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Success factors, challenges and obstacles in the collaborative care of elderly people with depression

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1 UNIVERSITY CLINIC HAMBURG-EPPENDORF Psychosocial Center Institute and Polyclinic for General Medicine Director Prof. Dr. med. Martin Scherer Success factors, challenges and obstacles in the collaborative care of elderly people with depression. A qualitatively contrasting case comparison of the patient perspective for the evaluation of the GermanIMPACT (QualIMP) INAUGURAL - DISSERTATION for obtaining the doctoral degree Dr. rer. biol. hum. / PhD at the Medical Faculty of the University of Hamburg. presented by: Thomas Kloppe M.A. from Neubrandenburg Hamburg 2017

2 Accepted by the Medical Faculty of the University of Hamburg on: February 20, 2018 Published with the permission of the Medical Faculty of the University of Hamburg. Examination board, the chairperson: Prof. Dr. Martin Scherer Examination Board, second reviewer: Prof. Dr. Olaf von dem Knesebeck Examination Committee, third reviewer: Prof. Dr. Harald Ansen

3 Contents Contents Contents ... III Tables and List of Figures ...

4

5 Contents 10 Acknowledgments ... IX 11 Curriculum vitae ... X Appendix ... XI I II III IV V VI Patient-Health-Questionnaire (PHQ-9) ... XI Patient information ... XII Declaration of consent ... XIV Ethics -Votum ... XVI data CD ... XVIII Affidavit ... XIX V

6 Tables and List of Figures Tables and List of Figures Table 1: Symptoms of a depressive episode (F32) according to ICD Table 2: Main degrees of severity of depressive episodes according to ICD Figure 1: Depressive courses ... 8 Figure 2: Differential diagnosis of depressive symptoms ... 9 Figure 3: Administrative Prevalence by age and gender in Germany Table 3: Somatic comorbidities in elderly people suffering from depression Figure 4: Age distribution of suicide rates in Germany Figure 5: Risk factors that can trigger a depressive disorder Figure 6: Depression as comorbidity Table 4: Frequent conditions that trigger depression Figure 7 : Etiological model of depressive disorder Table 5: Relationship between coping family, adaptation process and the associated functions ..

7 Tables and list of figures Table 15: Description of the population Table 16: Utilization typology based on the primary three characteristic spaces Table 17: Topic matrix reorganized based on the identified utilization types Figure 23: Representation of the utilization types Figure 24: Linear distribution of beneficiaries Table 18: Topic matrix reorganized based on the categories for Symptom development Table 19: Simplified disease perspective of the symptom development types Table 20: Counting of the coping strategy codes according to groups Figure 25: Relationship between the secondary characteristics and the intensity of use Figure 26: Relationship between the secondary characteristics and the depressive symptoms Table 21: Recommendations for the care of elderly people with depression Figure 27: WHO Mental Health Service Organization Pyramid VII

8 Tables and list of figures The simplest, and probably the most clinically useful type of approach to a person s personal constructs, is to ask him to tell us what they are. (Kelly 1955, p. 139) VIII

9 Introduction 1 Introduction The World Health Organization (WHO) placed depression at the center of World Health Day 2017 because, with a share of eleven percent, it is the most common reason for years of life impaired due to illness (WHO 2013). In particular, economically poor countries have to struggle with a comparatively high to very high prevalence of depressive illnesses (Ferrari et al. 2013). Worldwide (WHO 2013) and in Germany (Wittchen et al. 2010) every fifth person suffers from a clinically relevant depressive disorder at least once in their lifetime. Every seventh German is affected within one year (Andreas et al. 2017). Depression affects quality of life and increases the risk of, or the burden of disease, diabetes mellitus type 2, coronary heart disease, chronic pain and other geriatric syndromes, especially in old age (Schulz et al. 2012). The increased morbidity goes hand in hand with an increased mortality. In addition, depression is the main cause of suicide (van Orden and Conwell 2011). At the same time, depressive illnesses are associated with very high social costs. Krauth et al. (2014) estimate the annual costs per sick person at euros and thus at total costs of 15.6 billion euros in Germany. In general practitioners' practice, depression is the most common mental illness (Wittchen et al. 2010, p. 21). Often, however, comprehensive care cannot be provided because there is often a lack of time and, in some cases, technical resources. Older people are not affected by depression more often than younger people (Amrhein et al. 2015, p. 87), but they avoid it due to self-stigmatization (Stenkamp et al. 2016a, p. 55) and negative images of old age (Hüll and Hölzel 2017, p. 303) specialized offers and remain at least 50 percent exclusively in the family doctor's practice. At the same time, the general workload in general practitioners' practices, the specialization in the treatment of individual illnesses and the number of depressed elderly patients are increasing due to demographic development alone (Areán 2012). The question of how patients, especially if they are affected by multimorbidity in old age, can be cared for holistically, effectively and inexpensively, determines the discussion in politics, research and practice (Andersson 2017). The GermanIMPACT study: Coordinated treatment of age-related depression in primary care: Implementation of the IMPACT program in Germany is a response to this 1

10 Introduction Discussion. Based on the US model (Unützer et al. 2002), she piloted a collaborative approach to care for people with depression aged 60 and over in the cities of Freiburg and Hamburg. The aim of this project was to support general practitioners in the treatment of elderly people with depressive illness through trained therapy attendants and thus to improve the care situation for those affected. This approach has already proven its effectiveness in numerous studies both inside and outside the USA (Archer et al. 2012), in which it was able to cost-effectively improve the state of health of patients (Grochtdreis et al. 2015). GermanIMPACT was a complex intervention study that consisted of different methodological elements. The complex intervention led 25.6 percent of the intervention patients to a remission of the depressive symptoms. In the control group, symptoms remitted in 10.9 percent of all participants. Despite the success, this result means: three quarters of the intervention group could not benefit from the therapy support. In the development of the primary outcome measure depression, the treatment, consisting of psychoeducational elements, activation, monitoring, medication advice, possibly problem-solving techniques, the therapeutic relationship to therapy support and the subjective disease perspective of the depressed elderly patients were of different importance (Chew-Graham et al. 2007). How the individual elements are to be weighted, which components of the intervention contributed to the observed effects and to what extent cannot be explained in detail (Vlasveld et al. 2008). The consideration of the views of depressed patients has been neglected in relation to the quality of treatment. Petrosyan et al. (2017, p. 6), recently compiled quality indicators in the treatment of depression and, for 53 identified indicators, came up with exactly one indicator that included the patient's perspective. Coventry et al. (2014, p. 12) state that in order to increase the effectiveness of collaborative care approaches, it is absolutely necessary to better understand which intervention components work in which way on which patients. With this understanding it could be possible to develop tailor-made care offers for the difficult to reach, depressed, elderly people. 2

11 Introduction This motivation forms the basis of the present work. It includes a differentiated qualitative consideration of the intervention package and the participating GermanIMPACT patients. The main goal-oriented question is: Which patient-specific and intervention-specific moderating factors are responsible for a successful or an unsuccessful intervention? To answer this question, a theoretical discussion will first create the heuristic framework of this work. First, diagnostic, epidemiological and etiological perspectives on depressive disorders in old age are described. Then paradigms of subjective theories are introduced, which represent the basis for tracing the patient's perspective. These aspects are then explored in relation to illness, health and age, as well as depression. The numerous aspects of subjective disease prospects are then contrasted with the current medical care landscape with its various intervention approaches. The barriers in care outlined here prepare the introduction of the collaborative care model GermanIMPACT, as well as the presentation of the results of the quantitative evaluation study. The methodological concept of mixed methods and the value of qualitative studies are opposed to the associated lack of explanation with regard to beneficial or hindering factors. On the basis of this research methodology, the question is explicated in Chapter 3 and transferred to a study design at the beginning of the fourth chapter. This is accompanied by the empirical part of this work, in which the participants of the intervention are interviewed and examined in a cross-case analysis. The qualitative contrasting case comparison based on this results in Chapter 5 in two typologies of the participants. It is shown which individual influencing factors are associated with the effectiveness of the intervention and which obstructing or conducive factors exist for the response to the intervention. These factors and the typology as such are discussed in Chapter 6 against the background of the current state of research and articulated in various recommendations for adaptation that can increase the effectiveness of the intervention. The conclusion of this work is the critical consideration of the methodological approach in this study. 3

12 Background 2 Background Depression in old age offers multifaceted medical, psychological and sociological approaches. Their individual manifestation is highly subjective and their care is accordingly complex. The theoretical part of this thesis initially includes a diagnostic approximation of the clinical picture, the epidemiological extent of the more depressive illnesses and the etiological factors that can be responsible for the occurrence of depression. In preparation for the subjective perspective of elderly patients suffering from depression, the basics of subjective theories are then outlined. Subjective theories try to explain individual cognitive processes in connection with social interpretations and the resulting behavior (Flick 1991a, p. 24). For depression in old age, it is therefore also important to trace general ideas about health and illness, more specific theories of illness, social images of old age and subjective images of health in old age. They are all jointly responsible for the disease perspective of elderly people suffering from depression and the associated coping strategies. The perspective of the illness is one of the decisive factors in making use of various approaches to care that those affected can fall back on. The family doctor's practice is the central point of contact for depressive illnesses in old age and the point of contact for the GermanIMPACT intervention. Therefore, the family doctor's practice is given special weight in the presentation of the care offers. Further therapeutic and complementary approaches are only sketched out so that the IMPACT intervention can be located in the care landscape in Germany. The overview of the care approaches concludes with frequent obstacles in care, which are the reason for the increasing importance of collaborative care models such as GermanIMPACT. Then the study design and the course of the study of GermanIMPACT is described. In particular, the components of the complex intervention are presented in detail, as their weighting is a key question of why some patients benefit from therapy support and some do not. The research methodological chapter on mixed methods then underlines the value of qualitative research methods for the 4th

13 Background Explanation of quantitative study results and allows the development of a specific question that forms the conclusion of the theoretical background. 2.1 Depressive disorders in old age Depressive episodes and recurrent depressive disorders are affective disorders with typical behavior such as depressed mood, loss of interest, reduced performance and listlessness (Wittchen et al. 2010, p. 7). Depression in old age, in particular, can also be associated with a variety of somatic syndromes. This section provides basic information on the diagnosis, epidemiology and etiology of depressive disorders in the general population and specifies the specifics of depressive disorders in old age Diagnosing depressive disorders The individual symptoms and the extent of the subjective impairment determine whether the manifestation is mild, moderate, severe or very severe. Diagnosis in Germany is mainly based on Chapter V of the ICD-10 classification system, the international statistical classification of diseases and related health problems (Dilling 2011). This diagnostic system in its tenth revision is published by the World Health Organization and defines the diagnostic criteria for recognized clinical pictures worldwide. Another system is the Diagnostic and Statistical Manual of Mental Disorders in its fifth edition: DSM-5 of the American Psychiatric Association (APA 2013). In Germany, it is primarily to be understood as a supplement to the ICD-10 and contains more specific diagnostic criteria that are particularly US-American and are used internationally in science (Wittchen et al. 2000, p. 4). The basis for the diagnosis and the assessment of the severity according to ICD-10 is the list of symptoms in Table 1. Essential for a diagnosis of depression are the occurrence of at least two main symptoms and two further symptoms over a period of at least two weeks. 5

14 Background Table 1: Symptoms of a depressive episode (F32) according to ICD-10 Key symptoms 1. Depressed mood and joylessness 2. Loss of interest 3. Reduced drive with rapid fatigue or exhaustion Other common symptoms 1. Reduced concentration, attention and memory disorders 2. Decreased Self-esteem and self-confidence 3. Feelings of guilt and worthlessness 4. Negative and pessimistic future prospects 5. Thoughts, self-harm or suicidal behavior 6. Sleep disorders 7. Decreased appetite Somatic (vegetative) symptoms: 1. Loss of interest or loss of enjoyment in normally pleasant activities 2. insufficient ability to react emotionally to a friendly environment or favorable events 3. early morning awakening (2 or more hours before the usual time) 4. morning low 5. the objectified finding of psychomotor inhibition or agitation 6. significant loss of appetite u nd chronic constipation 7. Weight loss, often more than 5% of body weight in the previous month 8. Significant loss of libido Illustration based on Wolfersdorf and Schüler (2005, p. 26) If only the main symptoms are met, it is a slight depressive episode. If further symptoms are recognized through specific inquiries, the severity increases, as shown in Table 2, up to a severe depressive episode. Suicidality is the most devastating symptom of a depressive episode in which the person concerned strives for their own death in thought, through active action, admitting or omitting (Wolfersdorf and Schüler 2005, p. 175). A direct connection between suicidality and depression cannot always be established, but it is estimated that 45 to 70 percent of all suicides are the result of a major depressive illness. Depressive episodes are thus the greatest risk factor for suicide and suicidality is a strong indicator of depression. 60 to 70 percent of those affected have suicidal thoughts (ÄZQ and DGPPN 2015, p. 40). In addition to the key and additional symptoms, the ICD-10 also recognizes the somatic syndrome, which is diagnosed when three other somatic symptoms are present, e.g. Lack of emotion, low mood depending on the time of day or weight loss (Dilling 2011). Chronobiological depressive episodes with rapid alternation or seasonal occurrence, such as spring or winter depression, are typical here (ÄZQ and DGPPN 2015, p. 31). 6th

15 Background In addition to the symptoms from ICD-10 and DSM-5, Winkler et al. (2005) reported an atypical, gender-specific symptomatology that can be observed in some male patients. It is characterized in particular by a low stress tolerance with high irritability, aggressiveness and general anti-social behavior. Women, on the other hand, are more likely to be very tired during the day and have heavy limbs. Table 2: Main degrees of severity of depressive episodes according to ICD-10 ICD-10 Category Degree of severity of the depressive illness Core symptoms Other common symptoms F 32.0 mild depressive episode at least 2 key symptoms are present F 32.1 moderate depressive episode at least 2 key symptoms are present 1 or more symptoms (total number incl. Key symptoms 4 or 5) 3 or more symptoms (total number including key symptoms 6 or 7) F 32.2 severe depressive episode without psychotic symptoms all key symptoms are present several symptoms are present, some of them particularly pronounced (total number of symptoms including key symptoms at least 8) none Hallucination, delusion or depressive immobility F 32.3 Severe depressive episode with psychotic symptoms All key symptoms are present. Severe depressive episode as described under F32.2, there are also hallucinations, delusional ideas, severe psychomotor inhibition or immobility ung an Lützenkirchen (2008, p. 23) Another distinguishing feature of depressive illnesses is the course form (Figure 1). Depressive disorders can occur once (a) and remitting, they can subside incompletely (b), they can recur or relapse after remission (c), they can manifest themselves in the form of dysthymia (d) on a milder level, they can be from a Dysthymia turn into an acute, more serious depressive episode, the Double Depression (s), and in the worst case they can become chronic at a very stressful level. Particularly in the case of recurrent depressive disorders (c), it should be checked whether an episode with very high mood and activity had previously occurred in order to rule out bipolar depression (ÄZQ and DGPPN 2015, p. 29), as it requires special treatment. 7th

16 Background Figure 1: Depressive courses (Losekam and Konrad 2017, p. 20) On average, a treated depressive episode (a, b, e) lasts 13 weeks or six to eight months if it is not treated. For a third of those affected, the disease remains one-time, while another third has repeated episodes and the other third is either chronically ill with depression or at least not completely recovered (Wittchen et al. 2000, p. 5). In the DSM-5, types (a) to (c) are summarized as major depression. The classification also includes minor depression, which, analogous to mild depression in the ICD-10, denotes a quantitative lack of symptoms. However, this does not have to have an impact on the severity of the disease or the associated subjective level of suffering (Wolfersdorf and Schüler 2005, p. 33). The Patient-Health-Questionnaire-9 - PHQ-9 (Appendix I) is an established instrument for recording depressive symptoms. This is done by the patients themselves 8

17 Background questionnaire, consists of nine questions on the symptom areas of the ICD-10 (Table 1). A four-point scale is used to ask how often those affected were plagued by depression, for example, in the past two weeks (Löwe et al. 2004). A suspected diagnosis made in this way must in any case be backed up with a differential diagnostic procedure. This includes, for example, the Composite International Diagnostic Interview (CIDI) validated by Wittchen (1994) or the one for older people by Wittchen et al. (2015) adapted version (CIDI65 +) available. The latter has a simpler structure, the language is adapted, the items are sometimes more differentiated, somatic complaints are given greater consideration and current loss, sickness and loneliness situations are also recorded. These points have a greater influence on the symptoms in depressed older patients than in younger patients and are difficult to distinguish, as shown schematically in Figure 2. Larvae depressions are also typical of depressive episodes in old age. The symptoms are hidden behind a larva (mask), which often manifests itself in the form of physical complaints. The somatic complaints are then a sign of psychological conflicts that are difficult to recognize as such, since older people often suffer from additional illnesses anyway (Wolfersdorf and Schüler 2005, p. 33). If a masked depression is suspected, the symptom-related history is therefore very important. It must be expanded through psychiatric, physical-internal and neurological, if necessary instrumental diagnostics, so that physical illnesses can be completely excluded as a cause (ÄZQ and DGPPN 2015, S). Figure 2: Differential diagnosis of depressive symptoms (Stenkamp et al. 2016a) 9

18 Background Diagnostic procedures using magnetic resonance imaging and biomarkers are currently also being investigated. There are indications that in older people with depressive illness specific differences can be demonstrated in the left frontoparietal network, in the sensory motor network as well as in the left dorsolateral prefrontal cortex and in the left superior parietal lobe compared to unaffected persons (Cieri et al. 2017) Old age Depressive disorders in old age are the most common mental illnesses behind anxiety disorders. The prevalence figures vary from study to study, depending on the methodology and target group. In the study on adult health in Germany (DEGS1), the annual prevalence of a depressive disorder in the general population is estimated at 7.7 percent. Women are affected twice as often with 10.6 percent as men with 4.8 percent (Jacobi et al. 2014b). Another study, based on billing data from six million people with statutory health insurance in Germany, reports an administrative one-year prevalence in the general population of 13.4 percent, which, however, varies considerably depending on gender and age group (Melchior et al. 2014). Figure 3: Administrative prevalence by age and gender in Germany (Melchior et al. 2014) For the older population, a literature review by Djernes (2006) shows an enormous variance of 0.9 percent to 42 percent. Another systematic review by 10

19 Background Volkert et al. (2013), which included 25 studies and examined the prevalence of mental illness in older people aged 50 and over, reported a one-year prevalence for moderate depressive episodes of 16.5 percent. A meta-analysis with 24 epidemiological studies by Luppa et al. (2012) reported that an average of 7.2 percent of people aged 75 and over in industrialized countries are affected by moderate depression. A cohort study from Norway suggests an increase with increasing old age and observed an increase to 15 percent around the age of 85 (Solhaug et al. 2012). A primary study with clinical interviews of men and women aged 65 and over from 6 European cities by Andreas et al. (2017) documents a one-year prevalence of 11.6 percent. Even if the prevalence rates differ depending on the study, overall the group of over 65-year-olds does not show any significant peculiarities compared to people of other age groups who are depressed (Amrhein et al. 2015, p. 87). The federal government pragmatically estimates that one in ten will be affected by a depressive episode within a year (BMFSFJ 2010, p. 169), whereby the incidence rate for women at 15 percent differs significantly from that for men at approx. 8 percent (BMFSFJ 2006, p. 29). Only after the age of 70 do the gender differences gradually decrease (Adam 1998, p. 259). Explanations could be that older (single, widowed) women are generally more often affected by income poverty and possibly less self-efficacy due to a fragile employment history. At the same time, the presentation of symptoms by women is more pronounced (Lützenkirchen 2008, p. 34), while men tend to have atypical or masked symptom patterns more frequently (Winkler et al. 2005). What is remarkable in this context is the 13-fold increase in the mortality rate of men compared to women after the death of a partner. The less pronounced social competence, which makes it difficult for men to enter into new meaningful relationships, is seen as an explanation (Wolfersdorf and Schüler 2005, p. 143). The depression rate always correlates strongly with the context of the investigation. 15 percent of patients who are admitted to a general hospital due to physical illnesses also suffer from depression (Arolt et al. 1997). In a comparative study, older people with chronic health problems (Table 3) suffered from depression to around 20 to 50 percent (Lützenkirchen 2008, p. 32; Arolt and Rothermundt 2003) 11

20 background regardless of whether they were in the hospital at the time (Härter et al. 2007). In the Berlin age study, 36.8 percent of people with at least three chronic illnesses (multimorbidity) also suffered from depression (Helmchen et al. 1996), and in a Scottish study based on accounting data, the risk was with five simultaneous somatic illnesses increased almost sevenfold, at the same time suffering from a mental illness (Barnett et al. 2012). Table 3: Somatic comorbidities in elderly people with depression Disease Depression rate Disease Depression rate (%) Myocardial infarction 20% HIV% Cerebral insult% Multiple sclerosis% Cancer diseases% Dementia 40% Parkinson's disease% Chronic kidney failure% (illustration based on Arolt and Rothermundt 2003) Somatic Diseases that have a strong influence on functional health in the sense of the International Classification of Functioning, Disability and Health (WHO), in turn, also have an influence on the success of the therapy. Oslin et al. (2002) observed 671 elderly patients who were admitted to 71 psychiatric clinics because of depression. While diseases such as type 2 diabetes mellitus and high blood pressure can be easily controlled and have no effect on the remission rate, skin diseases, glaucoma, speech disorders and arthritis, but above all the accumulation of various somatic diseases, partially halved the success of the therapy . Treated depressive disorders have three typical forms. A Dutch observational study by Beekman et al. (2002), who questioned 277 older people with depression at 14 points in time, showed 35 percent of the depressions occur episodically, i.e. for a limited period of time for about three months. 23 percent remained in remission over the entire observation period, while twelve percent were affected by a depressive episode again. 32 percent of the depressive syndromes persisted, but fluctuated in their severity. Another 32 percent showed a chronic long-term course. This shows a typical gradient: the more severe the depression, the more likely it is that the depression will recur or become chronic (Beekman et al. 2002). Hölzel et al. (2011) identify a ranking of 12 in a systematic review of 25 primary studies

21 Background Risk factors associated with chronic depression: first depressive episodes at a young age, long periods of illness, a positive family history. Additional mental illnesses are less strongly associated but consistent across the majority of the studies: in particular anxiety disorders, personality disorders and substance abuse, poor social integration, negative social interactions and a comparatively low severity of symptoms. The simultaneous occurrence of another mental illness is common and increases the risk of chronification and suicidality. The chances of remission decrease (Hasin et al. 2005). The DEGS1 study, for example, showed that 60.7 percent of all people diagnosed as depressed had at least one psychological comorbidity in the last twelve months and 24.1 percent had more than two additional mental illnesses (Jacobi et al. 2014a). Half of all people who suffer from depression will also develop an anxiety disorder in the course of their life (Hasin et al. 2005), and a third develop substance abuse with alcohol, medication or other drugs. In up to 60 percent of addicts, depression is a consequence of the disease (Raimo and Schuckit 1998; Rich and Martin 2014). Often times, depression also occurs in those with eating disorders, personality disorders, and somatoform disorders. 20 to 40 percent of them also suffer from a depressive disorder, although the data situation is not yet confirmed (Godart et al. 2007; Tyrer et al. 1997). Another outstanding risk factor is loneliness or the lack of trusting personal relationships (Mushtaq et al. 2014; van den Brink et al. 2017; Domenech-Abella et al. 2017). Single people without close caregivers have a one-year prevalence of 16.3 percent compared to people living in a partnership, for example, and only 7.3 percent affected by a depressive disorder within one year (Jacobi et al. 2014a). The prevalence rates also correlate with the social gradient. 14 out of 100 people from lower social classes with a low level of education and insecure professional or economic conditions develop depression within a year, while only six people in the higher social classes are affected (Jacobi et al. 2014a). Urbanity also seems to have an influence. While only eight out of 100 people fall ill in small municipalities among residents, in the city the figure is almost 14 percent (Jacobi et al. 2014a). 13th

22 Background It is assumed that the overall prevalence of depressive illnesses will increase. The WHO estimates that by 2020 depression will be the second most common disease after ischemic heart disease (calcification of the coronary arteries). In fact, it is already the most common reason for lost years of life due to illness (WHO 2013). Ultimately, the demographic development will also ensure a higher rate of depression, since the longer life expectancy simply increases the likelihood of suffering from a depressive episode in the course of a lifetime. Etiology of depressive disorders in old age From the age of 65, depression turns into depression in old age or often referred to synonymously as age depression. In the foreground of depressive illnesses in old age are primarily mild and moderate forms of depression (Wolfersdorf and Schüler 2005, p. 14). The history of depression in old age can be divided into two manifestations, which occur in roughly equal parts. Late-onset depression (LOD) without a first episode in earlier years of life and early-onset depression (EOD) with at least one depressive illness phase in younger years (Hüll 2017). In the case of early-onset depression, the etiological focus is primarily on the relapsing character and it is assumed that a genetic predisposition is more likely than in the case of late-onset depression. The latter, on the other hand, is more closely associated with the biological and social aging process (Brodaty et al. 2001). Studies rarely distinguish a third group from the age of 75, the very late-onset depression (Hüll and Bjerregaard 2015, p. 210). This classification, as well as the specific consideration of depression in old age, is not explained in the ICD-10 (Dilling 2011) or in the DSM-5 (APA 2013), since no significant differences are recognized in the phenomenology of the disease and they are not symptomatic independent depression disorders are involved (Brodaty et al. 2001). Concepts such as depressive discomfort, late-night depression or the often used depression of old age are therefore misplaced and come from rather unreflected everyday situations (BMFSFJ 2010, p. 170). The severity of symptoms with regard to loss of interest or apathy as well as motor and cognitive impairments are identical in both groups and in younger patients. Among other things, the Berlin age study on the 14th

23 Background Conclusion that age in itself does not trigger depression (Helmchen et al. 1996). Therefore, being depressed is not typical for the elderly either. Primarily, the disease has nothing to do with age (Wolfersdorf and Schüler 2005, p. 29). At the same time, numerous authors describe differences in the presentation of symptoms, the etiology, the risk and protective factors as well as the optimal therapeutic strategies in each case (Fiske et al. 2009). The descriptive diagnosis of DSM-5 and ICD-10, which only counts symptoms, deleted the categories endogenous, reactive and neurotic and which does not look for reasons for the development of depression, is particularly common in general medicine, but also in parts of psychiatry rated as critical (Sielk et al. 2009).What is specific to some of the group of older depressed people is that they have internalized negative images of old age and deficit models (Section 2.2.4) and ask themselves: What should be happy in old age? (Wolfersdorf and Schüler 2005, p. 20). With increasing age it is said that the individuality of each person increases, which can be expressed in the symptoms of depressive illnesses typical of biographies and the depressive episodes are more colorful. (Wolfersdorf and Schüler 2005, p. 29). In addition, as shown in the previous section, depressive syndromes often interact with additional illnesses and are mutually dependent in older people. The Berlin age study (Helmchen et al. 1996) also showed that minor or mild depression with less clear symptoms occur three times as often in old people than in the general population. Since this form is considered to be less relevant clinically and is usually overlaid by somatic symptoms, the depressive illness is very difficult to diagnose in these cases. In many cases, it remains untreated and, with increasing duration, can lead to disability, restricted psychosocial living space, increased need for care, high consumption of psychotropic drugs and, in some cases, also to alcohol dependence. The result is often a clearly diagnosable depressive illness (Wolfersdorf and Schüler 2005, p. 33). Differences sometimes show up in the affective symptoms. It is described that older people with depressive illness are less demeaned, but rather are perceived as dismissive or even friendly overadapted. They tend to be anxious about body-related worries and particularly suffer from the feeling that they have nothing to show at the end of their life (Wolfersdorf and Schüler 2005, p. 24). 15th

24 Background In fact, there is a tendency towards a longer duration of the illness if there is a somatic comorbidity and the chance of a complete remission (permanent relief of symptoms) decreases, the severity of the depression increases as does the risk of suicide (Schoevers et al. 2009). Older people with depression also consider a change in their suffering situation to be less possible than younger people, which also increases suicidality considerably, as shown in Figure 4 (van Orden and Conwell 2011). Hopelessness is therefore not only a key symptom of depression, but also a major risk factor for the development of depression (Kuo et al. 2004). Suicide rate in Germany by age group in the year, 0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 0.5 4.7 6.9 8.1 9.5 9, 6 12.2 13.5 15.7 17.4 14.6 14.1 19.7 22.3 27.6 33.0 37.4 12.3 Suicides per inhabitant Figure 4: Age distribution of suicide rates in Germany in 2015 ( Federal Statistical Office 2017) As biographical depression-triggering aspects of depression in old age, memories of war, the loss of the parental home or the deprivation of a carefree childhood and adolescence are increasingly described. Furthermore, her episode-lasting thoughts revolve around impoverishment or worries about the children and the loss of autonomy (Wolfersdorf and Schüler 2005, p. 42). Further risk factors for the development of LOD or EOD are the female sex, a somatic illness, loneliness or the lack or loss of close social contacts, severe stress, insomnia, a previous depressive episode or depressive mood and, with broad evidence above all, a 16

25 Background cognitive impairment and functional impairment are described (Djernes 2006; Holley and Mast 2007; Weyerer et al. 2008; Lyness et al. 2009; Mushtaq et al. 2014; Sjöberg et al. 2017). There are also indications of an increased risk of the disease for smoking (Weyerer et al. 2013) for obesity (Almeida et al. 2009), financial stress (Cole and Dendukuri 2003), alcohol and physical inactivity (Almeida et al. 2011). Generally, as shown in simplified form in Figure 5, it can be assumed that everything that causes stress; drastic losses, other complex stressful life events, a harmful lifestyle, various comorbidities and a general susceptibility to mental disorders can act as triggers (Almeida 2014). On the other hand, a high socio-economic status, higher education, voluntary, religious or spiritual commitment, social support from life partners and friends as well as a feeling of satisfaction and meaningfulness with regard to one's own life have a protective effect (Lützenkirchen 2008, p. 28; Fiske et al. 2009). Figure 5: Risk factors that can trigger a depressive disorder (Almeida 2014) Overall, social-psychiatric, genetic, neurobiological and various environmental factors are described as influencing factors on the development of a depressive illness. Typical psychological depression triggers are experienced or threatened loss of relationships (Schoevers et al. 2006), as well as other decisive biographical events that are interpreted differently by various psychological theories. The three best known theories are psychoanalysis, learning theory and cognitive theory. 17th

26 Background Psychoanalysis assumes that the causes of the development of depression lie in too great a dependency on parents or in too early independence. The need for care and protection in the oral phase of the child was over or under met, which is expressed in the development of unstable self-esteem. Experiences of loss and changed life situations then confront those affected with existential coping tasks that they cannot solve (Wolfersdorf and Schüler 2005, p. 38; Lützenkirchen 2008, p. 26). The psychoanalyst Hubertus Tellenbach also assumed that those affected were of a melancholic type whose personality traits such as orderliness, conscientiousness and responsibility are strongly predisposed to the development of depression (Tellenbach 1983, p. 55). Learning theory assumes that there are no bonuses that promote behavior and that those affected then wean themselves off of positive behaviors and develop depressive styles of experience and behavior. Seligman (1975) describes this phenomenon as learned helplessness. When losses such as partner death or retirement occur, it is even more difficult for people who have already developed negative behavioral styles to maintain constructive attitudes. The result is a vicious circle that leads to less and less reinforcement (Lützenkirchen 2008, p. 27). It is similar with the theory of cognition. Experiences from bad relationships cause self-esteem to shrink and negative thought patterns to develop. In the theory of learned helplessness, which also emerges here, people become depressed when they consider desired goals to be unachievable and negative consequences to be inevitable. Failures are attributed exclusively to the person, while experiences of success are attributed and devalued to other influences. Positive confirmations are therefore missing and those affected ultimately have the feeling that they have no control over their lives. In this way, they lose the motivation for their own activities and, in the worst case, become paralyzed (Seligman 1999, p. 60; Hautzinger 2000, p. 35; Wolfersdorf and Schüler 2005, p. 37). Organic and biological factors also take an important role Role one. Disorders of the thyroid function, hormonal changes during pregnancy or an incorrect vitamin B12 and folic acid balance can trigger depression (ÄZQ and 18

27 Background DGPPN 2015, p. 29). Depression often occurs as a companion to other illnesses. People who suffer from a brain tumor, a cardiovascular disease, type 2 diabetes mellitus, Parkinson's disease, multiple sclerosis or dementia have an increased risk of developing depression (Helmchen et al. 1996; Barnett et al. 2012) . At the same time, people suffering from depression have a higher risk of developing type 2 diabetes mellitus, suffering a heart attack (Katon and Ciechanowski 2002) or developing Alzheimer's disease (Xu et al. 2015). Two types of pathogenetic relationships are described. The first type is when somatic and mental illness exist independently of one another. The Lübeck general hospital study by Arolt et al. (1997) showed this coexistence, described side by side, in about half of the patients examined. In the second type, as shown in Figure 6, the somatic disease is the trigger for the depression. Either because the physical illness is processed mentally incorrectly, because the illness (e.g. organic Figure 6: Depression as a comorbidity (Schulz et al. 2012, p. 456) brain disease) or its treatment (e.g. hepatitis C with interferon-α) organic changes that lead to depression or because a common trigger, such as chronic stress, can be responsible for both the development of depression and the development of a metabolic syndrome (Arolt and Rothermundt 2003; Holley and Mast 2007). Inflammatory reactions in the body could also play a pathophysiological role. Cepeda et al. (2016) discovered in an observational study with those examined that the value of the inflammatory marker C-reactive protein was 30 percent higher in people with depression than in people who were not affected. The relationship between the composition of the microbiome, i.e. the entirety of all intestinal bacteria and the development of depression is currently also being intensively researched. There are indications that people suffering from depression and those suffering from stress have a less diverse bacterial composition in their intestines. Tests on mice and humans have also shown that the targeted administration of bacteria with food, so-called microbiota, is associated with depression and stress 19

28 Background behavior that can influence positively. The microbiota transplantation from a healthy donor into the intestine of a sick person also promises positive effects in experimental studies. Evidence in the form of randomized controlled studies is still pending (Sherwin et al. 2017, p. 9 10). In all cases it must be assumed that depression and physical illnesses correlate positively and that the resulting subjective stress increases negatively. Comorbid patients show a significantly higher symptom burden and mortality (Katon et al. 2007), place a much greater strain on the health system (Mask et al. 2017) and take significantly more medication on a long-term basis (Holvast et al. 2017) than non-depressed persons. Comorbid mental illnesses can also be related to depression. The various cause-effect relationships are identical to the somatic diseases. The depression can be causal for a substance addiction, a generalized anxiety disorder in turn can be causal for a depressive disorder, an experience of loss or several complex factors can trigger both a depression and an anxiety disorder at the same time. In some cases, mental illnesses cannot be distinguished from one another and the symptoms of anxiety, depression and dementia, for example, overlap (ÄZQ and DGPPN 2015, p. 20). In addition, results from twin and family research suggest that genetic factors have an influence on the risk of the disease and that vulnerable people are at an increased risk. Children whose parents already suffered from depression are also more likely to develop the disease themselves. Arloth et al. (2015) were able to show that certain gene variants have an unfavorable effect on the glucocorticoid receptors and are therefore responsible for an adverse reaction to stressful situations. This increases the risk of mental illness. There is evidence that the same genetic predisposition is responsible for depression, sleep disorders and pain disorders (Gasperi et al. 2017). Caspi et al. (2003) suggest that a change in the serotonin transporter gene 5-HTT moderates the general influence of stress-inducing life events on depression. 20th

29 Background The initial genetic situation, however, remains only a coefficient that always occurs in connection with other active factors (Lützenkirchen 2008, p. 30). It is likely that harmful environmental factors, which act in addition to a genetic predisposition, trigger organic brain change processes that are reflected in disturbances in the transmission of stimuli. Brain research observes neurotransmitter disorders in noradrenaline and serotonin and concludes that stressful experiences can change the way the brain functions (Wolfersdorf and Schüler 2005, p. 29; J. Bauer 2002, p. 95). As already shown, age itself is not a significant factor in the development of depression. It may be assumed that the burden of losses and illnesses increases with increasing age (Amrhein et al. 2015), but at the same time, increasing age usually also means increased problem-solving skills (Chapter 2.2.4: Compensation approach), which before a Protect disease (see BMFSFJ 2010, 168). However, numerous conditions can be factors that trigger depression, as listed in Table 4 as an example. Table 4: Frequent conditions triggering depression Loss of important caregivers (e.g. risk of insufficient mourning work) Loss of friends and acquaintances (e.g. death, moving to a home) Loss of household, living, work, leisure time, environment (e.g. home, pension) Farewell of life concepts (e.g. from the middle phase of life with gainful employment) decline or loss of physical functionality and self-availability (e.g. rheumatism) fear of getting old / being old as fear of loss of autonomy, dependence on the last phase of life, objective material problems, housing problems, transport problems, relationship problems in old age (change of role : partner in need of care, overburdening with children) (illustration based on Wolfersdorf and Schüler 2005, 41) Older people see themselves confronted with the end of their working life and at the same time with ideal age images of successful aging. It should be remembered that there are somatic prevention programs for nutrition or exercise, but planning a psychosocially satisfactory existence in old age is less possible. In particular women, who are affected by poverty in old age much more frequently than men due to their employment history, show an increased vulnerability here (Wolfersdorf and Schüler 2005, p. 43). From a sociological perspective, the overall social orientation towards a competitive, subject-related performance society is decisive for the increasing 21

30 Background Significance of Depressive Diseases. At the individual (Ehrenberg 2008) and macroeconomic level (Ferrari et al. 2013) it is assumed that depression is the downside of a capitalist society that defines the creative, productive, entrepreneurial individual as the norm. Anyone who is not able to develop projects independently and be motivated and flexible in the process lacks initiative (Ehrenberg 2008, p. 245) and: The lack of initiative is the fundamental disorder of the depressed person. (Ehrenberg 2008, p. 223). At the same time, this development leads to the weakening of social ties and increasing privatization. According to Ehrenberg, the ubiquitous dogma is that everyone should develop an original identity and realize themselves. In the past, however, the ideal of a cohesive society was more restraint, conformism and submission. In capitalism, however, the term performance society underlines that it is less about personal freedom than about the development of economic competition. Ehrenberg therefore interprets depression as an illness of responsibility (Ehrenberg 2008, p. 15). According to this reading, the career of the depression begins with the increasing personal responsibility of each individual, the compulsion for autonomy and self-optimization. Older people in particular cannot live up to this ideal of constant activity and initiative, as they retire from working life and can no longer do justice to the canon of values ​​of the capitalist performance society (cf. Lützenkirchen 2008, 42). This state of affairs solidifies in the dismantling of traditional family structures. The support services that were formerly offered by the classic family network have in part no longer been available due to increasing mobility and demographic changes or have been replaced by professional services. Older people in particular live alone and have to provide for themselves (Wolfersdorf and Schüler 2005, 165). In summary, one can speak of a multifactorial etiopathogenesis in the case of depressive illnesses, in which, as shown schematically in Figure 7, genetic and biological, developmental, psychosocial and physical factors play an important role. All individual factors must always be considered in the interplay between the person and the environment (Brakemeier et al. 2008). When exactly a pathological reaction or adaptation occurs has not yet been conclusively investigated. 22nd

31 Background Figure 7: Etiological model of depressive disorder according to Callahan and Berrios 2004, p.7) 2.2 Subjective conceptions of health, illness and age Classification-diagnostic, epidemiological and etiological approaches strive for the greatest possible degree of objectivity, measurability and comparability. For the success of medical or non-medical treatment, however, the consideration of the individual experience of health and illness as well as the subjective perspective are decisive factors (Dierks et al. 2001, p. 23). It determines the perceived limitations and burdens that a disease manifests in very different ways. In addition, the subjective perspective is decisive for health-promoting behavior as well as the use of care and adherence to treatment (Hoefert and Brähler 2013, p. 238). For example, Wittchen et al. (1998, S) in their handbook Mental Disorders four dimensions for the way of the subjective manifestation of mental disorders: 1. how people experience and express their feelings, 2. how they think, judge and learn, 3. how they feel behave, 4. how they feel physically. 23

32 Background In the following, the paradigms of subjective theories will first be outlined in order to build on them to introduce subjective theories of health and illness. They are formed against the background of everyday, social and professional ideas, so-called social representations. In the course of introducing various disease theories, terms such as patient career, disease perspective and coping are introduced at the same time. In addition, the ideas of normative images of old age and the associated effects on subjective disease theories are extremely important when considering older people. On this basis, the prospects for the illness of elderly people with depressive illness are then traced in Chapter 2.3. Symbolic interactionism has a close theoretical connection to subjective theories. However, it occurs rather implicitly in the writings on subject orientation (Flick 2016, p. 86), which is why it will not be used in this chapter. A brief reference is made in chapter, since it is elementary for the epistemological background of the author Aspects of Subjective Theories The subject-theoretical paradigm that constitutes subjective theories in psychology, sociology and educational sciences is condensed into a subject term that means an autonomous, responsible being that itself grasped in his relationships to the world and can shape it according to his ideas. This knowledge subject is constituted by its own complex cognitive systems, the adequacy of which is constantly checked within its own frame of reference and which are decisive for its individual behavior (Groeben and Scheele 2000). Subjective theories are highly complex because they can basically contain any available knowledge (Flick 1991a, p. 14). They position themselves diametrically against simplistic psychological behavioristic concepts (Skinner 1973) in which only observable behavior is considered. Accordingly, the founders of the research program Subjective Theories Groeben and Scheele (2010) postulate that interpersonal research that wants to do justice to the subject model must always examine behavioral dimensions together with internal cognitive aspects. They take special account of the fact that people are not always 24

33 background and acting rationally everywhere, or their ability to rationalize and act are often influenced by latent motives. Subjective theories thus differ from the general validity claims of other scientific theories. Rational, realistic action is particularly limited in situations of disintegration of emotions and cognitions such as occur in mental illnesses (Groeben and Scheele 2010, p. 153). The sole recourse to disposition, for example a depressive illness, can only ever provide an incomplete explanation (Groeben 1986, p). But even if the rational, realistic action is sometimes or predominantly restricted, the sociologist Alfred Schütz (1953) describes, among others, that every human action is inherent in a subjective meaning, even if this cannot be recognized immediately but only in retrospect: They become meaningful if I grasp them as well-circumscribed experiences of the past and, therefore, in retrospection. Only experiences which can be recollected beyond their actuality and which can be questioned about their constitution are, therefore, subjectively meaningful. (Schütz 1945, p. 535) The discovery of this subjective meaning is the task of subject-oriented research. Among other things, she draws on the early concept of personal constructs by the psychologist George Kelly (1955, S), according to which people see themselves as scientists and actively plan, model, construct and test hypotheses in their own living environment (Flick 1991b, 14ff). This lifeworld is not structured in a scientific sense, but it forms the totality of the subjective perception of the world. It must be reconstructed as best as possible by the researcher so that the subjective meaning can be phenomenologically discovered and understood (Husserl 2012). Accordingly, subject-oriented research forces us to recognize the individual person in his current life situation and to understand him as acting and responsible even if it is an apparently suffering victim. According to Michael Winkler (1988, S), a subject is constituted by the never-ending, individual, active appropriation of the environment that is objectively confronted with it. The process takes place in the confrontation with concrete conditions, the objectivity. In the process of appropriation, the subject gives its secure mode of identity (Winkler 25

34 Background 1988, p. 153) temporarily and changes into a phase of non-subjectivity, as a prerequisite for the process of appropriation. By this, Winkler means that the person in the learning process must be ready to expand and, if necessary, revise their previous thought patterns. In doing so, he risks his own subject status and shifts his subjectivity into the future. So he has a perspective on the outcome of the appropriation process. Then what is potentially appropriated is measured in the social context against the standard of normality. If this challenge could be processed productively by the subject's abilities, the mode of identity re-enters and the person feels that his or her ability to act has been confirmed. Since the described steps are influenced by the environment and the variable constitution of the individual, an omnipresent contingency is inherent in the process of appropriation. As a prerequisite and result of a successful acquisition process, the social pedagogue Winkler describes the mode of ability, which ultimately means accumulated acts of acquisition. Developed subject potentials result in subjectivity. However, if the phase of non-subjectivity (Winkler 1988, p. 152) cannot be overcome and the act of appropriation is hindered, a productive use of the environment cannot arise. The subject gets into the mode of difference. Every subject is confronted with this state at times and one or the other object of appropriation remains foreign, but if a solidification occurs, for example due to insufficient cognitive skills or as a survival strategy, the subject can lose control over his living conditions. Further development on your own is then hardly possible. From here Winkler speaks of the absolute mode of difference: the connection between one's own actions and the real world has slipped away from the subject, it feels at odds with society, is subject to external control and is unable to act (Winkler 1988, p. 164) Health and types of subjective health theories The preceding process of appropriation, especially in its contingency, also takes place in the subjective interpretation of one's own health or illness. The scientific approaches to this research area are diverse. 26

35 Background Medical sociology also understands illness as a process of interaction between individuals and their environment, but shifts the focus from the individual definition of illness to the social construction of health and illness, which is fed by culture, politics, moral concepts and zeitgeist (Richter and Hurrelmann 2016, 12ff). Social psychology describes a similar model of images, beliefs and symbolic behaviors and calls this, among other things, social representation (Moscovici 2001, 41ff) of illness and health, which must be taken into account in the scientific reconstruction of subjective clinical pictures. Subjective health and illness schemes also have a very high priority in health psychology. They have a decisive influence on the individual perception of health risks as well as on the implementation of health-promoting behavior and thus form the basis for the target group-specific conception of preventive and curative offers (Flick 1991b, p. 27). Subjective health theories also decide on an individual level what influence those affected attribute themselves to their state of health and the logic with which they take or fail to take health-related measures, so-called health action (Faltermaier et al. 1998, p. 312). Subjective notions of health and illness are accordingly a cross-disciplinary conglomerate of everyday and scientific theories, concrete experiences and skills. Qualitative studies are particularly suitable for reconstructing these influencing factors (Faller et al. 1991). In a summary of various qualitative studies by Faltermaier et al. (1998, p. 312) a health term is drawn that is characterized by the dimensions: mental well-being (mental balance, satisfaction, positive mood), performance (with regard to fulfilling role obligations), physical strength (robustness, resilience and energy potential) and the absence of sickness is characteristic. Faltermaier and Kühnlein (1998) also examined subjective health theories with regard to the associated health behavior of 61 subjectively healthy laypeople in qualitative interviews, taking into account the biographical and social context. The respondents were between 20 and 50 years old and half were artisans and half were 27

36 Background to the other half from administrative employees. The authors discovered four types of subjective health theories: 1. The people in the first group see themselves as being threatened primarily by environmental factors and their personal lifestyle, and their health actions are aimed at minimizing risks. 2. The second group involves maintaining and strengthening external or internal resources such as physical and psychological disposition, one's own way of life and the social environment. The resources are seen here as resistance forces to ward off negative influences. 3. The third type describes a compensation model. Risks in one area of ​​life such as gainful employment can be offset by physical, psychological and social resources in other areas of life. 4. Members of the fourth group describe themselves as passive victims of random influences on health. They see prevention and the restoration of health as the task of doctors at best. The typology impressively shows that the more complex the perceived interaction between health hazards and protective factors, the greater the individual's conviction of control and the greater the subjective scope for action. However, the resulting concrete health action cannot be predicted at the level of cognitive health beliefs. It is also important to consider the subjective importance of health and the context in which health action can be implemented. At the end of their study, Faltermaier and Kühnlein (1998) describe: In everyday life, health-related action always competes with other action goals and requirements. There will be conflicting goals, even if health is very important in life. Amann and Wipplinger (1998, p. 170), on the other hand, described in a simplified overview that health and illness behavior is largely dependent on knowledge about a disease and awareness of the complex etiological relationships. 28

37 Background Subjective theories of illness, patient careers and coping The subjective theories of illness and health are crucially dependent on how people are affected. While the previous study primarily depicts the individual interpretations of societal ideas or social representations of health and illness, when looking at sick people, the individual experience of illness complements the subjective theory. Uwe Flick (1991b, p. 25) draws this cognitive process based on Klaus Dörner (1975, S) and very close to Leventhal et al. (1992, p. 144) in the concept of the patient career. In the first stage of symptom experience, the subject seeks explanations and definitions for something that is wrong, what it defines as unhealthy. The second phase I am sick describes the awareness of being sick and the first personal interventions against the background of subjective health theories. The third stage, I have to see a doctor, describes seeking professional help and becoming aware of a medical diagnosis, which leads to the fourth stage, I am a patient, in which the main focus is on trust in the treatment and compliance, but also on the reactions from the environment. The fifth stage, will I get well, forms the chronological conclusion in the development of subjective disease theories and combines individual experiences, social representations and prognostic assessments (Flick 1991b, p. 25). For Erving Goffman (1959, p. 127), all, but above all the last part of the process, is what defines the value of the term patient career, since it marks the intersection between personal development and social institutions and helps to trace these influences: The concept of career, then , allows one to move back and forth between the personal and the public, between the self and its significant society, without having overly to rely for data upon what the person says he thinks he imagines himself to be. In this regard, Uta Gerhardt (1986, 25f) assigns particular weight to the status dimension, as she sees the socio-economic, i.e. professional, financial and family status threatened, especially in the case of chronic illnesses. The term career accordingly also expresses the social struggles for rank in the sense of Pierre Bourdieu (2015), which are carried out in the social space under the influence of the disease. 29

38 Background With regard to subjective disease theories and patient careers, the concept of coping with illness, or synonymously, the concept of coping, has developed analogously to the concept of health action described above. He describes the coping reactions to the illness-related disorder across all phases, which on the one hand concern self-evident behavior in everyday life, but also more profound disorders of the subjective explanatory system (Gerhardt 1986, p. 38), such as can be found in particular in mental disorders such as depression are. There are close relationships with general coping behavior or with theories of coping with stress. The general coping with life as a striving for psychosocial ability to act in critical life constellations (Böhnisch and Schröer 2013, p. 30) is focused on cognitive process chains that are triggered by a stress-inducing illness. The individual life situation is impaired in connection with the ascribed subjective ideas about the disease and the life impairments associated with it. In particular, the relevant subjective control and competence assessments, one's own self-image, personality and the available social support determine the transition to problem-oriented and emotion-regulating coping strategies. The success or failure of these coping strategies is one of the deciding factors in the adaptation process that the subject designs in response to the illness (Lazarus and Folkman 1984, p. 44). Gerhardt (1986, p. 34) also describes this process as psychological coping and means analogous to Lazarus and Folkman (1984) the cognitive processing in which the individual tries to interpret through interpretation, at best based on a positive self-image or an awareness of environmental control, arrive at a less threatening view of the disease. This can then result in new adaptations to the environment, which harmonize with the conditions of the reduced forces and possibilities. With regard to the disease and its effects, coping is not only achieved by the subject, but also by the family, the social environment and society, which has a decisive share of responsibility, particularly in terms of socio-economic existence (Gerhardt 1986, p. 38). 30th

39