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313-THE POSITION OF PRIVATE PRACTICE IN TRAINING
Abstracts / Journal of Psychosomatic Research 56 (2004) 581–673
153 DETERMINANTS OF THE QUALITY OF LIFE OF PATIENTS WITH CONGENITAL HEART DISEASE Rose M, Ko¨hler K, Ko¨hler F, Sawitzky B, Fliege H, Georgiewa P, Klapp BF. Dpt. of Psychosomatic Medicine, Charite´ University Medicine, Campus Mitte, Berlin, Germany. Objective: The improvement of the quality of life of chronically-ill patients has become an important goal in treatment. We examined the relative significance of biological factors, compared to psychological and social factors, for the various quality of life dimensions in patients with congenital heart disease. Research Design and Methods: 111 patients (aged 33 b 12 years) with different degrees of cardiac dysfunction were examined (NYHA 0 – IV). All patients for whom there was no contraindication underwent a treadmill ergometry in order to determine their level of cardiopulmonary functioning (peak oxygen consumption: VO2max). All patients were asked to fill out questionnaires concerning their quality of life (WHOQOL-Bref), their cardiac complaints (Giessener Complaint Questionnaire GBB), their personality traits (Giessen Test GTS), and the social support they experience (Social Support Questionnaire SOZU-k22). The data were analyzed using a linear structural equation model (SEM). Results: In all aspects but the social domain, the HRQL of CgHD patients was significantly diminished compared to the normal population. The SEM proposed was valid, showing good indices of fit (chi2 = 1.18 p = .55, AGFI = .92). The level of cardiopulmonary functioning was most significant for the reporting of specific cardiac complaints (b = 28) and for the physical component of the general HRQL (b = 32), although the former was also influenced by a depressed disposition (b = .20) and the extent of social support experienced (b = .18). The objective findings, however, had virtually no individual significance for the psychological (b = .09) and social domains (b = .02). These HRQL domains are ` = 26/ primarily influenced by depressive personality traits ( f O .16) and the social support experienced (b = .51/.51). Conclusions: The patient’s organic dysfunction primarily determines illness-specific complaints but has little relevance for the psychological and social aspects of the HRQL. These aspects are predominantly determined by the patient’s depressive disposition and by the experienced social support. A successful therapy should therefore take biological as well as psycho-social determinants of the quality of life into account.
26 PSYCHIATRIC AND PSYCHOSOCIAL OUTCOME OF CARDIAC SURGERY: A PROSPECTIVE 12-MONTH FOLLOW-UP STUDY Rothenha¨usler HB, Grieser B, Nollert G, Kapfhammer HP, Department of Psychiatry, University of Medicine of Graz, Austria. Background: Little is known concerning the natural history of psychiatric morbidity, postoperative delirium, cognitive decline, and health status in cardiac surgery patients, and the impact of neurocognitive dysfunction on health status after cardiac surgery with cardiopulmonary bypass (CPB). Methods: In a prospective study, we followed up for 1 year 30 of the original 34 patients, who had undergone cardiac surgery with CPB. Patients were assessed preoperatively, before discharge, and at 1 year after surgery with the SCID for DSM-IV, and a series of neuropsychological tests (SKT, MADRS, PTSS-
661
10, SF-36). Delirium Rating Scale was used daily over the course of ICU treatment. Results: During ICU treatment, mild delirium occurred in 7 patients, moderate delirium in 2 patients, and severe delirium in 2 patients. In 4 patients, delirium was diagnosed within the first day after cardiac surgery. Delirious states lasted between 1 and 7 days, however, 9 out of 11 delirious patients recovered quickly within 3 days or less. At discharge, we recorded 11 patients to have adjustment disorder with depressed features, 6 patients to have acute full in-hospital posttraumatic stress disorder, 6 patients to have major depression, and 13 patients to suffer clinically relevant cognitive deficits. At 12 months, the severity of depression and anxiety disorders improved and returned to the preoperative level, and 6 out of the 30 followed-up patients displayed cognitive deficits. The diagnostic status of delirium was not associated with cognitive decline over time. Our patients’ health status SF-36 selfreports significantly improved compared with baseline quality of life data. However, 1-year overall cognitive function scores were associated with lower health status. Discussion: An advantage of our study was that we used detailed psychiatric interviews as a way of monitoring mental state changes. We therefore avoided the pitfalls inherent in sole reliance on subjective self-report rating scales. To sum up, cardiac surgery with CPB is associated with improvements in health status relative to the preoperative period, but the presence of cardiac surgery-related cognitive decline impairing health status is a complication for a subgroup of cardiac surgical patients in the long-term outcome.
313 THE POSITION OF PRIVATE PRACTICE IN TRAINING Ru¨th-Behr B. German Society for Psychosomatic Medicine and Psychotherapy, Hamburg, Germany. The role of private practice in the training of physicians in psychosomatic medicine is central, because the majority of patients with psychosomatic illnesses are given treatment as out-patients. The function of this part of the in-service training programme is the teaching of the ability to practise psychotherapy in crises under outpatient conditions, and also to conduct long-term psychotherapy. A training programme can currently be carried out in the course of work in private practice over an 18-month period; alternatively, it can be organized as part-time supplement for those working in hospital for the duration of their entire training. Supervision by several teachers is the central component of training. The supervisors cooperate within a structure that includes the medical director of the private practice, a cooperating institute, and, if appropriate, the psychosomatic clinic. They have the aim of supporting the learning processes of the trainees.
24 STRESSFUL LIFE EVENTS AND HYPER-PROLACTINEMIA. A CONTROLLED STUDY Ruini C. Affective Disorders Program, Department of Psychology, University of Bologna, Italy. Little is known about the relationship between recent life events and onset of hyperprolactinemia, despite the well-known effect of acute psychological stress on prolactin levels in healthy subjects. Recent life events in patients with hyperprolactinemia compared to healthy controls were therefore investigated. We studied 52
153 DETERMINANTS OF THE QUALITY OF LIFE OF PATIENTS WITH CONGENITAL HEART DISEASE Rose M, Ko¨hler K, Ko¨hler F, Sawitzky B, Fliege H, Georgiewa P, Klapp BF. Dpt. of Psychosomatic Medicine, Charite´ University Medicine, Campus Mitte, Berlin, Germany. Objective: The improvement of the quality of life of chronically-ill patients has become an important goal in treatment. We examined the relative significance of biological factors, compared to psychological and social factors, for the various quality of life dimensions in patients with congenital heart disease. Research Design and Methods: 111 patients (aged 33 b 12 years) with different degrees of cardiac dysfunction were examined (NYHA 0 – IV). All patients for whom there was no contraindication underwent a treadmill ergometry in order to determine their level of cardiopulmonary functioning (peak oxygen consumption: VO2max). All patients were asked to fill out questionnaires concerning their quality of life (WHOQOL-Bref), their cardiac complaints (Giessener Complaint Questionnaire GBB), their personality traits (Giessen Test GTS), and the social support they experience (Social Support Questionnaire SOZU-k22). The data were analyzed using a linear structural equation model (SEM). Results: In all aspects but the social domain, the HRQL of CgHD patients was significantly diminished compared to the normal population. The SEM proposed was valid, showing good indices of fit (chi2 = 1.18 p = .55, AGFI = .92). The level of cardiopulmonary functioning was most significant for the reporting of specific cardiac complaints (b = 28) and for the physical component of the general HRQL (b = 32), although the former was also influenced by a depressed disposition (b = .20) and the extent of social support experienced (b = .18). The objective findings, however, had virtually no individual significance for the psychological (b = .09) and social domains (b = .02). These HRQL domains are ` = 26/ primarily influenced by depressive personality traits ( f O .16) and the social support experienced (b = .51/.51). Conclusions: The patient’s organic dysfunction primarily determines illness-specific complaints but has little relevance for the psychological and social aspects of the HRQL. These aspects are predominantly determined by the patient’s depressive disposition and by the experienced social support. A successful therapy should therefore take biological as well as psycho-social determinants of the quality of life into account.
26 PSYCHIATRIC AND PSYCHOSOCIAL OUTCOME OF CARDIAC SURGERY: A PROSPECTIVE 12-MONTH FOLLOW-UP STUDY Rothenha¨usler HB, Grieser B, Nollert G, Kapfhammer HP, Department of Psychiatry, University of Medicine of Graz, Austria. Background: Little is known concerning the natural history of psychiatric morbidity, postoperative delirium, cognitive decline, and health status in cardiac surgery patients, and the impact of neurocognitive dysfunction on health status after cardiac surgery with cardiopulmonary bypass (CPB). Methods: In a prospective study, we followed up for 1 year 30 of the original 34 patients, who had undergone cardiac surgery with CPB. Patients were assessed preoperatively, before discharge, and at 1 year after surgery with the SCID for DSM-IV, and a series of neuropsychological tests (SKT, MADRS, PTSS-
661
10, SF-36). Delirium Rating Scale was used daily over the course of ICU treatment. Results: During ICU treatment, mild delirium occurred in 7 patients, moderate delirium in 2 patients, and severe delirium in 2 patients. In 4 patients, delirium was diagnosed within the first day after cardiac surgery. Delirious states lasted between 1 and 7 days, however, 9 out of 11 delirious patients recovered quickly within 3 days or less. At discharge, we recorded 11 patients to have adjustment disorder with depressed features, 6 patients to have acute full in-hospital posttraumatic stress disorder, 6 patients to have major depression, and 13 patients to suffer clinically relevant cognitive deficits. At 12 months, the severity of depression and anxiety disorders improved and returned to the preoperative level, and 6 out of the 30 followed-up patients displayed cognitive deficits. The diagnostic status of delirium was not associated with cognitive decline over time. Our patients’ health status SF-36 selfreports significantly improved compared with baseline quality of life data. However, 1-year overall cognitive function scores were associated with lower health status. Discussion: An advantage of our study was that we used detailed psychiatric interviews as a way of monitoring mental state changes. We therefore avoided the pitfalls inherent in sole reliance on subjective self-report rating scales. To sum up, cardiac surgery with CPB is associated with improvements in health status relative to the preoperative period, but the presence of cardiac surgery-related cognitive decline impairing health status is a complication for a subgroup of cardiac surgical patients in the long-term outcome.
313 THE POSITION OF PRIVATE PRACTICE IN TRAINING Ru¨th-Behr B. German Society for Psychosomatic Medicine and Psychotherapy, Hamburg, Germany. The role of private practice in the training of physicians in psychosomatic medicine is central, because the majority of patients with psychosomatic illnesses are given treatment as out-patients. The function of this part of the in-service training programme is the teaching of the ability to practise psychotherapy in crises under outpatient conditions, and also to conduct long-term psychotherapy. A training programme can currently be carried out in the course of work in private practice over an 18-month period; alternatively, it can be organized as part-time supplement for those working in hospital for the duration of their entire training. Supervision by several teachers is the central component of training. The supervisors cooperate within a structure that includes the medical director of the private practice, a cooperating institute, and, if appropriate, the psychosomatic clinic. They have the aim of supporting the learning processes of the trainees.
24 STRESSFUL LIFE EVENTS AND HYPER-PROLACTINEMIA. A CONTROLLED STUDY Ruini C. Affective Disorders Program, Department of Psychology, University of Bologna, Italy. Little is known about the relationship between recent life events and onset of hyperprolactinemia, despite the well-known effect of acute psychological stress on prolactin levels in healthy subjects. Recent life events in patients with hyperprolactinemia compared to healthy controls were therefore investigated. We studied 52