Jochen Jordan

Long‐Term Consequences of Live Kidney Donation Follow‐Up in 93% of Living Kidney Donors in a Single Transplant Center

Live kidney donation is increasing rapidly. Increases of blood pressure and proteinuria but no accelerated loss of renal function in kidney donors have been described. The credibility of this research is hampered by retrieval rates of only 50–70% of donors.

Screening for psychosocial risk factors in patients with coronary heart disease-recommendations for clinical practice

Psychosocial risk factors like low socio-economic status, chronic family or work stress, social isolation, negative emotions (e.g., chronic depression or acute anxiety), and negative personality patterns such as Type-D-pattern or hostility, may contribute significantly to the development and adverse outcome of coronary heart disease. Therefore, systematic screening for psychosocial risk factors in cardiological practice is recommended in order to initiate adequate intervention strategies, e.g., to involve additional psychosocial counselling or treatment. Reliable methods to assess psychosocial risk factors are: (1) standardized, structured interviews; (2) standardized questionnaires, and (3) ‘single-item’ questions to be included into the cardiologists clinical interviews. While structured interviews should be restricted to trained professionals, questionnaires are easily to administer, and have frequently been used in the field of cardiology. ‘Single item’ questions are sufficiently reliable and the most timesaving way to screen for psychosocial factors. For clinical practice, a two-step evaluation is recommended: firstly, cardiologists should include ‘single-item’ questions into their routine interview and/or use questionnaires in order to screen for a potential problem. Secondly, if problems are indicated, patients should be passed to qualified professionals for structured clinical interview. Instruments of all three methods are briefly presented, and implications for further treatment are discussed.

Position paper on the importance of psychosocial factors in cardiology: Update 2013.

Background: The rapid progress of psychosomatic research in cardiology and also the increasing impact of psychosocial issues in the clinical daily routine have prompted the Clinical Commission of the German Heart Society (DGK) to agree to an update of the first state of the art paper on this issue which was originally released in 2008. Methods: The circle of experts was increased, general aspects were implemented and the state of the art was updated. Particular emphasis was dedicated to coronary heart diseases (CHD), heart rhythm diseases and heart failure because to date the evidence-based clinical knowledge is most advanced in these particular areas. Differences between men and women and over the life span were considered in the recommendations as were influences of cognitive capability and the interactive and synergistic impact of classical somatic risk factors on the affective comorbidity in heart disease patients. Results: A IA recommendation (recommendation grade I and evidence grade A) was given for the need to consider psychosocial risk factors in the estimation of coronary risks as etiological and prognostic risk factors. Furthermore, for the recommendation to routinely integrate psychosocial patient management into the care of heart surgery patients because in these patients, comorbid affective disorders (e.g. depression, anxiety and post-traumatic stress disorder) are highly prevalent and often have a malignant prognosis. A IB recommendation was given for the treatment of psychosocial risk factors aiming to prevent the onset of CHD, particularly if the psychosocial risk factor is harmful in itself (e.g. depression) or constrains the treatment of the somatic risk factors. Patients with acute and chronic CHD should be offered anti-depressive medication if these patients suffer from medium to severe states of depression and in this case medication with selective reuptake inhibitors should be given. In the long-term course of treatment with implanted cardioverter defibrillators (ICDs) a subjective health technology assessment is warranted. In particular, the likelihood of affective comorbidities and the onset of psychological crises should be carefully considered. Conclusions: The present state of the art paper presents an update of current empirical evidence in psychocardiology. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiological practice and highlights areas of high priority. The evidence for estimating the efficiency for psychotherapeutic and psychopharmacological interventions has increased substantially since the first release of the policy document but is, however, still weak. There remains an urgent need to establish curricula for physician competence in psychodiagnosis, communication and referral to ensure that current psychocardiac knowledge is translated into the daily routine.

A Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) — Rationale and design of a multicenter, randomized trial in depressed patients with CAD

OBJECTIVE Depressive symptoms are highly relevant for the quality of life, health behavior, and prognosis in patients with coronary artery disease (CAD). However, previous psychotherapy trials in depressed CAD patients produced small to moderate effects on depression, and null effects on cardiac events. In this multicentre psychotherapy trial, symptoms of depression are treated together with the Type D pattern (negative affectivity and social inhibition) in a stepwise approach. METHODS Men and women (N=569, age 18-75 years) with any manifestation of CAD and depression scores ≥ 8 on the Hospital Anxiety and Depression Scale (HADS), will be randomized (allocation ratio 1:1) into the intervention or control group. Patients with severe heart failure, acutely life-threatening conditions, chronic inflammatory disease, severe depressive episodes or other severe mental illness are excluded. Both groups receive usual medical care. Patients in the intervention group receive three initial sessions of supportive individual psychotherapy. After re-evaluation of depression (weeks 4-8), patients with persisting symptoms receive an additional 25 sessions of combined psychodynamic and cognitive-behavioral group therapy. The control group receives one psychosocial counseling session. Primary efficacy variable is the change of depressive symptoms (HADS) from baseline to 18 months. Secondary endpoints include cardiac events, remission of depressive disorder (SCID) and Type D pattern, health-related quality of life, cardiovascular risk profile, neuroendocrine and immunological activation, heart rate variability, and health care utilization, up to 24 months of follow-up (ISRCTN: 76240576; NCT00705965). Funded by the German Research Foundation.

Functional heart pain

Zusammenfassung.Funktionelle Herzschmerzen sind weit verbreitet und werden nach ICD-10 als „somatoforme autonome Funktionsstörungen des kardiovaskulären Systems“ bezeichnet. An erster Stelle der Symptome stehen Brustschmerzen, gefolgt von Schwächegefühlen, Erschöpfungsneigung und Atemnot. Auch die Wahrnehmung veränderter Herztätigkeit wie Herzjagen, Herzklopfen, Herzstolpern oder Arrhythmien ist in hohem Maße beunruhigend und damit angstauslösend. Eine verantwortungsvolle kardiale Diagnostik ist Grundlage für jedes weitere Vorgehen, aber es empfiehlt sich, möglichst sofort eine kurze Anamnese hinsichtlich der Vorgeschichte zu erheben. So können bereits erfolgte somatische Abklärungen, das parallele Aufsuchen mehrerer Ärzte oder die wiederholte Inanspruchnahme von ärztlichen Notdiensten richtungweisend sein. Im Verlauf der Diagnostik sollte bereits früh auf mögliche funktionelle Ursachen hingewiesen werden, um einer somatischen Fixierung zu einem frühen Zeitpunkt entgegenzuwirken. Die gesundheitspolitische Bedeutung, die in der Früherkennung funktioneller Beschwerden liegt, ist sehr hoch.Abstract.Functional heart symptoms, especially chest pain, are very widespread and, according to the International Classification of Diseases (ICD-10), are described as “somatoform autonomous functional disorders of the cardiovascular system”. Although they are very often accompanied by considerable anxiety about having a heart attack, for example, they are initially not recognizable as such and have to be distinguished from somatic complaints. The most prevalent of these symptoms (Table 2) are chest pains, followed by feelings of weakness, a tendency to become easily fatigued and breathing difficulties. The perception of changes in cardiac activity, such as tachycardia, heart palpitations, irregular heartbeat or arrhythmias, is also extremely unsettling and thus anxiety-provoking. Therefore, although a responsible cardiac diagnosis is the basis for every further step taken, it is advisable to carry out a brief anamnesis immediately, if possible, to determine the prior history (Table 1). For example, previously conducted clarification of somatic causes, consultations with more than one physician in parallel or repeated medical emergency calls can be helpful for orientation. Moreover, in the interview during the diagnostic measures, the possibility of functional causes should always be pointed out in order to counteract a somatic fixation early on. The health-care policy role that lies in early diagnosis of functional cardiac complaints has to be regarded as highly relevant.Following exclusionary diagnosis, the patients should not be discharged as “healthy” from the cardiological practice without a more in-depth anamnesis of their complaints, because differentiated questioning of the patient not only about typical physical and psychic symptoms, but also about behavior patterns (Table 3) that can accompany functional cardiac complaints, works in favor of a doctor-patient relationship that is based on trust. Since, in addition to anxiety disorders, above all depressive states accompany functional heart complaints, and can also cause them in the sense of a comorbidity, a knowledge of characteristics related to depression (Table 4), such as a depressed mood, loss of interest or low motivation, is very helpful for a better understanding of the patients. The “vicious circle” that rapidly develops precisely in the case of this group of patients, consisting of physical symptoms, avoidance behavior and psychological as well as interpersonal difficulties, is described and possible solutions are pointed up.In summary, the following recommendations can be formulated for day-to-day clinical practice: 1. From the very beginning, a holistic approach should be conveyed in the interview by addressing psychological and social aspects as well, and taking them into account as possible causes. 2. The somatic diagnosis should, if possible, not go beyond that which is urgently necessary from a cardiological standpoint and presented in guidelines. One should, above all, not give in to pressure from the patients if it is a matter of repeated examinations within a short period of time. 3. A differentiated and focused anamnesis helps the patients to feel understood and taken seriously. 4. A relationship based on trust enhances the chances for a successful transfer to psychosomatic examination and treatment.

Drei stationäre Therapieverläufe von essgestörten Patientinnen, verglichen mit der Methode des Zentralen Beziehungskonfliktthemas (ZBKT)

In this article the results of a research with the CCRT-method on the psychotherapies of three in-patients suffering from eating disorders are presented. The CCRT describes recurrent internal and interpersonal relationship patterns in narratives. Each therapy session was recorded on tape and transcribed. The CCRT components were identified from the verbatim transcripts. All three patients clearly showed a negative self-perception and despite a more graded attitude regarding other people they felt rejected by the community throughout the entire therapy. The CCRT of each patient was different: patient 1. had conflicts between dependence and independence with increasing autonomy; patient 2. had great symbiotic desires, which at the beginning of the therapy were warded off with a performance ideal; patient 3. showed self-assertion and an increasing level of openness against the community, despite a high level of fear and self-isolation at the onset of therapy. Despite methodological deficiencies the CCRT method proved to be sensitive enough to show similarities and differences among the individual courses of treatment.

The relationship between attachment orientations and the course of depression in coronary artery disease patients: A secondary analysis of the SPIRR-CAD trial

OBJECTIVE The relationship between attachment orientations and the recovery from depressive symptoms in patients diagnosed with coronary artery disease (CAD) with and without a psychotherapeutic intervention was examined in this study. METHODS In a multicenter trial of 570 depressed CAD patients (SPIRR-CAD), assigned to usual care plus either a stepwise psychotherapy intervention or one information session, 522 patients provided attachment data at baseline. Attachment was measured with the Relationship Scales Questionnaire (RSQ), yielding four attachment orientations. The primary outcome was change in Hospital Anxiety and Depression Scale depression (HADS-D) scores from baseline to follow-up at 18 months. Secondary outcomes were HADS-D scores at 1, 6, 12, and 24 months. RESULTS Independent of treatment assignment, attachment was related to change in depression at 18 months (p < 0.01) with secure attachment resulting in a significant reduction (-2.72, SE = 0.27) in depression compared to dismissive-avoidant (-1.51, SE = 0.35, p = 0.040) and fearful-avoidant (-0.65, SE = 0.61, p = 0.012) attachment. Patients with anxious-preoccupied attachment showed changes similar to secure attachment (-2.01, SE = 0.47). An explorative subgroup analysis across all assessment time points revealed patients with a dismissive-avoidant attachment benefitted from psychotherapy (average mean difference = 0.93, SE = 0.47, p = 0.048). CONCLUSION Attachment played an important role for improvement in depressive symptoms. Only dismissive-avoidant patients seemed to benefit from the intervention. The lack of improvement in fearful-avoidant patients shows a need for specific interventions for this group. TRIAL REGISTRATION www.clinicaltrials.govNCT00705965; www.isrctn.com ISRCTN76240576.