Background Strategies to improve the care of elderly, multimorbid patients frequently focus on implementing evidence-based knowledge by structured assessments and standardization of care. In Germany, disease management programs (DMPs), for example, are run by general practitioners (GPs) for this purpose. While the importance of such measures is undeniable, there is a risk of ignoring other dimensions of care which are essential, especially for elderly patients: their spiritual needs and personal resources, loneliness and social integration, and self-care (i.e., the ability of patients to do something on their own except taking medications to increase their well-being). The aim of this study is to explore whether combining DMPs with interventions to address these dimensions is feasible and has any impact on relevant outcomes in elderly patients with polypharmacy. Methods An explorative, cluster-randomized controlled trial with general practices as the unit of randomization will be conducted and accompanied by a process evaluation. Patients aged 70 years or older with at least three chronic conditions receiving at least three medications participating in at least one DMP will be included. The control group will receive DMP as usual. In the intervention group, GPs will conduct a spiritual needs assessment during the routinely planned DMP appointments and explore whether the patient has a need for more social contact or self-care. To enable GPs to react to such needs, several aids will be provided by the study: a) training of GPs in spiritual needs assessment and training of medical assistants in patient counseling regarding self-care and social activity; b) access to a summary of regional social offers for seniors; and c) information leaflets on nonpharmacological interventions (e.g., home remedies) to be applied by patients themselves to reduce frequent symptoms in old age. The primary outcome is health-related self-efficacy (using the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES-6G)). Secondary outcomes are general self-efficacy (using the General Self-Efficacy Scale (GSES)), physical and mental health (using the Short-Form Health Survey (SF-12)), patient activation (using the Patient Activation Measure (PAM)), medication adherence (using the Medication Adherence Report Scale (MARS)), beliefs in medicine (using the Beliefs About Medicines Questionnaire (BMQ)), satisfaction with GP care (using selected items of the European Project on Patient Evaluation of General Practice (EUROPEP)), social contacts (using the 6-item Lubben Social Network Scale (LSNS-6)), and loneliness (using the 11-item De-Jong-Gierveld Loneliness Scale (DJGS-11)). Interviews will be conducted to assess the mechanisms, feasibility, and acceptability of the interventions. Discussion If the interventions prove to be effective and feasible, large-scale implementation should be sought and evaluated by a confirmatory design. Trial registration ...

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Eugen Bleuler, in 1911, renamed the group of mental disorders with poor prognosis which Emil Kraepelin had called "dementia praecox" "group of schizophrenias", because for him the splitting of personality was the main symptom. Biographical, scientific and methodological influences on Bleuler's concept of schizophrenia are shown with special reference to Kraepelin and Freud. Bleuler was a passionate and very experienced clinician. He lived with his patients, taking care of them and writing down his observations. Methodologically he was an empiricist and an eclecticist with a wide reading knowledge. In an impaired association of ideas, in disordered affectivity, in marked ambivalence and autism Bleuler saw the main symptoms of schizophrenia. For him these so-called pathological phenomena actually seemed to be only exaggerations of normal psychic functions. So there were only a quantitative, not a qualitative difference between schizophrenia and normal psychic processes and studies on schizophrenic "pathology"--seen as a disturbance, not as a disease--might analogously illustrate normal psychic reactions and vice versa. In etiology as well as in therapy Bleuler took into account psychological and (neuro)physiological (somatic) mechanisms--thus combining organicism and dynamic psychiatry and coming very close to modern concepts, e.g. the one of stress and vulnerability. Bleuler's main merit is the stressing on an idiographic "understanding" of the patient and a plausible and subtle explanation of schizophrenia which helped to reduce the alienation of the affected persons.

Background This study presents a concept for training general practitioners (GPs) in taking a spiritual history. In the same workshop, medical assistants (MAs) were trained in counselling elderly, chronically ill patients on social activities and home remedies. After the training, GPs and MAs will apply the acquired skills in their practices within the scope of the HoPES3 intervention study, which aims at raising patients’ self-efficacy. Methods Sixteen GPs and 18 MAs were trained in a 5-hour workshop and completed an evaluation questionnaire. Results All participants reported great satisfaction. In particular, 85% of GPs (n=11) affirmed increased capacity to address patients’ spiritual needs. About 88% (n=15) of MAs were satisfied with the training, yet expressed difficulties in integrating theoretical knowledge into daily professional routine. Discussion While the evaluation of the workshop is promising, the results of the randomized-controlled trial evaluating the effectiveness of the complete HoPES3 intervention have to be awaited. Conclusion To our knowledge, this is the first interdisciplinary, holistic care training in primary care in Germany. It fosters GPs’ and MAs’ competency in providing a proactive support in spirituality, social activities, and home remedies to their patients. If the concept proves to be effective, it could be integrated into existing care models and curriculums and provide clear guidance on how to consider elderly patients’ spiritual needs and strengthen their self-efficacy in primary care settings.

ZusammenfassungIm psychiatrischen Alltag wird die spirituelle Dimension einer Erkrankung meist nicht explizit berücksichtigt. Dabei spielt sie bei den großen psychiatrischen Diagnosen oft eine wesentliche Rolle und zwar sowohl auf der Seite des Patienten als pathogenetischer und/oder heilsamer Faktor als auch auf der Seite des Behandlers, der mit der Grenzsituation einer schweren psychiatrischen Erkrankung existenziell konfrontiert wird. Dies soll an Fallbeispielen zu Demenz, Sucht, Schizophrenie, Depression, Manie und Angsterkrankung gezeigt werden.