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Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.

Zusammenfassung Ziel der Studie Darstellung der Erwerbssituation und Suche nach Determinanten der Erwerbstätigkeit in Abhängigkeit der Symptomschwere bei geflüchteten Menschen mit posttraumatischer Belastung. Methodik Befragung 133 geflüchteter, in Deutschland lebender Menschen syrischer Herkunft mit posttraumatischer Belastungssymptomatik und explorative Datenanalyse. Ergebnisse Nach knapp 4 Jahren im Asylland ist ein Viertel der Teilnehmenden (27,1 %) erwerbstätig. Dabei stehen einer erwerbstätigen Frau 6 erwerbstätige Männer gegenüber (13,9 % vs. 86,1 %; p = 0,001). Zusammenhänge zwischen psychischer Gesundheit und Erwerbstätigkeit ließen sich darstellen (posttraumatische Belastung p = 0,039, Depressivität p = 0,020, Somatisierung p = 0,026). Hinsichtlich sozialer Unterstützung, Traumaerleben sowie Aufenthaltsstatus und -dauer zeigten sich keine Unterschiede zwischen Geflüchteten mit und ohne Erwerbstätigkeit. Schlussfolgerung Die aktuelle Analyse zur Erwerbssituation einer umschriebenen Gruppe syrischer Geflüchteter stellt die Bedeutung der psychischen Symptombelastung in den Mittelpunkt.

Zusammenfassung Ziel der Studie Adipositas, eine exzessive Gewichtszunahme und psychische Belastungen während der Schwangerschaft sind mit erheblichen gesundheitlichen Risiken für die Mutter und das ungeborene Kind verbunden. Ziel der Studie war die Erfassung der Prävalenz von Adipositas und einer exzessiven Gewichtszunahme sowie von Zusammenhängen zur psychischen Gesundheit der Mutter nach der Entbindung. Methodik In die Studie eingeschlossen wurden 774 Frauen im Alter zwischen 18 und 43 Jahren. Die postpartale psychische Gesundheit wurde mithilfe des BDI-II und der SCL-90-R erfasst. Ergebnisse 47,3 % der Frauen wiesen eine exzessive Gewichtszunahme auf. Die Prävalenz von Übergewicht und Adipositas betrug 15,4 % bzw. 7,6 %. Übergewicht und Adipositas waren relativ zum Normalgewicht mit einem höheren Risiko für eine exzessive Gewichtszunahme assoziiert (2,92 ≤ OR ≤ 3,75; p Schlussfolgerung Adipositas und exzessive Gewichtszunahme in der Schwangerschaft stellen auch in unserer Stichprobe ein häufiges und ernstzunehmendes Problem dar. Die Ergebnisse verdeutlichen die Notwendigkeit effektiver Präventionsprogramme sowie der Berücksichtigung der mütterlichen psychischen Gesundheit.

Zusammenfassung Ziele Übergewicht und Adipositas in der Schwangerschaft sowie Figur- und Gewichtssorgen sind mit erhöhter physischer und psychischer Belastung assoziiert. Bisher ist allerdings wenig über die Entwicklung von Figur- und Gewichtssorgen bei schwangeren Frauen mit Übergewicht und Adipositas sowie Zusammenhänge mit der psychischen Gesundheit bekannt. Methodik Die Studienteilnehmerinnen (N = 218) füllten validierte Fragebögen zu Figur- und Gewichtssorgen (Eating Disorder Examination-Questionnaire), Depression (Edinburgh Postnatal Depression Scale) und Stress (Perceived Stress Scale) in der 18.–22. Schwangerschaftswoche (SSW) (T1), der 28.–32. SSW (T2) und 12 bis 16 Wochen nach der Geburt (T3) aus. Der Einfluss von Body Mass Index (BMI) auf Figur- und Gewichtssorgen wurde mittels ANCOVAs mit Messwiederholungen untersucht. Korrelationen und multiple Regressionsmodelle wurden angewandt, um Zusammenhänge zwischen Figur- und Gewichtssorgen und der Depressions- und Stresssymptomatik zu explorieren. Ergebnisse Frauen mit Übergewicht berichteten zwischen der 28.–32. SSW und der 12.–16. Woche nach der Geburt eine stärkere Zunahme von Figur- und Gewichtssorgen als normalgewichtige Frauen. In adjustieren Analysen sagten Figur- und Gewichtssorgen zu T1 über alle BMI-Kategorien hinweg Depressions- und Stresssymptome zu T3 vorher. Schlussfolgerungen Die Ergebnisse dieser Studie zeigen, dass vor allem die Zeit nach der Entbindung eine Risikoperiode für die Entwicklung von Figur- und Gewichtssorgen bei Frauen mit erhöhtem BMI ist. Köperbildspezifische Interventionen vor und nach der Geburt könnten dazu beitragen, die psychische Belastung von Frauen mit Übergewicht und Adipositas zu verringern.

Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the “Sanadak” randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.

Description of employment situation and search for determinants of employment depending on symptom severity in refugees with posttraumatic stress.Standardized interviews with 133 Syrian refugees (18 to 65 years) living in Germany with posttraumatic stress symptoms and exploratory data analysis.27.1 % of the participants were employed; including 13.9 % women and 86.1 % men (p = 0.001). Links between mental health and employment can be shown (posttraumatic stress p = 0.039, depressiveness p = 0.020, somatisation p = 0.026). With regard to social support and type of trauma, as well as residence status and duration of residence, there were no differences between refugees with and without employment.The current analysis on the employment situation of a circumscribed group of Syrian refugees focuses on the importance of psychological symptom burden.Darstellung der Erwerbssituation und Suche nach Determinanten der Erwerbstätigkeit in Abhängigkeit der Symptomschwere bei geflüchteten Menschen mit posttraumatischer Belastung.Befragung 133 geflüchteter, in Deutschland lebender Menschen syrischer Herkunft mit posttraumatischer Belastungssymptomatik und explorative Datenanalyse.Nach knapp 4 Jahren im Asylland ist ein Viertel der Teilnehmenden (27,1 %) erwerbstätig. Dabei stehen einer erwerbstätigen Frau 6 erwerbstätige Männer gegenüber (13,9 % vs. 86,1 %; p = 0,001). Zusammenhänge zwischen psychischer Gesundheit und Erwerbstätigkeit ließen sich darstellen (posttraumatische Belastung p = 0,039, Depressivität p = 0,020, Somatisierung p = 0,026). Hinsichtlich sozialer Unterstützung, Traumaerleben sowie Aufenthaltsstatus und -dauer zeigten sich keine Unterschiede zwischen Geflüchteten mit und ohne Erwerbstätigkeit.Die aktuelle Analyse zur Erwerbssituation einer umschriebenen Gruppe syrischer Geflüchteter stellt die Bedeutung der psychischen Symptombelastung in den Mittelpunkt.

Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy-based self-help in the Arabic language for Syrian refugees with posttraumatic stress.The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app.In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach.Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff -0.90, 95% CI -0.24 to 0.47; P=.52) and after 4 months (Diff -0.39, 95% CI -3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS-stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay.Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach.German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTMLTRIAL_ID=DRKS00013782.RR2-10.1186/s12888-019-2110-y.

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Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce.The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement.The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures.A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P.001; ηThe web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer.German Clinical Trial Register U1111-1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTMLTRIAL_ID=DRKS00011001.

BACKGROUND Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce. OBJECTIVE The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement. METHODS The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures. RESULTS A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: Pη2=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health. CONCLUSIONS The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer. CLINICALTRIAL German Clinical Trial Register U1111–1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001

Refugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the “Sanadak” randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.

Refugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (−0.17, p &lt, 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.

The Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ) was developed to measure depressive and anxious avoidance behaviors, which, according to cognitive-behavioral models, are supposed to play an important role in the development and maintenance of prolonged grief. The present study aimed to develop a German version of the DAAPGQ and evaluate its psychometric properties and validity within a representative sample of the German general population (N = 2531). The German-language DAAPGQ was developed using a forward-backward translation procedure. Then, a subsample of individuals who reported having lost a significant other (N = 1371) of a representative sample was assessed with the German DAAPGQ, along with information on sociodemographic characteristics, prolonged grief symptom severity (PG-13), general anxiety (GAD-2) and depression (PHQ-2). The factor structure of the DAAPGQ was evaluated using confirmatory factor analyses, reliability by calculating internal consistency on subscale level and convergent validity by correlations between DAAPQG subscale sores with PG-13, GAD-2 and PHQ-2 sum scores. As expected, a two-factor model with correlated latent variables showed good fit to the data, replicating findings from the original version. Internal consistency was high for both subscales (Cronbach’s α .86 and .95, respectively). Convergent validity was established by theoretically expected and statistically significant positive correlations of DAAPGQ subscales with symptom severity of prolonged grief, depression, and anxiety and negative correlations with time since loss. Furthermore, the addition of depressive and anxious avoidance significantly improved the prediction of prolonged grief symptom severity over sociodemographic and loss-related information. In sum, our results suggest that the German-language DAAPGQ is a reliable and valid measure of depressive and anxious avoidance and a useful tool to improve our knowledge on the role of avoidance in prolonged grief. We also provide descriptive data to improve the applicability of the DAAPGQ for individual diagnostics.

BACKGROUND Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress. OBJECTIVE The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. METHODS In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. RESULTS Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. CONCLUSIONS Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. CLINICALTRIAL German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782 INTERNATIONAL REGISTERED REPORT RR2-10.1186/s12888-019-2110-y

Objectives For many women, the postpartum period is a particularly vulnerable time to experience body image dissatisfaction. We aimed to examine the impact of social media usage frequency in the context of postpartum body image dissatisfaction and eating disorder psychopathology. We therefore empirically tested a hypothetical model assuming that social media usage influences postpartum body image dissatisfaction and eating disorder psychopathology via multiple mediation through appearance-related social comparisons and thin ideal internalization. Design Cross-sectional online-survey. Setting Online forums, social media groups, community groups Participants Two-hundred-fifty-two new mothers who had given birth within the last 26 weeks prior to the assessment. Measurements Social media use was assessed by the average frequency of using Facebook, Instagram, Youtube or other per week. Body image dissatisfaction was assessed with the Body Shape Questionnaire and eating disorder psychopathology with the Eating Disorder Examination-Questionnaire. Path analyses using SPSS Amos were conducted to examine whether the hypothetical model fitted our data. Results After minor modification, the final model revealed a good fit to the data, CFI = .977, TLI = .964, SRMR = .061, RMSEA = .056 (90%CI .027, .084), and as expected the indirect multiple mediation pathway via appearance-related social comparisons and thin ideal idealization was significant, IE = 4.395; 95%BCaCI 2.969, 7.394; p = .001. The number of target groups for appearance-related social comparisons did not moderate the results. Key conclusions Our results provide first evidence that social media use may play an important role in postpartum body dissatisfaction and eating disorder psychopathology. Mediational pathways proposed by socio-cultural theories of body image also hold for the postpartum period. Implications for practice Practitioners in the field should be aware of the association between social media use and body image dissatisfaction and mediating factors among new mothers and sensitive when directing new mothers to those media.

Background Cancer is one of the most common causes of death. The period of time between receiving a terminal diagnosis of cancer and the death of a loved one has been operationalized as pre-loss grief and, more recently, as preparedness for death. Originally, grief before loss was thought to have positive effects on the bereavement outcome, but some studies have revealed contradictory findings. This systematic review investigates definitions and measurement tools of pre-loss grief and preparedness for death, as well as the associations of both constructs with caregiver characteristics, pre-loss psychological aspects and post-loss adjustment among caregivers of people living with terminal cancer. Methods PubMed/Medline, PsycINFO and Web of Science were searched for studies published up until October 2020. Quantitative empirical studies from peer reviewed journals were included if a measurement tool for pre-loss grief or preparedness for death was used and if they focused on adult caregivers of adult people with cancer in an end-of-life trajectory and were excluded when they were not written in English or were descriptive/qualitative studies. Quality assessment of all studies was performed. Results Most studies used convenience samples and had a mean number of 725 participants. Overall, 16,326 participants in 35 articles were included and narratively synthesized. High levels of pre-loss grief, as well as low levels of perceived preparedness for death, were associated with poor post-loss adjustment (e.g., prolonged grief, depressive symptoms, etc.). Conclusions Caregivers with high levels of pre-loss grief and low levels of preparedness for the death of their loved one would benefit from targeted support for post-loss adjustment. Results are limited by an inconsistent operationalization of both constructs.

Obesity and depression are prevalent complications during pregnancy and associated with severe health risks for the mother and the child. The co-occurrence of both conditions may lead to a particular high-risk group. This review provides a systematic overview of the association between pre-pregnancy obesity and antenatal or postnatal depression. We conducted a systematic electronic literature search for English language articles published between January 1990 and March 2017. Inclusion criteria were (a) adult pregnant women, (b) women with pre-pregnancy obesity and normal weight controls, (c) definition of obesity according to the IOM 1990/2009 criteria, (d) established depression measure, and (e) report on the association between pre-pregnancy obesity and antenatal or postnatal depression. Fourteen (eight prospective (PS), six cross-sectional (CS)) studies were included. One study reported data from a large community-based sample, and one reported cross-national data. Of 13 studies examining pre-pregnancy obesity and antenatal depression, 9 found a higher risk or higher levels of antenatal depression among women with obesity relative to normal weight (6 PS, 3 CS), while 4 studies found no association (2 PS, 2 CS). Of four studies examining pre-pregnancy obesity and postnatal depression, two studies found a positive association (two PS), one study (CS) reported different findings for different obesity classes, and one study found none (PS). The findings suggest that women with obesity are especially vulnerable to antenatal depression. There is a need to develop appropriate screening routines and targeted interventions to mitigate negative health consequences for the mother and the child. Research addressing the association between obesity and postnatal depression is too limited to draw solid conclusions. Results are mainly based on selective samples, and there is a need for further high-quality prospective studies examining the association between pre-pregnancy obesity and antenatal and postnatal depression.

Objective: Group health education is an important aspect of medical rehabilitation. While interaction and active involvement are important characteristics of group health education, little is known about patients’ understanding of their role in this form of education. This study explored patients’ understanding of their role in group health education as part of inpatient rehabilitation. Design: Qualitative, in-depth study. Setting: Six orthopaedic rehabilitation facilities in Germany. Methods: A total of 30 patients participated in six focus groups, and data were analysed using interpretative phenomenological analysis. Results: Findings reveal a complex picture concerning patient role both during and after group health education. Participants expected that patients should fulfil an active patient role and be good patients, but also said that some patients did not always comply with these expectations. Participants perceived that personal, group health education–related and environmental factors can affect the fulfilment of their role. Conclusion: Group health education should not be seen in isolation but in the context of the complex network of personal, group health education–related and environmental factors. Engagement with these factors can contribute to patients’ fulfilment of an active patient role and sustainable success after rehabilitation.

The effect of fluid velocity on the corrosion rate of low carbon steel in inhibited 4 M HCl at 80 °C has been examined. When the inhibitor film fully covers the metal surface, the corrosion rate slightly increases with increasing flow velocity which can be attributed to a partial erosion of the inhibitor film. When the inhibitor film coverage is in the lower range, the corrosion takes place at the diffusion limit and an increase in flow velocity results in a strong decrease in corrosion rate due to an increased rate of mass transport of the corrosion inhibitor to the metal surface.

Ziel des Artikels: Ziel ist es, die Entwicklung, die Manualisierung und die Ergebnisse der formativen Evaluation einer patientenorientierten Schulung zur Forderung der Gesundheitskompetenz chronisch Kranker („Aktiv in der Reha“) darzustellen. Methodik: Auf Basis von 17 Fokusgruppen wurden die Themen fur die Schulung abgeleitet. Zur Validierung der Inhalte wurde ein Expertentreffen durchgefuhrt. Die formative Evaluation erfolgte auf Basis eines Fragebogens (Nmax=295 Patienten und Nmax=39 Schulungsleiter). Ergebnisse: Die Schulung beinhaltet 4 Module mit 3 zentralen Themen (bio-psycho-soziales Krankheitsmodell, Reha-Ziele, Kommunikationskompetenzen). Die Bewertungen der einzelnen Module liegen im guten bis sehr guten Bereich. Aus der Analyse der Freitexte und einer Nachbefragung der Schulungsleiter konnten hilfreiche Hinweise fur die Verbesserung der Schulung abgeleitet werden. Schlussfolgerung: Die Ergebnisse zur formativen Evaluation zeigen, dass die Schulung bei Pa­tienten und Schulungsleitern auf Bedarf trifft und akzeptiert wird.

Bariatric surgery is an effective method for treating morbid obesity and improving patientsʼ health-related quality of life (HRQoL). As research on predictors that contribute to the amelioration of HRQoL is sparse, our prospective study was conducted to examine the predictive value of demographic, psychological and physiological variables on physical and mental HRQoL 6 and 12 months after surgery. We surveyed 154 participants who had undergone either a laparoscopic Roux-en-Y gastric bypass (LRYGB) or a laparoscopic sleeve gastrectomy (LSG). Prior to surgery and both 6 and 12 months after the procedure, patients completed questionnaires concerning their demographic data, height and weight, co-morbid conditions, HRQoL (Short Form Health Survey-12), depression severity (Beck Depression Inventory-II), and eating psychopathology (Eating Disorder Examination-Questionnaire). Multiple linear regression analyses were conducted to detect predictors of physical and mental HRQoL 6 and 12 months post-operation. The predictors included within the models explained 50 to 58% of the variance of post-operative physical and mental HRQoL, respectively. Higher baseline depression severity was associated with reduced HRQoL after surgery, whereas changes from pre- to post-surgery in BDI-II scores positively predicted HRQoL values, especially mental HRQoL. The persistence of somatic co-morbid disorders had a negative effect on physical HRQoL. Depression severity before surgery and changes in depression scores were found to be major predictors of HRQoL after bariatric surgery. Therefore, we recommend screening patients regularly for depression both before and after bariatric surgery and offering them adequate psychotherapeutic and/or psychopharmacologic support.

Objective Syrians have been the largest group among asylum seekers in Germany since 2014. Refugees are exposed to various risks along the migration process, indicating the need for adequate psychosocial support. Following the advice of the United Nations High Commissioner for Refugees to consult the target group, this is the first study qualitatively investigating the perspectives on mental health and coping strategies of Syrian refugees in Germany. Methods A qualitative design with semi-structured focus group discussions was applied. Three focus groups with a total of N = 20 participants were conducted. Focus group discussions were analyzed using content-structuring content analysis. Results Hopelessness, fear, and worries were reported most frequently as emotional consequences of war, fleeing, and resettlement, along with cognitive, physical, social, and behavioral consequences. Among the reported consequences, symptoms of PTSD were identified. Contrary to depression and schizophrenia, PTSD was not explicitly mentioned. Possibilities of coping and support referred to meeting basic needs (e.g., mental health care), fostering participation and personal coping, with the social network stated as most important source of support. Barriers of accessing mental health and psychosocial support (MHPSS) services included poor information, stigma, and language difficulties. Conclusion In contrast to earlier research, Syrian refugees reported numerous emotional symptoms as well as mental disorders as consequences of war, fleeing, and resettlement, indicating awareness of mental health sequelae. However, PTSD was not reported as possible consequence. The findings indicate the need for adequate psychoeducation, matching the participants' wish for improved information on mental health to reduce barriers accessing MHPSS.

Objective In the popular and scientific literature an association between breastfeeding and attachment is often supposed although this has not been systematically investigated. This is the first review that provides a systematic overview of the current state of research on the association between breastfeeding and attachment. The objective is to determine whether breastfeeding is associated with child attachment as well as if maternal attachment is associated with breastfeeding behaviour. Design A systematic electronic literature search for English language articles published from 1963 to 2019 using the databases Web of Science, PubMed, PsycInfo, and PsycArticles was conducted. Studies were included if (1) the association between breastfeeding and attachment of the child or maternal attachment style and breastfeeding was investigated, (2) participants were mothers or mother-child dyads, and (3) quantitative measures of breastfeeding and attachment were used. Study quality was rated using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Participants Studies examining mothers or mother-child dyads were reviewed. Sample sizes varied between N = 60 and N = 8900 participants. On average, mothers were between 27.56 and 32.50 years old. Findings Eleven studies were eligible for inclusion. Of seven studies examining breastfeeding and child attachment, four found that a longer duration of breastfeeding was significantly associated with higher levels of attachment security after controlling for various covariates. No significant differences in attachment security between breastfeeding and bottle-feeding were reported, but one study found higher levels of attachment disorganization for bottle-feeding, although mean levels were below a clinically relevant level. The initiation of breastfeeding directly after childbirth was not related to child attachment. Of four studies examining maternal attachment and breastfeeding, three found a significant association between secure attachment of the mother and breastfeeding behaviour. Secure attached mothers initiated breastfeeding more often and preferred breast- over bottle-feeding than insecure attached mothers. Mixed results were found for breastfeeding duration. Most studies had limitations regarding adequate sample size, and valid and reliable measurement of breastfeeding. Key conclusions The findings provide some evidence that breastfeeding might contribute to child attachment security. Furthermore, maternal attachment style might play a role in breastfeeding behaviour. However, more prospective studies are needed to draw a solid conclusion. Implications for practice With regard to breastfeeding recommendations, health professionals should be aware of and communicate towards clients that the effect of breastfeeding on child attachment might be rather small. Screening of maternal attachment style as a part of maternity practice could be useful to support insecure attached mothers experiencing breastfeeding difficulties.

It was our aim to develop a questionnaire for patients with chronic musculoskeletal diseases to self-report their health education literacy, to analyse the psychometric properties of the instrument and to test hypotheses concerning sociodemographic predictors of health education literacy. A total of 577 patients with chronic back pain or osteoarthritis who underwent inpatient rehabilitation were surveyed. The resulting 'HELP questionnaire' (health education literacy of patients with chronic musculoskeletal diseases) consists of 18 items and three scales (comprehension of medical information, applying medical information, communicative competence in provider interactions). The instrument's psychometric properties are good (Cronbach's alpha between 0.88 and 0.95, unidimensionality and Rasch model fit established). Our sample's average level of self-reported health education literacy is quite high. However, 20-30% of the patients admitted to having difficulty understanding important aspects of health education programmes (i.e. comprehending what medical information means in relation to their disease). The variance explained by sociodemographic and basic medical variables is small (4-8%). Greater effort is required to make health education programmes easier to understand. There is a need for more research on interindividual variability of complex aspects of health literacy.

Background Adaption to the loss of a loved one due to suicide can be complicated by feelings of guilt, shame, responsibility, rejection, and stigmatization. Therefore people bereaved by suicide have an increased risk for developing complicated grief which is related to negative physical and mental disorders and an increased risk for suicidal behavior. Grief interventions are needed for this vulnerable population. The aim of this systematic review was to provide an overview of the current state of evidence concerning the effectiveness of interventions that focus on grief for people bereaved by suicide. Methods We conducted a systematic literature search using PubMed, Web of Science, and PsycINFO for articles published up until November 2016. Relevant papers were identified and methodological quality was assessed by independent raters. A narrative synthesis was conducted. Results Seven intervention studies met the inclusion criteria. Two interventions were based on cognitive-behavioral approaches, four consisted of bereavement groups, and one utilized writing therapy. As five of the seven interventions were effective in reducing grief intensity on at least one outcome measure, there is some evidence that they are beneficial. Bereavement groups tend to be effective in lowering the intensity of uncomplicated grief, as are writing interventions in lowering suicide-specific aspects of grief. Cognitive-behavioral programs were helpful for a subpopulation of people who had high levels of suicidal ideation. Limitation On average, methodological quality was low so the evidence for benefits is not robust. The stability of treatment effects could not be determined as follow-up assessments are rare. Generalizability is limited due to homogeneous enrollments of mainly female, white, middle-aged individuals. Conclusions People bereaved by suicide are especially vulnerable to developing complicated grief. Therefore, grief therapies should be adapted to and evaluated in this population. Prevention of complicated grief may be successful in populations of high risk individuals.

Wesentliche Voraussetzung fur die Zielerreichung im Rahmen der Patientenschulung ist eine fur die Patienten verstandliche Gestaltung der Schulungen. Ziel der vorliegenden explorativen Studie ist es zu ermitteln, wie die Verstandlichkeit von Patientenschulungen bzw. das patientenseitige Verstandnis der Schulungsinhalte in der Routineversorgung der stationaren orthopadischen Rehabilitation von Rehabilitanden und Schulungsleitern bewertet wird. Zudem soll untersucht werden, welche Faktoren als hinderlich bzw. forderlich fur die Verstandlichkeit von Patientenschulungen angesehen werden und welche Ideen und Wunsche beide Gruppen bezuglich einer verbesserten Verstandlichkeit haben. In 9 stationaren Rehabilitationseinrichtungen wurden leitfadengestutzte Fokusgruppen mit 50 Patienten mit chronischen Ruckenschmerzen oder Arthrose im Alter zwischen 22 und 71 Jahren (M=50,4, SD=9,4) und 35 Schulungsleitern im Alter zwischen 26 und 61 Jahren (M=44,9, SD=9,8) durchgefuhrt. Die qualitative Auswertung der Interviewtranskripte erfolgte nach dem inhaltsanalytischen Ansatz von Mayring mithilfe der Software Atlas.ti. Rehabilitanden und Schulungsleiter bewerten die Patientenschulungen uberwiegend als gut verstandlich. Forderliche Faktoren der Verstandlichkeit werden vor allem im Einbezug von Patienten in die Schulungen gesehen. Patienten beschreiben mangelhafte (z. B. zu allgemeine/widerspruchliche) Informationen als hinderlich fur die Verstandlichkeit. Schulungsleiter thematisieren vor allem eine fehlende Motivation und Eigenverantwortung als Grund fur mangelndes Verstandnis der Inhalte auf Patientenseite. Die von beiden Gruppen genannten Ideen und Wunsche lassen sich den Themenbereichen Schulung (z. B. hoherer Alltagsbezug der Schulungsinhalte), Schulungsleiter (z. B. Verbesserung der Schulungsleiterqualifikation), Informationen (z. B. mehr Informationen), Einbezug der Patienten (z. B. starkere Berucksichtigung patientenseitiger Interessen), Organisation (z. B. kleinere Gruppen) sowie Zielklarung (z. B. Klarung von Erwartungen) zuordnen. Die Ergebnisse liefern Hinweise darauf, dass in der Routineversorgung der orthopadischen Rehabilitation eine gute Verstandlichkeit der Patientenschulungen erreicht wird und welche Aspekte zu einer guten Verstandlichkeit beitragen. Die von Rehabilitanden und Schulungsleitern thematisierten hinderlichen Faktoren der Verstandlichkeit liefern Hinweise auf ein mogliches weiteres Verbesserungspotenzial der Schulungen im Hinblick auf die Verstandlichkeit.

OBJECTIVE In the context of an increasing patient orientation in health care, surveying patients on the success of treatment has become highly relevant. The objective of the study was to develop and test an instrument for surveying the patients' perceptions of the participation relevance of changes in health status after inpatient medical rehabilitation with respect to various areas of life for 3 diagnoses: breast cancer, chronic ischemic heart disease, and chronic back pain. METHODS The instrument refers to certain disease-specific areas of health (e. g., mobility) with regard to which the patients are asked whether they perceived an improvement and if so, what improvement in participation had ensued as a result. A questionnaire study (measuring time points: end of rehab and 6 months after the end of rehab) was conducted in 3 samples (breast cancer: n=297, chronic ischemic heart disease: n=295, chronic back pain: n=186) to test the methodology. The share of missing values and undesirable ceiling/floor effects were assessed to analyze the distribution characteristics. In a partial sub-sample, a third measuring time point was introduced approx. 10 days after the second measuring time point, and the retest reliability of the assessment of participation relevance is determined using the ICC. We also present descriptive results relative to the participation relevance from the patient perspective. RESULTS The instrument shows good distribution characteristics for the items. Regarding retest reliability, there were satisfactory values for all diagnoses in all areas of health. The descriptive analyses showed that patients who perceived a noticeable improvement in their health status at the end of rehabilitation or 6 months after inpatient rehab generally assessed the participation relevance of this improvement in health to be "moderate" to "strong". DISCUSSION The concept of assessing the participation relevance from the patient perspective is a satisfactorily reliable construct. By including the subjective significance of treatment success it takes into account the concept of clinical significance from the patient's perspective, a concept which has thus far been considered only insufficiently. Results show that patients ascribe the health improvements achieved by rehabilitation a noticeable relevance for their participation.

The patient-reported outcome measurement information system (PROMIS®) initiative has developed and evaluated a set of publicly available, efficient, and flexible measures of patient-reported outcomes in different health domains, including mental health. The objective of this study was to translate the PROMIS Depression item bank into German and evaluate the psychometric properties of the translated items. Items were translated using forward and backward translation and cognitive interviews. Distribution characteristics, unidimensionality, Rasch model fit, reliability, construct validity, and internal responsiveness were investigated in a sample of 234 patients in in-patient psychosomatic rehabilitation centers in Germany. The translated items showed good psychometric properties, the distribution characteristics were satisfactory, and the sufficient unidimensionality was obtained by fitting a bifactor model. The construct validity was demonstrated, and it was reliable and was shown to detect clinically significant changes. The translated items can be recommended for the assessment of depression. Future studies should examine the generalizability of the results.

Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait-lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n=69) or a wait-list condition (n=70). Binge-eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination-Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, 6-, and 12-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d=1.02, between group) in the treatment group relative to the wait-list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the wait-list condition (0.82≤d≤1.11). In the treatment group significant improvement was still observed for all measures 1year after the intervention relative to pretreatment levels. The Internet-based intervention proved to be efficacious, significantly reducing the number of binge-eating episodes and eating disorder pathology long term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.

Background Obesity and anxiety during the perinatal period are common and associated with poor health outcomes for the mother and the child. Despite the well-documented health risks of both pregnancy obesity and anxiety, associations between the two have rarely been explored. With this review we aim to provide a systematic overview of the current state of evidence concerning associations between ante- and postnatal anxiety and pregnancy obesity, excessive gestational weight gain, and postpartum weight retention. Methods We conducted a systematic literature search in PubMed, Web of Science, and PsychINFO. Results 13 Records matched our inclusion criteria. Five out of seven studies focusing on pregnancy obesity and anxiety suggest a positive association with ante- or postnatal anxiety. Surprisingly, no study examined anxiety disorders according to DSM and it remains unknown whether anxiety symptomatology reaches clinical relevance. Results from a small number of life-style intervention studies ( n =3) suggest that interventions could benefit from a stronger focus on mental health. There were not enough studies on associations between excessive gestational weight gain ( n =2) or postpartum weight retention ( n =3) and anxiety making it difficult to draw conclusions about possible associations. Limitation The number of included studies is rather small and studies were included irrespective of the study quality which might limit the generalizability of the results. Conclusions The majority of the included studies suggest that obese pregnant women might constitute a subgroup that is especially vulnerable for comorbid anxiety and in need of targeted psychological support. However, further high-quality studies, particularly including anxiety disorders, are needed.