Michael M. Berner

Psychotherapy of attention deficit hyperactivity disorder in adults--a pilot study using a structured skills training program.

Abstract In clinical practice many adult patients with attention deficit hyperactivity disorder (ADHD) ask for an additional psychotherapeutic intervention besides the medical therapy. In this paper we present a structured skill training program particularly tailored for adult patients with ADHD. The program is based on the principles of cognitive-behavioral treatment for borderline personality disorder developed by M. Linehan. It was modified to suit the special needs of adult patients with ADHD. In this exploratory pilot study we tested this program in a group setting. The following elements were presented: neurobiology of ADHD, mindfulness, chaos and control, behavior analysis, emotion regulation, depression, medication in ADHD, impulse control, stress management, dependency, ADHD in relationship and self respect.In an open study design patients were assessed clinically using psychometric scales (Attention Deficit Hyperactivity Disorder Checklist according to DSM-IV, 16 items of the SCL-90-R, Beck-Depression Inventory, visual analogue scale) prior to and following group therapy. This treatment resulted in positive outcomes in that patients improved on all psychometric scales.

St John's wort for depression: meta-analysis of randomised controlled trials.

BACKGROUND Extracts of Hypericum perforatum (St Johns wort) are widely used to treat depression. Evidence for its efficacy has been criticised on methodological grounds. AIMS To update evidence from randomised trials regarding the effectiveness of Hypericum extracts. METHODS We performed a systematic review and meta-analysis of 37 double-blind randomised controlled trials that compared clinical effects of Hypericum monopreparation with either placebo or a standard antidepressant in adults with depressive disorders. RESULTS Larger placebo-controlled trials restricted to patients with major depression showed only minor effects over placebo, while older and smaller trials not restricted to patients with major depression showed marked effects. Compared with standard antidepressants Hypericum extracts had similar effects. CONCLUSIONS Current evidence regarding Hypericum extracts is inconsistent and confusing. In patients who meet criteria for major depression, several recent placebo-controlled trials suggest that Hypericum has minimal beneficial effects while other trials suggest that Hypericum and standard antidepressants have similar beneficial effects.

Effect of Sexual Function on Health-Related Quality of Life Mediated by Depressive Symptoms in Cardiac Rehabilitation. Findings of the SPARK Project in 493 Patients

INTRODUCTION Empirical evidence suggests associations between cardiovascular diseases, sexual functioning, depressive symptoms, and quality of life. However, to date, the interrelation of these constructs has not been examined simultaneously in a structural analysis. AIM To estimate the prevalence of sexual disorders and depressive symptoms and to examine the association between sexual disorders, depressive symptoms, and quality of life in patients in the rehabilitation of cardiovascular disorders. AIM A postal survey in five German inpatient rehabilitation centers for cardiovascular diseases was conducted. Prevalence of sexual disorders and depressive symptoms were assessed using psychometrically sound instruments. To analyze complex associations, structural equation modeling was used. MAIN OUTCOME MEASURES For epidemiological questions, proportions with 95% confidence intervals were calculated. The strength of association in structural equation models was expressed as a standardized regression coefficient. RESULTS Data from 493 patients were analyzed (response rate 22.7%). At least moderate erectile dysfunction proved to be present in 20.3% of men. The prevalence of female sexual dysfunction lay at 43.1%. At least moderate depressive symptoms were present in 14.4% of men and 16.5% of women. A considerable association between sexual functioning and quality of life was found in both sexes, which was largely mediated by depressive symptoms. Major drawbacks of the study are imprecision of the estimates due to limited sample size and questionable generalizability of the findings due to possible self-selection bias. CONCLUSIONS Considering the high prevalence of depressive symptoms and their role as a mediating factor between sexual functioning and quality of life, it is recommended to routinely screen for depression in men and women with cardiac disease.

Psychometric properties of the German version of the Motivational Interviewing Treatment Integrity Code

Motivational interviewing (MI) is effective in the treatment of addictions. To evaluate MI adherence of therapists, the Motivational Interviewing Treatment Integrity Code (MITI) was developed. MI is used in German-speaking countries, but there is no equivalent to the MITI. Our aim was to adapt the MITI for use in German language settings (MITI-d). Twenty-eight session tapes of Alcoholism Specific Psychotherapy utilizing MI were rated by two student raters and the MITI-d instructor. To evaluate interrater reliability, intraclass correlation coefficients (ICCs) were computed. ICCs were good to excellent for relevant MI constructs, except for Complex Reflections, MI-nonadherent Behaviors, Empathy, and MI Spirit. The evaluation of test-retest reliability for the student raters showed good to excellent results. The MITI-d is a psychometrically sound instrument for evaluating basic MI competence in German language settings.

Characteristics of predrinking and associated risks: a survey in a sample of German high school students

ObjectivesFinding predictors for predrinking and placing the new phenomenon of predrinking on a greater database. Predrinking is defined as alcohol consumption, alone or with friends, at home or at public places, before going out in the evening to a party or in bars or discotheques.MethodsData were collected from a representative sample of 757 ninth- and tenth-grade students from 31 high schools located in a south German rural region and a city.ResultsPredrinkers, especially those who show this behaviour frequently, were notably more likely to engage in hazardous drinking, and experienced significantly more frequent involvements in fights and alcohol-induced blackouts. They also stated more often that they had the intention of getting drunk when consuming alcohol.ConclusionsPredrinking proves to be a high-risk behaviour, particularly when it occurs at a high frequency. This behaviour has to be seen as part of a new youth culture, which does not seem to be limited to a certain subgroup—with all of the associated risks.

Association of Sexual Functioning and Quality of Partnership in Patients in Cardiovascular Rehabilitation—A Gender Perspective

INTRODUCTION In the general population, studies indicate a strong association between sexual dysfunction and partnership quality. Despite a high prevalence of sexual problems in patients with cardiovascular diseases, this association has not yet been examined in this sample. AIM The central task of this paper is to determine the association between sexual dysfunction and quality of partnership under a gender-specific view. METHODS A written survey was handed out to all newly admitted patients in five participating inpatient rehabilitation centers for cardiovascular diseases in Germany. The survey included a gender-specific questionnaire to assess sexual functioning (International Index of Erectile Function for men, and Female Sexual Function Index for women), and a Partnership Questionnaire. MAIN OUTCOME MEASURES Correlations were calculated between sexual function and relationship satisfaction, and differences between groups (cardiovascular diseased men and women with and without sexual problems) were tested using covariance analyses. RESULTS Overall, 44.3% of 98 female participants and 52.7% of 395 male participants stated to have at least one sexual problem. Patients with sexual problems showed significantly more quarrelling (P = 0.001), significantly less tenderness (P < 0.001), communication (P < 0.001), as well as significantly lower overall quality of partnership (P < 0.001), compared with cardiac men and women without sexual problems. Suffering from a sexual problem impaired partnership quality for women to a significantly greater extent than for men. CONCLUSIONS Possible shortcomings of our study are selection bias, i.e., it is unknown whether all newly admitted patients received the questionnaire by their physician, as well as an overall low response rate, probably because of the private character of questions. This study suggests for the first time that men and women who suffer from cardiovascular diseases and sexual problems show a significantly decreased partnership satisfaction compared with those without sexual dysfunction. Further longitudinal studies might confirm the causal nature of found correlations.

General practitioners and online continuing medical education - which factors influence its use?

Introduction: Although several online continuing medical education (CME) offers exist, the utilization of these by physicians is still low. In this study, we aimed to investigate the attitude towards and use of the Internet and online CME in German general practitioners (GPs) and to identify potential starting points to increase the use of online CME. Methods: In June 2006, a standardized 6-page questionnaire with 27 questions on the topic “Internet and online continuing education” was sent to all general practitioners in 6 districts (n=1304) of South Baden and South Württemberg in Germany. Data were analyzed using descriptive statistics, and exploratory regression analyses were performed to identify predictors of online CME usage. Furthermore, selected barriers were investigated in detail. Results: A total of 351 questionnaires were sent back, of which 349 could be included in the analysis (27% response rate). The sample is representative of the population contacted with respect to gender and qualifications. Univariate analyses showed that users of online CME were two years younger than non-users on average. Users spent two hours more on the Internet per week than non-users, and had been using the Internet for one year longer. Finally, users had better Internet skills, more often had previous experiences with online CME, and assessed the effectiveness of online CME to be higher and perceived fewer problems than non-users. Discussion: Measures to implement and increase the use of online CME can be aimed at different levels. The most important starting points are likely to be offering GPs the possibility to gain experience with online CME and improving their attitudes towards online CME. But for some physician populations, e.g. elderly or physicians with less Internet experience, e-learning might be an inferior option in comparison to traditional CME.

Is One Question Enough to Detect Female Sexual Dysfunctions? A Diagnostic Accuracy Study in 6,194 Women

INTRODUCTION Literature shows that recognition of sexual dysfunctions in women is insufficient and existing instruments to aid detection are mostly too extensive to be used in routine practice. AIM To develop a brief and accurate screening instrument to detect female sexual dysfunctions in routine care. METHODS The initial item pool for the index test consisted of 15 items. In a 4-year period, a total of 12,957 persons filled out the test on a specifically designed web-site. Six thousand one hundred ninety-four complete data sets could be used for statistical analysis. The validated German version of the Female Sexual Function Index (FSFI-d) served as reference standard to estimate the accuracy of the screening test. In order to test several possible ways of combining items a multi-step procedure employing univariate analyses, multiple logistic regression, and classification and regression tree analysis was applied to a learning sample and cross-validated in a test sample. MAIN OUTCOME MEASURES Diagnostic performance (sensitivity, specificity, positive and negative predictive value, accuracy, diagnostic odds ratio as well as adjusted odds ratio) of the items and resulting models to discriminate women with sexual dysfunction from those without were calculated. RESULTS One dichotomous question for overall satisfaction proved to show high accuracy as a stand-alone instrument and played also a central role in multivariate models. It may be recommended as a one-question screening test (76.4% sensitivity and 76.5% specificity in the test sample). A hierarchical two-question test yielded higher sensitivity (93.5%) and lower specificity (60.1%). A slightly more extensive version consists of five questions (83.1% sensitivity and 81.2% specificity). CONCLUSIONS Despite some methodological limitations of our study all developed tests showed acceptable to good diagnostic performance, all are very short and could therefore be easily implemented into routine care. Further tests of psychometric properties in other settings are needed.

The Efficacy of Stepped Care Models Involving Psychosocial Treatment of Alcohol Use Disorders and Nicotine Dependence: A Systematic Review of the Literature

Of particular interest in the psychosocial treatment of addictions is determining how much therapy is required to bring about behaviour change. Stepped care approaches, where non-responders to a less intensive therapy receive a more intensive intervention, aim to only provide intensive assistance to those who need it, thereby allocating therapeutic resources more efficiently. This paper provides a systematic review of stepped care models involving different levels of psychosocial intervention for the treatment of alcohol use disorders and smoking cessation. Five publications on alcohol and three on smoking were included in the review. Due to the heterogeneity of outcome measures, participant characteristics and interventions, a narrative review format was employed. Overall, little evidence was found to suggest that stepping up non-responders to more intensive therapy improved outcomes, a finding that could partially be attributed to a lack of power to find significant effects. In one study, the application of a stepped care approach was found to reduce treatment costs compared with usual care. There was some evidence that the greater differentiation between the intensity of the interventions offered at each step, the better the outcome. Further research is needed to evaluate the efficacy of stepped care approaches to providing psychosocial treatment, employing larger samples and/or consistent definitions of the nature of the interventions offered at each step, and assessing treatment response in a timely manner.

Das Konzept der “Evidence-based Medicine” in der Psychiatrie Ein Weg zu einer rationaleren Psychiatrie?

ZusammenfassungIn der Psychiatrie und Psychotherapie finden weiterhin viele Therapieverfahren Anwendung ohne dass ein empirischer Nachweis ihrer Wirksamkeit vorliegt. Die aus dem angloamerikanischen Sprachraum stammende “Evidence-based Medicine” bietet ein Konzept, medizinische Entscheidungen auf der Basis der besten zz. Verfügbaren externen Evidenz in Verbindung mit der individuellen klinischen Erfahrung zu treffen. In diesem Beitrag werden zunächst Beispiele einer “Non-evidence-based Psychiatry” aufgezeigt, ein klinisches Beispiel soll das Konzept einer “Evidence-based Psychiatry” vorstellen, am Ende schließlich steht die Betrachtung ihrer Anwendung, Grenzen und Möglichkeiten in der Praxis. Zum einen wird der Stellenwert dieser Methode für den klinisch tätigen Psychiater und Psychotherapeuten dargestellt. Zum anderen werden mögliche Konsequenzen diskutiert. Diese ergeben sich für Aufbereitung und Bereitstellung der Evidenz in Form von Datenbanken und systematischen Übersichtsarbeiten und in der Notwendigkeit von Umbauprozessen für die einzelne Institution wie auch für das Gesundheitssystem als Ganzes.SummaryMany of the diagnostic and therapeutic procedures in psychiatry and psychotherapy are based on opinion rather than evidence. The concept of evidence-based medicine aims to bridge the gap between clinical research and clinical decision-making by integrating the best available external evidence with personal expertise. In this article, we demonstrate several examples of the non-evidence-based medicine paradigm. Then we show the usefulness and practicability of the new evidence-based medicine paradigm by using a clinical example. Finally, we discuss the consequences, chances, and limitations of this new model. We also examine the role of the individual clinicians viewpoint as well as the need of institutional re-engineering and the possible restructuring of the entire health care system towards evidence-based methods.