Elisabeth Maria Balint

Background: Leadership in small and medium-sized enterprises (SMEs) is associated with a variety of challenges and stressors, which are reflected in their managers’ commonly experienced high stress levels. In this context, psychological strain can arise, but compared to large companies, SMEs face particular difficulties in implementing mental health promotion intervention. These difficulties partially originate in a profound lack of comprehensive research on the effectiveness and prospects of success of intervention strategies in SMEs. This study aims to close this gap by evaluating a stress management training for managers in SMEs (KMU-GO). Implementing established stress management strategies and making them more accessible within the SME context, the training aims to improve participants’ psychological and physiological well-being. Methods: We conducted a randomized controlled trial with an intervention and a waitlist control group in Germany. The intervention comprised 1.5 days of stress management training and two refresher sessions, focusing on short- and long-term coping strategies and self-reflection. Based on a sample of N = 155 managers, we conducted a multilevel analysis of covariance on psychological measures, namely stress reactivity, depression, and anxiety. Additionally, changes in physiological stress indices (i.e., hair cortisol concentration and salivary alpha-amylase activity) were examined. Results: Regarding the psychological measures, we found significant training effects six months after baseline. Twelve months after baseline, there were no significant differences between the intervention and control groups for either psychological or physiological variables. Conclusion: In conclusion, the present stress management training is effective in reducing psychological strain in SME managers. In order to achieve more sustainable effects, a continuation of the refresher sessions could be considered. Trial registration: Before including the first participant, the KMU-GO trial is registered at the German Clinical Trial Register (DRKS): DRKS00023457 (registered on 5 November 2020).

The construct of epistemic trust has garnered significant attention, both conceptually in relation to societal shifts in trust in communicated knowledge and social learning, and empirically in relation to psychopathology. Recently, the ETMCQ, a self-report tool, was developed to assess individual differences in epistemic stance (ES). This paper reports on the validation of a German version of the ETMCQ. Using a representative sample of 2,519 participants older than 16 years of age, the primary aim was to test the factorial validity of the instrument, while also examining associations with age, gender, and education level. A secondary aim explored associations between the three ETMCQ dimensions (trust, mistrust, and credulity) and retrospectively reported childhood maltreatment and other adversity, as well as other psychological factors, including psychopathology. Exploratory and confirmatory factor analyses revealed three correlated but distinct factors—Trust, Mistrust, and Credulity—largely in line with the original validation, resulting in a 12-item version for the German adaptation. Our findings support previous theoretical links between epistemic stance and psychological functioning, particularly the association between epistemic disruption (high mistrust and/or credulity) and increased symptomatology. Additionally, both Mistrust and Credulity were linked to childhood maltreatment, attachment avoidance, attachment anxiety, and fearful attachment. Key results suggest associations between ETMCQ factors and developmental psychopathology constructs, with these factors partially mediating the relationship between early adversity and current mental health symptoms. In terms of discriminant validity, we provide ES cut-offs in relation to widely used psychopathology screening tools. Differences in ES were also observed between individuals from the former East and West Germany, as well as in relation to income, gender, and education, suggesting cultural and socio-economic influences on the construct. In light of these findings, the ETMCQ can be seen as a brief and easy-to-administer tool that holds promise for enhancing clinical and theoretical understanding of interpersonal knowledge transfer.

Objective: Slow-paced breathing (SPB) with prolonged exhalation is assumed to stimulate vagal reflexes, which is represented by increased heart rate variability (HRV) values. However, most trials were conducted in healthy participants. We sought to evaluate the feasibility of SPB in hospitalized patients with confirmed bilateral COVID-19 pneumonia with major respiratory impairment and to investigate if SPB shows acute increasing effects on HRV measures in these severely ill patients with distinctly reduced vagal tone. Methods: This single-center randomized controlled clinical trial enrolled 23 patients in the intervention (4-second inhalation, 6-second exhalation for 20 minutes 3× daily) and 23 patients in the control group (IG/CG). The effects of SPB on HRV were calculated using post-hoc likelihood ratio tests. Baseline HRV measures between the groups over time were compared using multilevel mixed-effect linear regression models with random slope including the covariates relevant comorbidities, COVID-19 medication, and age. Results: HRV values at baseline were significantly decreased in all patients. During SPB, HRV parameters increased significantly (ln(SDNN), ln(LF), ln(TP); all p < .001). Higher breathing rate at baseline correlated with lower LF during SPB (p < .045). IL-6 morning levels were associated with lower HRV measures (p < .001). Resting HRV measures as well as subjective health increased over hospitalization time with no differences between IG and CG (comparing random slope with random slope interaction models: all LR χ ²(5) < 4.5; p > .48). Conclusion: SPB is feasible and safe in patients with bilateral COVID-19 pneumonia and appears to be an effective self-performed intervention to acutely increase HRV measures. This observation was independent of comorbidities and comedication. Further trials should corroborate these findings and extend it to other severely ill populations. Registration: German Clinical Trials Register under ID DRKS00023971 (https://drks.de/search/en/trial/DRKS00023971), with a Universal Trial Number (UTN) U1111-1263-8658

The irritation scale is a widely used and reliable self-report scale for measuring cognitive and emotional strain related to the work environment. It extends existing measures by providing a sensitive assessment for pre-clinical stress at work. Existing normative data are based on convenience samples and are therefore not representative. This study provides new normative data for the irritation scale based on a representative German sample (N = 1480). The new normative data indicate that the overall level of irritation in the German workforce is significantly lower compared to previously published data. Convergent and discriminant validity is confirmed by correlations with depression and anxiety (Patient Health Questionnaire-4 for Depression and Anxiety), somatic symptom scales (Bodily Distress Syndrome 25 checklist, Somatic Symptom Scale-8, Giessen Subjective Complaints List-8, comorbidity), psychological functioning (Mini-ICF rating for activity and participation disorders in mental illness), work-related stressors (overcommitment and bullying) and individual resources (self-efficacy). The results confirm the utility of the irritation scale and provide new benchmarks that avoid an underestimation of the levels of irritation in future studies.

Background: Occupational health physicians are increasingly confronted with mental health issues at their workplace. Facing them, most of them feel insecure and not sufficiently trained. Employee’s mental well-being depends at the same time on individual and significantly on organizational variables. This complicates the physician’s position, since they have to serve many interests. The focus of the present study is to investigate what difficulties occupational health physicians face and how organizational culture and management influence their work. Methods: Interviews were conducted with N = 25 physicians as part of a training for basic mental health care. Interviews were interpreted using qualitative content analysis. Results: Working with mentally ill employees was difficult for the physicians interviewed. Many felt insecure managing and preventing mental health issues. A need for further education was observed. Environmental factors (organizational culture, management) have a strong impact on the work of an occupational health physician and highlight its systemic dimension. Even though many of our participants report a meanwhile more open attitude towards mental disorders at their workplace, on the level of direct contact to the management prevail descriptions of little acceptance and a high priority of economic outcomes. Conclusions: More education on topics of mental health is needed for occupational health physicians. Future trainings should consider the intertwined nature of their work and enable them in dealing consciously with other actors in the company. For enhancing employee’s mental well-being occupational health physicians could be granted a strengthened position in companies or be supported through more exchange with colleagues in other companies.

(1) Background: A new health care offer called ‘psychotherapeutic consultation in the workplace’ is an early and effective intervention for employees with common mental disorders. Although cost-effective, it lacks a broader roll-out. This might be attributable to undefined context, mechanisms of change, and a lack of communication; therefore, this study explores how the new model works and where problems occur. (2) Methods: Semi-structured interviews on motivation, expectations and experiences with 20 involved experts. Experts were members of the company health promotion team, service users, and cooperating mental health specialists. Analysis was conducted with ATLAS.ti. (3) Results: The conceptual framework comprises three main topics: (a) structured implementation concept; (b) persons involved, shaping the concept’s processes; (c) and meaning and function of the offer within the given context. Concerning (c) we found three potential areas of conflict: (1) intra-corporate conflicts, (2) conflicts between company and employee, (3) and conflicts between the company health promotion and the health care system. Category (c) comprises the offer’s core characteristics which were described as low-threshold and preventive. Furthermore, the offer was perceived as convenient in handling, confidential, and having immediate impact on a person’s well-being. (4) Conclusions: Here we define structures, address the needs of the involved persons, and communicate foreseeable areas of conflict influences whether the implementation of the intervention succeeds.

Purpose: A characteristic problem occurring in COVID-19 is excessive elevations of pro-inflammatory cytokines (e.g. IL-6 and CRP) which are associated with worse clinical outcomes. Stimulation of the vagally-mediated cholinergic anti-inflammatory reflex by slow paced breathing with prolonged exhalation may present a clinically relevant way to reduce circulating IL-6.Method: Single-center randomized controlled clinical trial with enrolment of 46 patients hospitalized with confirmed severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection and moderate COVID-19 pneumonia (primary diagnosis). Differences between intervention (4sec inhalation, 6sec exhalation for 20 minutes 3x daily) and control group in IL-6 calculated using multilevel mixed-effect linear regression models with random slope including the covariates relevant comorbidities, COVID-19 medication, and age. Both groups received standard care.Results: Mean age was 57 years ± 13 years, N= 28 (60%) male, N=30 (65%) with relevant comorbidities. The model including group-by-time interaction revealed a significantly lower trajectory of IL-6 in the intervention group (effect size Cohens f² = 0.11, LR-test p=.040) in the intention-to-treat sample, confirmed by per-protocol analysis (f² = 0.15, LR-test p=.022). Exploratory analysis using the median split of practice time to predict IL-6 of the next morning indicated a dose-response relationship with beneficial effects of practice time above 45 minutes per day. Oxygen saturation remained unchanged during slow-paced breathing (95.1% ± 2.1% to 95.4% ± 1.6%).Conclusion: Patients practicing slow-paced breathing had significantly lower IL-6 values than controls with a small to medium effect size and without relevant side effects. Further trials should evaluate clinical outcomes and an earlier start of the intervention. Slow-paced breathing could be an easy to implement, low-cost, safe and feasible adjuvant therapeutic approach to reduce circulating IL-6 in moderate COVID-19 pneumonia.Clinical Trial Registration: https://www.drks.de, identifier DRKS00023971, Universal Trial Number (UTN) U1111-1263-8658.

The bio‐psycho‐social model highlights intra‐individual and inter‐individual interactions, including psychotherapy. The processing of these interactions within a person takes place, among others, in the central autonomic network (CAN). The CAN's autonomic output to the periphery can be indexed by heart rate variability (HRV), representing individual adaptive capacity. Further, the CAN influences the hypothalamus‐pituitary–adrenal axis with its product cortisol. The aim consisted in investigating HRV and cortisol as well as their relation to symptom course in response to short‐term psychotherapy. A single‐arm, uncontrolled, explorative study was conducted at an outpatient psychotherapeutic consultation in the workplace offered to employees with mental or psychosomatic complaints. Questionnaires included symptoms of depression, irritation and functional impairment. Circadian profile of HRV and salivary cortisol concentrations collected pre and post short‐term psychotherapeutic intervention (4–12 sessions) were assessed. Multilevel‐linear mixed regressions were calculated. Out of 29 participants (mean age 42; 72% female), 24% were on sick leave from work. Cortisol concentrations were neither affected by intervention nor by symptom course. The proportion of individuals showing a vagally mediated HRV in the range of the lowest quartile assessed for age‐ and sex‐matched healthy controls was reduced at follow‐up (pre 34%, post 22%; p = .017). Higher vagally mediated HRV at baseline predicted lower symptom burden at follow‐up. Thus, the results support the assumption that HRV reflects the capability of an organism to adapt and recover. Patients with reduced HRV might need additional psychotherapeutic sessions to achieve the same symptom improvements than patients with retained HRV.

Background: Mental illnesses have received increasing attention in the work context in recent years, yet they are still often accompanied by stigma. One starting point for stigma reduction is interventions in the workplace. The present study evaluated a one-day workshop for managers in a large company. Method: Enrolled managers (n = 70) were randomly assigned to the intervention group and the waiting control group. The training included a theoretical section on mental and stress-related diseases as well as the interplay between work and health, group work on personal stress experience, theoretical input on dealing with mentally ill employees, and a group discussion on this topic along with case studies. Both groups completed the following questionnaires at baseline and three months after training: Effort–Reward Imbalance Questionnaire, Patient Health Questionnaire, Mental Health Knowledge Schedule, Social Distance Scale, and the Irritation Scale. Results: Compared to the waiting group, the intervention group showed a significant improvement in the Mental Health Knowledge Schedule (U = 417.00, p = 0.040) and an increase in the Irritation Scale (U = 371.50 p = 0.011). All other scales remained unchanged. Conclusion: The content and duration of the training were adequate to reduce cognitive stigma towards mental illness. However, the present approach was not sufficient for an improvement in the subjective stress level of the participating managers.

Stress management interventions aim to reduce the disease risk that is heightened by work stress. Possible pathways of risk reduction include improvements in the autonomous nervous system, which is indexed by the measurement of heart rate variability (HRV). A randomized controlled trial on improving stress management skills at work was conducted to investigate the effects of intervention on HRV. A total of 174 lower management employees were randomized into either the waiting list control group (CG) or the intervention group (IG) receiving a 2-day stress management training program and another half-day booster after four and six months. In the trial, 24 h HRV was measured at baseline and after 12 months. Heart rate (HR), root mean square of successive differences (RMSSD), standard deviation of normal-to-normal intervals (SDNN), and standard deviation of the average of normal-to-normal intervals (SDANN) were calculated for 24 h and nighttime periods. Age-adjusted multilevel mixed effects linear regressions with unstructured covariance, time as a random coefficient, and time × group interaction with the according likelihood-ratio tests were calculated. The linear mixed-effect regression models showed neither group effects between IG and CG at baseline nor time effects between baseline and follow-up for SDANN (24 h), SDNN (24 h and nighttime), RMSSD (24 h and nighttime), and HR (24 h and nighttime). Nighttime SDANN significantly improved in the intervention group (z = 2.04, p = 0.041) compared to the control group. The objective stress axis measures (SDANN) showed successful stress reduction due to the training. Nighttime SDANN was strongly associated with minimum HR. Though the effects were small and only visible at night, it is highly remarkable that 3 days of intervention achieved a measurable effect considering that stress is only one of many factors that can influence HR and HRV.