Hamburger Modell der integrierten Versorgung von schwer erkrankten Psychosepatienten

The Hamburg model designates an integrated care model for severely ill patients with psychotic disorders. Based on evidence-based knowledge it was developed in 2005 and implemented in 2006 and is financed since May 2007 via §140 SGB V (German Social Code, book V) as a yearly per patient rate by various health insurances. It comprises comprehensive and long-term treatment within a network of the University Medical Center Hamburg-Eppendorf and private psychiatrists. The treatment model consists of therapeutic assertive community treatment (ACT) and need-adapted inpatient and outpatient care. Since 2012 the model has been extended to the indications of first episode adolescent and young adult patients in the age range of 12–29 years. The present article summarizes the contents of the model, important patient characteristics and results of the long-term treatment.     

Evidenzbasierte Psychotherapie der Depression

Depressive disorders are among the most frequent reasons for utilizing the health care system. Despite the availability of efficacious treatments and further advances throughout the last years, there is still a need for improving diagnostic and therapeutic procedures. A promising approach is the implementation of evidence- and consensus-based guidelines. The German “Nationale VersorgungsLeitlinie Unipolare Depression” are evidence- and consensus-based clinical practise guidelines for patients with unipolar depression. All relevant stakeholders have been involved in its development and have passed the final version at the end of 2009 to foster compliance throughout. The available evidence allows the derivation of differentiated treatment recommendations, also with regard to concomitant antidepressant medication or as alternative treatment options. In acute therapy watchful waiting over 14 days is recommended for mild depression and psychotherapy after persistence of symptoms. In cases of moderate depression, psychotherapy and pharmacotherapy are equally recommended, in cases of severe depression a combination of both is recommended.     

Vom Sinn der Depression

Depressive Erkrankungen, so qu?lend, st?rend, so in jeder Hinsicht beeintr?chtigend und niederdrückend sie uns erscheinen, k?nnen vom „salutogenetischen“ Standpunkt aus auch Aspekten der menschlichen Psyche zugeordnet werden, die auf l?ngere Sicht positive Perspektiven beinhalten. Das Verzweifeltsein von Menschen (M. Theunissen „Der Begriff Verzweiflung“; dies im Sinne von S. Kierkegaard) beinhaltet immer zugleich auch die Frage nach „Sinn“, nach der „Sinnstellung“ im Sinne von Martin Heidegger. Sinnfragen, die durchreflektiert und im Durchleiden vergegenw?rtigt werden, führen Menschen sehr oft zu einer „Wesensvertiefung“, die auf l?ngere Sicht mit sehr positiven L?sungen von Identit?tsund Pers?nlichkeitskrisen einhergehen. Diese Themen werden vom Standpunkt der evolution?ren Psychiatrie, der Typologie, der Psychodynamik und insbesondere der Fragen nach der Zeitdimension (Erinnern und Vergessen) im Hinblick auf depressive Erkrankungen behandelt.     

Zur Psychotherapie der Depression

Ohne Zusammenfassung     

Psychoanalytisch-orientierte Fokaltherapie der Depression bei Krebskranken

Emotional distress connected to a cancer disease may result in comorbid mental and especially depressive disorders. Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy of depression in cancer patients there is a lack of empirical studies which meet the criteria of evidence-based psychotherapy research. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy. As far as we know no manual for psychodynamic treatment of cancer patients has yet been published. In this article a manual for a 20-session short-term psychodynamic treatment is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. The SE treatment manual of depressions in cancer patients presented here is an adaptation of the general SET manual as well as the SE manual for depression. In the first part the general principles of SE therapy are presented. In the second part a manual specifically adapted to the treatment of depressive cancer patients is described. The treatment manual is presently being used in a large-scale randomized controlled multi-centered study comparing short-term psychodynamic psychotherapy and treatment as usual.     

Alltag mit der Depression des Partners

Objective. Clinical research on the quality of interpersonal relationships in individuals with unipolar depression supports the idea that the family plays a major role in the development and the course of major depression. In order to further explore how family functioning relates to unipolar depression, the authors examined changes in family functioning as viewed by the patients' spouses. Methods. Interview data from 54 spouses of patients with unipolar depression were analysed as part of the baseline assessment of a study on the economic and health burden experienced by families with mentally ill relatives. Results. Having a family member with a current major depressive disorder is a general stressor for families and has implications for the health and well-being of the patient's spouse. Depressive symptoms affect a wide range of aspects of marriage and family life and result in a process of adaptation and transformation of the patient's family. Thus, in assessing burden experienced by spouses particular attention should be paid both to the social environments and to different aspects of the relationship as perceived by the patient's spouse in order to further understand the factors mediating the interaction between major depression and family functioning.     

Das tschechoslowakische Modell des Sozialismus — Ursachen,Ziele, Folgen

Ohne Zusammenfassung     

Depression

Abstract— The theory of clinical depression presented here integrates etiological factors, changes in specific structural and cellular substrates, ensuing symptomatology, and treatment and prevention. According to this theory, important etiological factors, such as stress, can suppress the production of new neurons in the adult human brain, thereby precipitating or maintaining a depressive episode. Most current treatments for depression are known to elevate brain serotonin neurotransmission, and such increases in serotonin have been shown to significantly augment the ongoing rate of neurogenesis, providing the neural substrate for new cognitions to be formed, and thereby facilitating recovery from the depressive episode. This theory also points to treatments that augment neurogenesis as new therapeutic opportunities.     

Depression

Beck initially set out to test the Freudian notion that depression is a consequence of “anger turned inward” (rage directed the introjected parent for not gratifying infantile desires) but soon came to conclude that no such unconscious motivation existed and that instead depressed patients actually believe that they were unlovable or inadequate. He developed a treatment that he named cognitive therapy that is as efficacious as and more enduring than antidepressant medications. It stands as the most often tested and most widely practiced treatment for depression.     

Depression

Patients with myocardial infarction who suffer from a depression are at increased risk of dying of a subsequent heart attack or some other complication of coronary artery disease (CAD). A considerable body of research has provided evidence that a major depression, which is found in 16 to 23 percent of patients with CAD, but also subliminal depressive symptoms are independent risk factors for an unfavourable outcome of CAD. However, it is not yet clear whether depression is a causal risk factor having impact on the course of the heart disease or merely a prognostic marker that allows predicting the outcomes of interest, without any causal influence on them. Several pathways between depression and CAD have been discussed. These include behavioral mechanisms such as low compliance with both medical treatment and life style recommendations as well as neurobiological links. Much attention has been paid to the hypothalamic-pituitary-adrenocortical and sympathomedullary hyperactivity found in depression. Other possible links include diminished heart rate variability, stress-induced ischemia, platelet activation, and immunological dysregulation. To resolve the issue whether depression is a causal risk factor or only a prognostic marker, experimental studies are needed to evaluate interventions aimed at improving depression and test whether mortality is subsequently reduced. Such studies brought in the past mixed results. Whereas comprehensive intervention programs including risk factor management have produced a reduction in both coronary morbidity and mortality, a recent multicenter study providing either cognitive-behavioral therapy or usual care to depressed patients with CAD could not demonstrate a survival benefit among the participants of the intervention. Finally, results of evaluation studies regarding integrated disease management programs for patients with comorbid depression are presented.     

Multiple Depression

The subject of this paper is the problematisation of depression in today's mental health care. It is based on a study of the professional discussion on depression in Finland from the mid-1980s to the 1990s. The ways in which Finnish mental health experts define the object of depression treatment bring out an ambivalence that stems from the discrepancy between two parallel but incongruent notions of what depression is: the psychopharmacological and the psychotherapeutic. The analysis of the discussion demonstrates how clinical and practical rationales of today's mental health care are formed in the space between the two poles. Two tendencies of these rationales are also pointed out: first, the DSM paradigm of depressive illness inclines to become problematic and to dissolve in the actual practices. Second, they insinuate emphasis on antidepressant medication and overall neuropsychiatric approach in the treatment of depressive disorders, although in an ambivalent way.     

Psychoanalysis and Neuroscience in Dialogue: Commentary on Paper by Arnold H. Modell

Arnold H. Modell has been engaged in an ongoing effort to advance psychoanalysis as well as to integrate psychoanalytic theory and relevant domains of science, particularly neuroscience, with psychoanalytic practice. He has been articulating a biology and construction of meaning and the role of metaphor as he attempts to understand the relationship between mind and brain. Modell strives to understanding how “matter becomes imagination,” as well as the relationship between the first-person psychological unconscious and the third-person neurophysiological unconscious. The latter, according to Modell, is interpreted by a personal “autobiographical self” and given meaning. This discussion of Modell's theories will include historical and contemporary attempts to understand how “matter becomes imagination.” Although there is a growing neuroscience research base for articulating the reverse, i. e., “how imagination becomes matter,” the present author will focus on the project Modell h as placed before himself and his audience. The role of consciousness in the brain-mind interface, mirror neuron systems and intersubjectivity will be discussed. Clinically, the role of trauma's effects on memory and metaphor as well as the defensive functions of non-relatedness and counter-dependency will be examined within the wider context of the very rich and subjectively meaningful journey of matter becoming imagination.