Background and aims: This interdisciplinary thesis was designed to deepen understanding of the co-morbidity of anxiety and depression with chronic diseases of the digestive tract, and inflammatory bowel disease (IBD) in particular. The first part of the thesis aimed to explore the prevalence of psychological problems in IBD compared to irritable bowel syndrome (IBS) and chronic hepatitis C (HCV) groups. It also explored the relationship between the number of co-morbid functional gastrointestinal disorders and the severity of psychological problems in IBD and IBS. It also aimed to determine whether there is a relationship between psychological problems and the response to standard medical treatment/physical outcomes in patients with IBD, IBS and HCV. Furthermore, it aimed to explore whether disclosure of the psychological status of depressed and/or anxious IBD patients to their gastroenterologists influences doctors’ behaviour and affects patients’ responses to treatment/physical outcomes. The second part of the thesis aimed to investigate the potential role of antidepressants in IBD and to determine the feasibility of future randomised controlled trials on the role of antidepressants in IBD. Methods: Overall, a cohort of 139 outpatients (64 IBD, 41 HCV, and 34 IBS) and 18 gastroenterologists participated in the six studies comprising this thesis. A mixed methods design was applied. Two cross-sectional studies, an observational cohort prospective management study, a randomised controlled trial, a systematic review and an exploratory interview study were conducted. Differences between the groups for continuous variables were assesed with one way analysis of variance (ANOVA) and independent samples ttests. Differences in categorical variables were assessed with contingency tables with the Chi-Square test and the Fisher’s Exact Test. Propsective analyses were conducted with repeated measures ANOVA, logistic regression and Poisson regression. Qualitative data were analysed using content analysis. Results: Overall, 42% of participants were anxious and 19% were depressed. Participants with HCV had higher levels of psychological impairment compared with the IBS, the IBD group and the general population (p<0.05). Those IBD participants with fewer co-morbid functional disorders had better physical quality of life than participants with a greater number of these disorders (p=0.025). Moreover, depression/anxiety at baseline did not explain medical outcomes after 12 months in this cohort of patients with chronic diseases of the digestive tract. Doctors’ knowledge of patients’ psychological status was found to have no impact on IBD patients’ outcomes after 12 months. However, interestingly, the level of anxiety in IBD participants significantly dropped between the baseline and nine months indicating a possible benefit from participating in the study. In the literature review, insufficient evidence was found to conclude that antidepressants are efficacious for treatment of psychological co-morbidities or somatic complaints in IBD. However, the qualitative interview study indicated a potential positive impact of treatment with antidepressants on coping with disease symptoms and general wellbeing in patients with IBD. Conclusion: The thesis confirms that there is a significant burden of psychological co-morbidity in patients with chronic gastroenterological diseases. Interdisciplinary approaches to the management of these diseases are therefore warranted in Australian gastroenterology clinics. Anxiety targeted interventions and research in this setting are urgently needed, especially with respect to patients with HCV. Larger studies exploring the gastroenterologists’ role in treatment of co-morbid psychological problems in their patients are recommended. Longer prospective studies on homogenous samples of patients are also needed to clarify the nature of the relationship between psychological problems and relapse of somatic symptoms. Finally, randomised controlled trials exploring the efficacy of antidepressants in IBD are warranted. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1321006 / Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2008

The English Improving Access to Psychological Therapies (IAPT) programme is a government-funded initiative that aims to provide timely and equitable access to evidence-based psychotherapeutic interventions, within a primary care setting. Despite the many achievements of the programme, there are several issues regarding research to clinical gaps, as well as a high rate of variation between sites concerning outcomes and attrition. This thesis explores the implementation process of the IAPT delivery model to understand which factors are influential in the successful uptake and integration of evidence-based psychotherapeutic interventions. The aims of this thesis are:  To explore, identify and analyse the implementation process involved in establishing and delivering an IAPT service.  To uncover the factors that either facilitate or impede its development to provide a more in-depth and detailed account of the implementation and operation of services.  To develop an understanding regarding the applicability of evidence-based practice and the IAPT delivery model in a clinical setting, for the provision of psychological therapies. I conducted a series of semi-structured interviews with practitioners delivering and implementing services, across seven sites, and clients, across three sites. The design and analysis followed an Interpretative Phenomenological Analysis, focusing on personal meaning and sense-making processes. The objective of the interview was to understand the implementation process regarding the IAPT delivery model, exploring how this influences personal experiences and client engagement. Additionally, participant narrative was set in context using open-access data collected and published by the programme. The analysis generated three master themes for practitioners delivering and implementing services including: ‘A Call to Action’ describing how participants regarded this process as a genuine opportunity to make a real impact in mental healthcare; ‘Contextual Influences on Service Operation’ which explores the activities in becoming a locally determined, adaptable and relevant service; and a ‘Focus on Relationships’ outlining the relational and collaborative work involved during implementation. For the client group, three master themes were generated including: ‘A Personal Journey: From Discovery to Advocacy’ illustrating the changing experiences involved during service access and engagement; ‘Perception of Self’ which portrays how individuals made sense of their engagement by judging what it meant to them; 5 and ‘Outside Factors’ which explores the role of others and the physical journey made in getting to services. The analysis suggested that both groups made sense of their experiences in complex and varied ways. Heavily influencing the implementation of the IAPT delivery model is the over-arching need to boost throughput and quantity, possibly at a cost of quality. Additionally, it is argued that the use of routine outcome monitoring in services is useful for reflecting on the implementation process and engaging clients. The key to successful implementation appears to be about achieving integration, requiring a whole-systems based approach that considers the mediating pathways into and out of services. In light of the findings and literature, the thesis proposes several recommendations for future practice and further research.

Die Wiederaufnahme einer produktiven Beschäftigung ist ein wesentliches Ziel der Rehabilitation nach Organtransplantation. In Deutschland ist jedoch die Mehrheit der organtransplantierten Patienten im erwerbsfähigen Alter frühberentet. Die vorliegende Arbeit hat zum Ziel, die Beschäftigungssituation Organtransplantierter und mögliche Einflussfaktoren am Universitätsklinikum Leipzig zu untersuchen. Dabei interessiert insbesondere der Einfluss der psychischen Komorbidität auf die berufliche Reintegration. Im Rahmen einer katamnestischen Querschnittsstudie wurden insgesamt 82 Patienten ein bis acht Jahre nach Leber-, Nieren- oder Pankreastransplantation befragt. Neben der Beschäftigungssituation und der psychischen Komorbidität (SKID-I, HADS), wurden soziodemografische, medizinische und arbeitsbezogene Merkmale sowie die gesundheitsbezogene Lebensqualität (EORTC QLQ-C30) als potenzielle Einflussfaktoren auf die Arbeitswiederaufnahme und die psychische Komorbidität erhoben. Die Auswertung der Daten zeigt, dass berufstätige Organtransplantierte eine signifikant bessere gesundheitsbezogene Lebensqualität haben und signifikant seltener unter psychischer Komorbidität leiden als frühberentete Organtransplantierte. Dieser Zusammenhang sollte Beachtung finden bei der Rehabilitation und Nachsorge transplantierter Patienten. Ziel muss es sein, die berufliche Reintegration zu fördern und gleichzeitig psychische Komorbidität auch im Langzeitverlauf nach Transplantation frühzeitig zu erkennen und adäquat zu behandeln, um das Risiko für Frühberentung zu senken und eine verbesserte Lebensqualität und damit auch den Gesamterfolg der Transplantation langfristig zu sichern.

This thesis researches psychological aspects in adult patients undergoing heart surgery. The thesis is divided into theoretical and empirical part. The theoretical part discusses depressive and anxiety symptomatology, quality of life and type D personality, in the context of cardiac surgery. Basic characteristics, possible relations, impacts of occurrence of these aspects and possible related interventions, which seem to be beneficial for cardiac surgery, are presented for each topic. In the empirical part, the symptoms of depression, anxiety and health-related quality of life were examined using a sample of (N = 47) patients undergoing valve surgery. BDI-II, BAI and SF-36 methods were used. The research was conducted in three measurements. The first measurement took place before the surgery, the second before the end of hospitalization and the third took place 30 days after being discharged from the hospital. It was discovered that the depressive symptomatology of our sample differed significantly from the normative sample in the first and second measurements. In the first measurement, the respondents of our sample differed significantly from the norm in the symptomatology of anxiety. In both cases it was an increased symptomatology of depression or anxiety over the norm. In the dimensions of...

Der Schlaganfall ist die dritthäufigste Todesursache in Deutschland und die häufigste Ursache für eine lebenslange Behinderung im Erwachsenenalter. Ein erheblicher Anteil der Patienten leidet danach unter einer Verschlechterung der gesundheitsbezogenen Lebensqualität sowie unter affektiven Symptomen wie Depressivität und Angst. Die Intention der vorliegenden Arbeit bestand darin, jene Eigenschaften von Schlaganfallpatienten zu ermitteln, die mit einer häufigeren Belastung der gesundheitsbezogenen Lebensqualität und Symptomen von Depressivität und Angst einhergehen. Ziel ist eine möglichst frühzeitige Identifikation besonders gefährdeter Patientengruppen um wirksamer als in späteren Krankheitsphasen intervenieren zu können. Damit kann eine dauerhafte Senkung der Krankheitslast erreicht werden. Für die vorliegende Studie wurden 300 Patienten mit klinisch oder bildmorphologisch gesichertem Schlaganfall mittels vier sehr etablierter, unterschiedlich umfangreicher psychometrischer Tests zur Messung der gesundheitsbezogenen Lebensqualität (SF-36 und EQ-5D) und von Depressivität und Angst (HADS und PHQ-4) befragt. Die Patienten wurden klinisch und paraklinisch untersucht und es wurden soziodemografische Daten erhoben. Die Datenerhebung fand am Universitätsklinikum Leipzig zwischen Januar 2012 und Dezember 2014 statt. Die Auswertung erfolgte deskriptiv, mittels t-Test, einfaktorieller Varianzanalyse (ANOVA), als Korrelationsanalyse und als lineare Regressionsanalyse. Die Ergebnisse zeigten, dass die Patienten sich im Vergleich zur Allgemeinbevölkerung am stärksten bei alltäglichen körperlichen Aktivitäten eingeschränkt fühlten. Folgende Aspekte konnten als Prädiktoren einer herabgesetzten gesundheitsbezogenen Lebensqualität und höheren Prävalenz von Depressivität identifiziert werden: Schlaganfallschwere (mRS-Wert), ausgeprägteres neurologisches Defizit (NIHSS-Wert) und stärkere Einschränkungen der Fähigkeiten zu Aktivitäten des täglichen Lebens (Barthel-Index). Je langsamer die Patienten im 10-Meter-Gehtest liefen, desto häufiger fühlten sie sich in ihrer gesundheitsbezogenen Lebensqualität eingeschränkt und desto häufiger litten sie unter Symptomen von Depressivität. Dieser einfach, schnell und kostengünstig durchzuführende Test zeigte starke und konsistente Korrelationen in Bezug auf die gesundheitsbezogene Lebensqualität und Depressivität. Die Ergebnisse der Regressionsanalyse zeigten weiterhin ein signifikant besseres Therapieergebnis von Diabetikern im Vergleich zu Nicht-Diabetikern vor allem in Bezug auf eine Belastung durch Depressivität oder Angst. Dies ist möglicherweise durch bessere Coping-Strategien von Patienten mit Diabetes mellitus zu erklären. Ältere Patienten und Frauen fühlten sich häufiger körperlich eingeschränkt. Jüngere Patienten und Männer fühlten sich häufiger sozial und psychisch eingeschränkt. Die Schlaganfallschwere und die Einschränkungen der Fähigkeiten zu Aktivitäten des täglichen Lebens korrelierten stark mit den körperlichen Skalen der gesundheitsbezogenen Lebensqualität. Das neurologische Defizit war mit den meisten Subskalen der gesundheitsbezogenen Lebensqualität korreliert und mit jeder erhobenen Skala zu Angst und Depressivität. Der Früherkennung von belasteten Patienten kommt eine große Bedeutung zu, da die Behandlung von Depressivität innerhalb des ersten Monats nach Schlaganfall wirksamer ist als eine später einsetzende Therapie in Bezug auf die Fähigkeiten zu Aktivitäten des täglichen Lebens und die Erholung von körperlichen Einschränkungen. Weitere Studien sollten die Auswirkungen einer früh ansetzenden antidepressiven Therapie nach Schlaganfall untersuchen.

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Background: The role of the norepinephrine transporter (NET) has received increased focus in recent studies on the pathogenesis of attention-deficit/hyperactivity disorder (ADHD). The predictive value for pharmacological treatment and its link to other health or social limitations has been little-studied. This follow-up research on adult patients with ADHD aimed to explore whether the therapy response and health and social impairments depend on baseline individual NET availability. Methods: Data were collected from 10 patients on personal, family and professional situations, mental and physical health and treatments received after baseline via online and telephone surveys and were compared to baseline data to evaluate treatment-related changes. Results: The majority of our ADHD patients did not show therapy responses but showed improvements due to pharmacological treatment. There was no evidence of relationships between pre-treatment NET availability and therapy response or health/social limitations. Conclusions: Pharmacological monotherapy was insufficient to promote symptom remission, especially for participants with extreme insufficiency in NET availability, but improved outcomes in academic and social functioning. Psychotherapy should be considered as an add-on to the standard treatment approach due to its positive outcome in reducing social limitations. The prognostic value of individual NET availability in predicting the response to therapy needs further studies with large sample sizes

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.