalence of and factors associated with antidepressant (AD) prescriptions in order to draw a comprehensive picture of prescribing practices in Switzerland., Method: We conducted a population-based, cross-sectional descriptive study using a large Swiss healthcare claims database, covering approximately 13% of the Swiss population. AD prescription was determined by identifying patients (N = 105,663) with health claims data of at least 1 AD prescription in the year 2016. AD medication was identified using ATC-codes classified by the World Health Organisation. Univariate, bivariate and multivariate analyses using logistic regression were performed., Results: The extrapolated 1-year prevalence of AD prescription was 8.7% (95% CI, 8.7-8.8) with two thirds of AD recipients being female and the average age being 59 years (SD = 19.1). The regional distribution of prescription rates varied between cantons and ranged from 6.5 to 11.7%. Logistic regression revealed higher prescription rates among females compared to males (OR: 1.52) and an increased probability of AD prescription by age up until 54 years (OR: 2.25) and ≥ 85 years (OR: 2.32). Comorbidity is associated with higher odds (OR: 3.26 with 1-2 comorbidities) and enrollment in a managed care plan (compared to standard care) with lower odds for an AD prescription (OR: 0.85)., Conclusion: This study is the first in Switzerland to describe the prevalence of and factors associated with AD prescription based on a large health claims database reflecting routine care. The results provide important information about regional variation, prescription source, and potential over-prescription in the treatment of depressive disorders.

Background: Persistent depressive disorder (PDD) is defined as a depressive disorder with a minimum illness duration of two years, including four diagnostic subgroups (dysthymia, chronic major depression, recurrent major depression with incomplete remission between episodes, and double depression). Persistent forms of depression represent a substantial proportion of depressive disorders, with a lifetime prevalence ranging from 3% to 6% in the Western world. Growing evidence indicates that PDD responds well to several acute interventions, such as combined psychological and pharmacological treatments. Yet, given the high rates of relapse and recurrences of depression following response to acute treatment, long-term continuation and maintenance therapy are of great importance. To date, there has been no evidence synthesis available on continuation and maintenance treatments of PDDs., Objectives: To assess the effects of pharmacological and psychological (either alone or combined) continuation and maintenance treatments for persistent depressive disorder, in comparison with each other, placebo (drug/attention placebo/non-specific treatment control), and treatment as usual (TAU). Continuation treatments are defined as treatments given to currently remitted people (remission is defined as depressive symptoms dropping below case level) or to people who previously responded to an antidepressant treatment. Maintenance therapy is given during recovery (which is defined as remission lasting longer than six months)., Search Methods: We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 28 September 2018. An earlier search of these databases was also conducted for RCTs via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 Dec 2015). In addition we searched grey literature resources as well as the international trial registers ClinicalTrials.gov and ICTRP to 28 September 2018. We screened reference lists of included studies and contacted the first author of all included studies., Selection Criteria: We included randomized (RCTs) and non-randomized controlled trials (NRCTs) in adults with formally diagnosed PDD, receiving pharmacological, psychological, or combined continuation and maintenance interventions., Data Collection and Analysis: Two review authors independently selected studies and extracted and analyzed data. The primary efficacy outcome was relapse/recurrence rate of depression. The primary acceptance outcome was dropout due to any reason other than relapse/recurrence. We performed random-effects meta-analyses using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI)., Main Results: We included 10 studies (seven RCTs, three NRCTs) involving 840 participants in this review, from which five studies investigated continuation treatments and five studies investigated maintenance treatments. Overall, the included studies were at low-to-moderate risk of bias. For the three NRCTs, the most common source of risk of bias was selection of reported results. For the seven RCTs, the most common sources of risk of bias was non-blinding of outcome assessment and other bias (especially conflict of interest due to pharmaceutical sponsoring).Pharmacological continuation and maintenance therapiesThe most common comparison was antidepressant medication versus tablet placebo (five studies). Participants taking antidepressant medication were probably less likely to relapse or to experience a recurrent episode compared to participants in the placebo group at the end of the intervention (13.9% versus 33.8%, RR 0.41, 95% CI 0.21 to 0.79; participants = 383; studies = 4; I² = 54%, moderate quality evidence). Overall dropout rates may be similar between participants in the medication and placebo group (23.0% versus 25.5%, RR 0.90, 95% CI 0.39 to 2.11; RCTs = 4; participants = 386; I² = 64%, low quality evidence). However, sensitivity analyses showed that the primary outcome (rate of relapse/recurrence) showed no evidence of a difference between groups when only including studies with low risk of bias.None of the studies compared pharmacological or psychological treatments versus TAU.Psychological continuation and maintenance therapiesOne study compared psychological therapies versus attention placebo/non-specific control. One study compared psychotherapy with medication. The results of the studies including psychotherapy might indicate that continued or maintained psychotherapy could be a useful intervention compared to no treatment or antidepressant medication. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusions.Combined psychological and pharmacological continuation and maintenance therapiesThree studies compared combined psychological and pharmacological therapies with pharmacological therapies alone. One study compared combined psychological and pharmacological therapies with psychotherapeutic therapies alone. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusionsComparison of different antidepressant medications Two studies reported data on the direct comparison of two antidepressants. However, the body of evidence for this comparison was too small and uncertain to draw any high quality conclusions., Authors' Conclusions: Currently, it is uncertain whether continued or maintained pharmacotherapy (or both) with the reviewed antidepressant agents is a robust treatment for preventing relapse and recurrence in people with PDD, due to moderate or high risk of bias as well as clinical heterogeneity in the analyzed studies.For all other comparisons, the body of evidence was too small to draw any final conclusions, although continued or maintained psychotherapy might be effective compared to no treatment. There is need for more high quality trials of psychological interventions. Further studies should address health-related quality of life and adverse events more precisely, as well as assessing follow-up data.

In order to optimize patient allocation, guidelines recommend stepped and collaborative care models (SCM) including low-intensity treatments. The aim of this study is to investigate the implementation of guideline-adherent treatments in a SCM for depression in routine care. We analyzed care provider documentation data of n = 569 patients treated within a SCM. Rates of guideline-adherent treatment selections and initializations as well as accordance between selected and initialized treatment were evaluated for patients with mild, moderate and severe depression. Guideline-adherent treatment selection and initialization was highest for mild depression (91% resp. 85%). For moderate depression, guideline-adherent treatments were selected in 68% and applied in 54% of cases. Guideline adherence was lowest for severe depression (59% resp. 19%). In a multiple mixed logistic regression model a significant interaction between guideline adherence in treatment selection/initialization and severity degree was found. The differences between treatment selection and initialization were significant for moderate (OR: 1.8 [95% CI: 1.30 to 2.59; p = 0.0006]) and severe depression (OR: 6.9; [95% CI: 4.24 to 11.25; p < .0001] but not for mild depression (OR = 1.8, [95%-CI: 0.68 to 4.56; p = 0.2426]). Accordance between selected and initialized treatment was highest for mild and lowest for severe depression. We conclude that SCMs potentially improve care for mild depression and guideline adherence of treatment selections. Guideline adherence of treatment initialization and accordance between treatment selection and initialization varies with depression severity. Deficits in treating severe depression adequately may be more a problem of failed treatment initializations than of inadequate treatment selections., Competing Interests: The authors have declared that no competing interests exist.

Guidelines recommend stepped and collaborative care models (SCM) for depression. We aimed to evaluate the effectiveness of a complex guideline-based SCM for depressed patients. German primary care units were cluster-randomised into intervention (IG) or control group (CG) (3:1 ratio). Adult routine care patients with PHQ-9 ≥ 5 points could participate and received SCM in IG and treatment as usual (TAU) in CG. Primary outcome was change in PHQ-9 from baseline to 12 months (hypothesis: greater reduction in IG). A linear mixed model was calculated with group as fixed effect and practice as random effect, controlling for baseline PHQ-9 (intention-to-treat). 36 primary care units were randomised to IG and 13 to CG. 36 psychotherapists, 6 psychiatrists and 7 clinics participated in SCM. 737 patients were included (IG: n = 569 vs. CG: n = 168); data were available for 60% (IG) and 64% (CG) after 12 months. IG showed 2.4 points greater reduction [95% confidence interval (CI): -3.4 to -1.5, p < 0.001; Cohen's d = 0.45] (adjusted PHQ-9 mean change). Odds of response [odds ratio: 2.8; 95% CI: 1.6 to 4.7] and remission [odds ratio: 3.2; 95% CI: 1.58 to 6.26] were higher in IG. Guideline-based SCM can improve depression care.

Background: Although observer-rated instruments assessing therapist's adherence to relapse-preventive treatments are available, they do not adequately cover specific relapse-preventive elements that focus on implementation of strategies after terminating treatment. This study describes the development of the KERI-D (Kodierbogen zur Erfassung Rückfallprophylaktischer Interventionen bei Depression/Coding System to Assess Interventions of Relapse Prevention in Depression). The KERI-D is a new observer-based rating tool for acute or continuation/maintenance-phase sessions and assesses relapse-prevention elements including implementation into patient's daily routines., Methods: The development of the KERI-D included iterative steps referring to theoretical, clinical and empirical sources. It consists of 19 content items within four categories (self-care, early warning signs, triggering events/situations, termination of therapy) and one global item. For empirical analyses, videotaped psychotherapy sessions of 36 psychotherapies were rated by three independent observers and analyzed for their psychometric properties., Results: Most items showed moderate to good inter-rater reliability (median ICC = .80) and retest reliability (median ICC = .93). Principal-axis factor analysis revealed three subscales, and first evidence of content validity was demonstrated. No associations with clinical follow-up data were found., Limitations: Analysis was limited to a relatively small sample of selected psychotherapy sessions. Evaluation of predictive validity is a desirable next step to further examine applicability and scope of the instrument., Conclusions: The KERI-D is the first observer-based rating instrument measuring specific relapse-prevention strategies in psychotherapy for depression. It may help to identify elements that prove effective in reducing relapse/recurrence in the long-term and thereby help to optimize effect duration of depression treatment., (Copyright © 2017. Published by Elsevier B.V.)

Background: Patients with depression often have limited access to outpatient psychotherapy following inpatient treatment. The objective of the study was to evaluate the long-term effectiveness of a telephone-based aftercare case management (ACM) intervention for patients with depression., Methods: We performed a prospective randomized controlled trial in four psychotherapeutic inpatient care units with N = 199 patients with major depression or dysthymia (F32.x, F33.x, F34.1, according to the ICD-10). The ACM consisted of six phone contacts at two-week intervals performed by trained and certified psychotherapists. The control group received usual care (UC). The primary outcome was depressive symptom severity (BDI-II) at 9-month follow-up, and secondary outcomes were health-related quality of life (SF-8, EQ-5D), self-efficacy (SWE), and the proportion of patients initiating outpatient psychotherapy. Mixed model analyses were conducted to compare improvements between treatment groups., Results: Regarding the primary outcome of symptom severity, the groups did not significantly differ after 3 months (p = .132; ES = -0.23) or at the 9-month follow-up (p = .284; ES = -0.20). No significant differences in health-related quality of life or self-efficacy were found between groups. Patients receiving ACM were more likely to be in outpatient psychotherapy after 3 months (OR: 3.00[1.12-8.07]; p = .029) and 9 months (OR: 4.78 [1.55-14.74]; p = .006) than those receiving UC., Conclusions: Although telephone-based ACM did not significantly improve symptom severity, it seems to be a valuable approach for overcoming treatment barriers to the clinical pathways of patients with depression regarding their access to outpatient psychotherapy.

Background: The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders., Objective: This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy., Method: Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference., Results: Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model., Conclusion: Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

Background: Despite the availability of evidence-based treatments for depression, a large proportion of patients remains untreated or adequate treatment is initiated with delay. This situation is particularly critical in primary care, where not only most individuals first seek help for their mental health problems, but also depressive disorders - particularly mild to moderate levels of severity - are highly prevalent given the high comorbidity of chronic somatic conditions and depression. Improving the access for evidence-based treatment, especially in primary care, is hence a priority challenge in the mental health care agenda. Telephone usage is widespread and has the potential of overcoming many barriers that individuals suffering from mental health problems are facing: Its implementation for treatment delivery presents an option for optimisation of treatment pathways and outcomes., Methods/design: This paper details the study protocol for a randomised controlled trial (RCT) evaluating the effectiveness of a telephone-administered short-term cognitive-behavioural therapy (T-CBT) for depression as compared to treatment as usual (TAU) in the Swiss primary care setting. The study aims at randomising a total of 216 mildly to moderately depressed patients, which are either identified by their General Practitioners (GPs) or who self-refer to the study programme in consultation with their GP. The trial will examine whether telephone-delivered, manualised treatment leads to clinically significant reduction in depression at follow-up. It will further investigate the cost-effectiveness and acceptability of the intervention in the primary care setting., Discussion: Conducting a low-intensity treatment on the telephone allows for greater flexibility for both patient and therapist, can grant more anonymity and can thus lead to less hesitation in the patient about whether to attempt treatment or not. In order to benefit from this approach, large-scale studies need to prove superior effectiveness and cost-effectiveness of telephone-delivered therapy over routine care for patients with mild to moderate depression., Trial Registration: ClinicalTrials.gov NCT02667366 . Registered on 3 December 2015.

Objective: Case management (CM) programs are intended to improve care coordination for cancer patients. This quasi-experimental, controlled study evaluated whether such a program was effective in improving health-related quality of life and reducing the psychological distress of breast cancer patients., Methods: For the study, 126 patients with CM and 118 patients with treatment as usual (TAU) were surveyed at baseline, a 6-month follow-up and a 12-month follow-up. Comparisons of the two groups with regard to quality of life (Short Form-8, European Organization for Research and Treatment of Cancer-11; primary outcome) and psychological distress (Hospital Anxiety and Depression Scale, distress thermometer; secondary outcome) were conducted., Results: Univariate t-tests regarding the primary and secondary outcomes demonstrated improvements in the relevant outcomes at the 6-month and 12-month follow-ups for the intervention group as well as for the control group. An analysis of covariance revealed that the controls showed a higher level of physical quality of life at the 12-month follow-up than the other time points and no differences at 6 months after the baseline., Conclusions: The tested CM model did not improve the quality of life or psychological well-being of the patients beyond treatment as usual. Possible reasons include that the treatment was already of high standards in the control group or that there are possibly different impacts than found in the literature regarding different forms of organization in CM. The need for and the tailoring of this CM model as well as the transfer of CM to other oncological indications remain to be clarified. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

We present PictureSensation, a mobile application for the hapto-acoustic exploration of images. It is designed to allow for the visually impaired to gain direct perceptual access to images via an acoustic signal. PictureSensation introduces a swipe-gesture based, speech-guided, barrier free user interface to guarantee autonomous usage by a blind user. It implements a recently proposed exploration and audification principle, which harnesses exploration methods that the visually impaired are used to from everyday life. In brief, a user explores an image actively on a touch screen and receives auditory feedback about its content at his current finger position. PictureSensation provides an extensive tutorial and training mode, to allow for a blind user to become familiar with the use of the application itself as well as the principles of image content to sound transformations, without any assistance from a normal-sighted person. We show our application's potential to help visually impaired individuals explore, interpret and understand entire scenes, even on small smartphone screens. Providing more than just verbal scene descriptions, PictureSensation presents a valuable mobile tool to grant the blind access to the visual world through exploration, anywhere., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study examined symptom change trajectories during inpatient psychotherapy and the association of these changes with long-term outcomes. In an observational multicenter study, weekly measurements of symptom severity were performed during inpatient treatment and 6 months after discharge. The symptom severity was measured using the 18-item scale of the Hamburg Modules for the Assessment of Psychosocial Health. The sample included 576 inpatients (mean age: 43.9 years; 77.6% female; main diagnoses: depressive (57.2%), adjustment (15.8%), anxiety (7.4%), and eating disorders (7.2%); mean treatment duration: 42.0 days). With empirically and clinically informed growth mixture models four subgroups of symptom change were revealed: gradual response (71%), early response (9%), delayed response (5%), and nonresponse (11%). Particularly low educational level, non-employment and chronic disorders were associated with unfavorable symptom courses (non- and delayed response). Long-term outcomes differed systematically across subgroups (p<0.001; η(2)=0.165). The patients who responded early presented the highest rates of clinically significant improvement (43.9%) from admission to follow-up. Nearly all of these patients (92.7%) showed reliable improvement. Due to the high association of symptom change trajectories with long-term outcomes, results may contribute to interventions that are tailored to the needs of patients and may foster longer lasting therapeutic effectiveness., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: Which health care barriers do patients with anxiety and depressive disorders experience on their clinical pathways?, Methods: Semi-structured interviews were conducted among 30 patients with anxiety and depressive disorders. Interviews were audio-taped, transcribed, coded and content-analysed., Results: Following barriers perceived by patients were extracted: a lack of early diagnosis, communication and coordination problems between different services and providers, little information about their illness and its adequate treatment, as well as intrapersonal barriers., Conclusions: Patients perceive barriers on the individual, provider and system level. Especially barriers on the system and provider level indicate a need for more information, early recognition and support especially during the help-seeking process., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Evaluation of satisfaction and acceptance of a stepped care model in the Health Network Depression from the perspective of general practitioners, psychotherapists and psychiatrists., Methods: Cross-sectional questionnaire study with n = 61 care providers., Results: All elements of the stepped care model, e. g. screening, diagnostic, and monitoring checklists, guidelines, low-intensity treatment options and IT-tools were utilized by over 75 % of partners and obtained largely positive ratings., Conclusion: This positive evaluation provides a basis for further participative development and transfer into health care., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care., Purpose: To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care., Methods: A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP)., Results: In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562., Conclusion: Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Background: Depressive and anxiety disorders are highly prevalent, but only a small percentage (approximately 50%) of patients receive appropriate treatment. Relevant barriers include communication and coordination gaps between different providers that result from the lack of integration between different care-giving systems. Aftercare following inpatient treatment represents one of these gaps because systematic follow-up care does not exist. Case management-based aftercare coordination by phone might be a promising approach to overcoming this gap and improving long-term treatment outcomes. Case management is a patient-centered and situation-based approach comprising systematic tracking and support of patients by a case manager. The aim of this study is to evaluate the effectiveness of aftercare coordination by phone for patients with depressive and anxiety disorders., Methods/design: The effectiveness of aftercare coordination will be investigated in a prospective randomized controlled trial in four psychotherapeutic inpatient routine care units (St. Franziska-Stift Bad Kreuznach, MediClin Seepark Klinik Bad Bodenteich, Segeberger Kliniken Gruppe Bad Segeberg and Luisenklinik Bad Dürrheim). The patients receiving aftercare coordination (intervention group; IG) will be compared with those who receive treatment as usual (TAU control group; CG). Eligible patients will be required to have a diagnosis of an anxiety and/or depressive disorder and a recommendation for follow-up outpatient psychotherapy. The aftercare coordination consists of six phone contacts at intervals of two weeks that are performed by therapists in the inpatient units. The patients will complete questionnaires at discharge (t1), 3 months after discharge (i.e., at the end of the intervention (t2)) and 9 months after discharge (t3). The primary outcome will be change in symptom severity from t1 to t3, the secondary outcomes will be health-related quality of life and the proportion of patients who manage to begin outpatient psychotherapy by t3., Discussion: This study will determine whether case management-based aftercare coordination by phone is an adequate approach for overcoming treatment barriers in the clinical pathways of patients with depressive and anxiety disorders. If proven effective, an accessible supplementary treatment approach that will help to maintain and even improve long-term treatment outcomes will be made available for patients following inpatient treatment., Trial Registration: ClinicalTrials.gov: ( NCT02044913 ).

Background: Depression is one of the most widespread mental disorders in Germany and causes a great suffering and involves high costs. Guidelines recommend stepped and interdisciplinary collaborative care models for the treatment of depression., Objectives: Stepped and collaborative care models are described regarding their efficacy and cost-effectiveness. A current model project within the Hamburg Network for Mental Health exemplifies how guideline-based stepped diagnostics and treatment incorporating innovative low-intensity interventions are implemented by a large network of health care professionals and clinics., Materials and Methods: An accompanying evaluation using a cluster randomized controlled design assesses depressive symptom reduction and cost-effectiveness for patients treated within "Health Network Depression" ("Gesundheitsnetz Depression", a subproject of psychenet.de) compared with patients treated in routine care., Results: Over 90 partners from inpatient and outpatient treatment have been successfully involved in recruiting over 600 patients within the stepped care model. Communication in the network was greatly facilitated by the use of an innovative online tool for the supply and reservation of treatment capacities. The participating professionals profit from the improved infrastructure and the implementation of advanced training and quality circle work., Conclusions: New treatment models can greatly improve the treatment of depression owing to their explicit reference to guidelines, the establishment of algorithms for diagnostics and treatment, the integration of practices and clinics, in addition to the implementation of low-intensity treatment alternatives. These models could promote the development of a disease management program for depression.

Background: Depression is a widespread and serious disease often accompanied by a high degree of suffering and burden of disease. The lack of integration between different care providers impedes guideline-based treatment. This constitutes substantial challenges for the health care system and also causes considerable direct and indirect costs. To face these challenges, the aim of this project is the implementation and evaluation of a guideline-based stepped care model for depressed patients with six treatment options of varying intensity and setting, including low-intensity treatments using innovative technologies., Methods/design: The study is a randomized controlled intervention trial of a consecutive sample of depressive patients from primary care assessed with a prospective survey at four time-standardized measurement points within one year. A cluster randomization at the level of participating primary care units divides the general practitioners into two groups. In the intervention group patients (n = 660) are treated within the stepped care approach in a multiprofessional network consisting of general practitioners, psychotherapists, psychiatrists and inpatient care facilities, whereas patients in the control condition (n = 200) receive routine care. The main research question concerns the effectiveness of the stepped-care model from baseline to t3 (12 months). Primary outcome is the change in depressive symptoms measured by the PHQ-9; secondary outcomes include response, remission and relapse, functional quality of life (SF-12 and EQ-5D-3 L), other clinical and psychosocial variables, direct and indirect costs, and the incremental cost-effectiveness ratio. Furthermore feasibility and acceptance of the overall model as well as of the separate treatment components are assessed., Discussion: This stepped care model integrates all primary and secondary health care providers involved in the treatment of depression; it elaborates innovative and evidence-based treatment elements, follows a stratified approach and is implemented in routine care as opposed to standardized conditions. In case of positive results, its sustainable implementation as a collaborative care model may significantly improve the health care situation of depressive patients as well as the interaction and care delivery of different care providers on various levels., Trial Registration: This study is registered with ClinicalTrials.gov, number NCT01731717 (date of registration: 24 June 2013).

Objective: As an initiative of the German Pension Insurance Association (DRV), evidence-based therapeutic modules (ETM) for the rehabilitation of patients with depression were developed. The objective of the subsequent analysis was to analyse the therapeutic procedures in inpatient rehabilitation on the basis of the ETM to evaluate the principal needs for therapeutic standards., Methods: Data based on the German Classification of Therapeutic Procedures (KTL) for 21 529 patients treated in rehabilitation clinics for people with mental illnesses was analysed with respect to differences between diagnostic groups/clinics regarding type, quantity and duration of measures coded., Results: The mean quantity and duration of the interventions for patients with depressive disorders encoded varied greatly between the ETM. No or only minor differences were found between patients with depression and those with other diagnoses regarding the type, quantity and duration of measures coded. However, there were great variances between clinics., Conclusions: Therapeutic standards for rehabilitative practice appear necessary in order to reduce treatment heterogeneity between rehabilitation facilities, which could improve the quality of healthcare., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The aim of this study was to investigate fear of disease progression (FoP) during the year following diagnosis of breast cancer and its association with general self-efficacy (SE)., Methods: In a prospective study, 118 breast cancer patients were recruited shortly after diagnosis disclosure (response rate: 54%) and at 1-year follow-up (follow-up rate: 90%). Participants completed self-report measures of general self-efficacy (General Self-Efficacy Scale) and fear of progression (short form of the Fear of Progression Questionnaire)., Results: Cross-sectional regression analysis revealed that high FoP is significantly associated with low SE, even when controlling for demographic and medical characteristics (total R² = 0.17). Having children and a relatively short time since diagnosis also significantly predicted higher FoP. Longitudinal analyses showed that FoP decreased significantly over time (p = 0.001; d = 0.25), but a significant decrease was only observed for patients with high initial FoP (p < 0.001; d = 0.74) and not for those with low initial FoP (p = 0.688; d = 0.08). SE was not a significant predictor of FoP at follow-up when controlling for initial FoP and other patient characteristics (incremental R² = 0.001; p = 0.674; total R² = 0.47). Overall, only initial FoP significantly predicted FoP at follow-up (p < 0.001; β = 0.671)., Conclusion: Findings that low SE is associated with high FoP can help to improve the treatment of dysfunctional fears in breast cancer patients. As FoP changes only slightly over time, treatment to enhance SE and reduce FoP should be initiated soon after disease disclosure., (Copyright © 2011 John Wiley & Sons, Ltd.)

With the public-funded research and development project psychenet: the Hamburg Network for Mental Health (2011-2014), the Federal Ministry of Education and Research contributes to strengthening healthcare regions in Germany by establishing new trans-sectoral cooperations and implement and evaluate selected innovations. More than 60 partners from research, health care, health industry and government in the Free and Hanseatic City of Hamburg are promoting innovative measures to improve the treatment for mental disorders. The main objective is to implement integrated healthcare networks based on evidence for effective treatment methods, deriving from high-quality research throughout five indications such as psychosis, depression, somatoform and functional syndromes, anorexia and bulimia and addiction illnesses in adolescence. Those networks are accompanied by additional measures, for example, for improving information and education, addressing occupational health or strengthening the participation of patients and their families suffering from mental illness.

We investigated the comparative effectiveness of cognitive-behavioural (CBT) and psychodynamic therapy (PDT) under clinically representative conditions as a subtrial of a prior study (Watzke et al., 2010, BJP). A consecutive sample of 147 patients with common mental disorders was randomised to either CBT or PDT in routine mental health care. In a primary per-protocol analysis patients randomised to CBT had a significantly better longer term outcome in the primary outcome symptom severity (General Severity Index of the SCL-14; p=.001; partial η(2)=0.073) as well as in health related quality of life (Mental Component Summary of the SF-8; p=.013; partial η(2)=.041) and concerning interpersonal issues (Inventory of Interpersonal Problems, IIP-C; p=.001; partial η(2)=.070) 6 months after treatment than patients randomised to PDT. These results could be confirmed in intention-to-treat analyses (n=180) suggesting that there was no substantial attrition bias due to drop outs at the follow-up assessment. Thus, the so called equivalence outcome paradox was not replicated in this study., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The primary goals of this paper are to describe the collection and evaluation of various nonpharmacological treatment options for depressive disorders and to establish a basis for the development of a standard for the treatment of patients with depressive disorders., Method: To identify evidence-based treatment elements, a comprehensive investigation of national and international guidelines was conducted. The extracted guidelines were then assessed with regard to aspects of methodological quality and evidence-based treatment elements. In a further step, specific and systematic literature searches for residual treatment elements were conducted. For the corresponding literature search, a hierarchical approach was chosen in which current guidelines were reviewed first and systematic reviews and meta-analyses second. Psychopharmacological treatments were excluded from the analysis because this is covered by specific guidelines., Results: The treatment elements with an adequate level of evidence were identified as follows: psychotherapeutic interventions, marital/couples/family therapy and counseling, inclusion of family members, psycho-education, exercise, problem solving therapy, guided self-help and behavioral activation treatments. Further evidence-based methods include diagnostic treatment elements, participative decision-making, development of the therapeutic alliance, Cognitive Behavioral Analysis System for Psychotherapy, computerized cognitive behavior therapy, psychopharmacological therapy, combined psychopharmacological and psychotherapeutic therapy, electroconvulsive therapy, phototherapy, sleep deprivation, repetitive trans-cranial magnetic stimulation (rTMS) and acupuncture., Conclusion: In summary, using a hierarchical approach, it was possible to assign different levels of evidence to the various treatment options for depression.