INTRODUCTION:Hearing loss is linked to cognitive decline, yet its relation to specific executive functions remains unclear. This study examines associations between planning ability, pure-tone audiometry and speech-in-noise performance. METHODS:Data were drawn from the Gutenberg Health Study (GHS), a large population-based cohort at the University Medical Center Mainz. Participants with complete pure-tone audiometry and planning ability data were included (N = 4,458; 2,314 males (51.9%), 2,144 (48.1%) females; mean age 58.0 ± 10.1 years, range 40-80). Audiologic testing included air- and bone-conduction pure-tone audiometry; hearing impairment was defined by WHO threshold. Speech-in-noise perception was measured using the German Matrix Test "Oldenburg Satztest". Planning ability was assessed using the Freiburg version of the Tower of London. Associations were analyzed with linear and logistic regression. RESULTS:Hearing loss (HL ≥ 20 dB; both ears) revealed a significant negative association with planning ability total score (β = -0.346, p < 0.01), but not significantly with clinical executive dysfunction (<16. Percentile total TOL) (OR=1.109, p = 0.43). Higher planning ability reduced the likelihood of hearing impairment (OR=0.97, p = 0.006) and was linked to better speech-in-noise perception (lower OLSA SRT, β = -0.035, p = 0.001). CONCLUSION:Hearing loss is linked to reduced planning ability, while higher planning ability decreases the likelihood of hearing impairment and increased speech perception in noise. These findings support models proposing that hearing loss imposes additional demands on working memory and attention. Longitudinal studies are needed to clarify causal directions and the potential role of interventions.

Personality functioning (PF) is a transdiagnostic construct central to contemporary models of personality pathology and a key mechanism linking childhood maltreatment (CM) to adult mental health difficulties. Yet the relative contributions of CM subtype, developmental timing, and cumulative exposure characteristics to adult PF impairment remain unclear. Gender-stratified conditional random forest regression was applied to data from a nationally representative German sample (N = 2,467; 51.8

Child maltreatment (CM) is a major health risk factor. However, perpetrator characteristics have been largely understudied in representative samples. Our aim is to describe perpetrator characteristics of CM and to identify risk constellation connecting onset of CM and perpetrator relations. Moreover, we look at differential effects of perpetrator relations on long term physical and mental health. In a cross-sectional observational approach, a representative sample of the German population (N = 2515) was assessed regarding CM characteristics (ICAST-R), physical and mental health as well as sociodemographic information. We used social network analysis to describe co-occurrences of perpetrator groups and ^2 tests to test differences in relative frequencies of perpetrator relations in onset groups. Multivariate Analysis of Variance and follow-up analyses were used to identify differences in sociodemographic, CM characteristics as well as health outcomes between onset groups. A Poisson regression was calculated to scrutinize the effect of perpetrator relation on physical and mental health. Perpetrator multiplicity and interconnectedness of perpetrator groups were high. Different frequencies of perpetrator groups across age of onset were observed for overall CM and CM subtypes. Participants who reported adolescent CM onset were younger than those with earlier CM onset. CM perpetrated by parents and by professionals in child related environments increased the risk of physical multimorbidity in adulthood. CM perpetrated by parents, relatives and others in the household, and peers and partners increased the risk of psychiatric multimorbidity in adulthood. This study provides insights into the risk constellations of CM by examining perpetrator relation, multiplicity, and co-occurrence. We found group differences in onset as well as differential risks for physical and psychiatric multimorbidity by perpetrator relation. These findings highlight the need for future research and prevention strategies that more explicitly address perpetrator characteristics.

ImportanceAssociations between child maltreatment (CM) and health have been studied broadly, but most studies focus on multiplicity (number of experienced subtypes of CM). Studies assessing multiple CM characteristics are scarce, partly due to methodological challenges, and were mostly conducted in patient samples.ObjectiveTo determine the importance of CM characteristics in association with physical multimorbidity in adulthood for women and men in a German representative sample.Design, Setting, and ParticipantsThis survey study used data from a representative sample of the German population between July and October 2021. Households were randomly selected within regional areas by a German demographic consultation company, and the Kish-Grid method was applied to ensure random participation. Reasons for nonparticipation were refusal of the selected household or target person to participate and failure to contact a household after 4 visits. Analyses took place between June 2023 and July 2024.ExposureCharacteristics of CM, including subtypes of CM, multiplicity, age at time of maltreatment (timing), number of years of experienced maltreatment (duration), frequency, and subjective severity (measured with the ISPCAN Child Abuse Screening Tools Retrospective version questionnaire).Main Outcomes and MeasuresThe main outcome was physical multimorbidity, defined as the sum score of lifetime leading morbidity and mortality causes in Western countries (obesity, diabetes, cancer, hypertension, myocardial infarction, chronic obstructive pulmonary disease, and incident stroke). Conditioned random forest regression analyses (a machine learning regression technique) were conducted to examine what characteristics of CM were most importantly associated with physical multimorbidity in adulthood while considering all other variables in the model.ResultsOf 5908 individuals invited, the study sample included 2514 participants (response rate, 42.6%), with 1297 (51.6%) women (mean [SD] age, 50.6 [17.9] years) and 1217 (48.4%) men (mean [SD] age, 49.5 [18.2] years). Duration of CM was the most important factor for physical multimorbidity in adulthood for both women (importance = 0.595; 95% CI, 0.599-0.601) and men (importance = 1.389; 95% CI, 1.386-1.394). Duration and timing variables were more importantly associated with outcomes than multiplicity in women and men. For women, severity and experiencing CM at age 4 years was significantly associated with physical multimorbidity in adulthood. For men, experiencing CM at age 11 years was most importantly associated with physical multimorbidity in adulthood.Conclusions and RelevanceIn this survey study, conditioned random forest regression analyses were applied to provide insights in the importance of duration and timing of CM for physical health in addition to the frequently studied multiplicity. These findings suggest that CM assessments should be considered in diagnostics of individuals with physical health conditions and may also inform strategies to mitigate the risk.

OBJECTIVES:Hearing loss is a prevalent factor contributing to reduced quality of life and has been linked to various comorbidities, with potential significant implications for psychosocial and cognitive health. The aim of this study was to give current information about the prevalence of hearing loss, loneliness and depression, and to examine the association between these. STUDY DESIGN:Cohort study. METHODS:The Gutenberg Health Study, a large representative cohort study for the general population, was initiated in 2007 at the University Medical Center Mainz, Germany. Hearing loss was assessed using pure-tone audiometry, with severity graduated in percentages according to the World Health Organization (WHO). Loneliness and depressive symptoms were assessed using self-report measures: Loneliness Scale (≥2) for loneliness and the PHQ-9 (≥10) for depressive symptoms. RESULTS:Among 5,948 participants (25-86 years), the prevalence of hearing loss was 38.7%. Loneliness was reported by 9.5% of the participants and the prevalence of significant symptoms of depression was 9.9%. The risk of loneliness was found to be significantly higher in participants with severe to complete hearing loss (OR = 3.92, p = 0.011). In addition, the odds ratio (OR) for depressive symptoms was significantly higher in those with a mild to severe hearing loss compared to those with normal hearing (OR = 1.3; p = 0.025). There was no association with hearing aid use. CONCLUSION:Hearing loss is associated with both loneliness and depressive symptoms. Longitudinal studies are required to clarify the causal relationships and to further investigate the direct impact of early hearing aid fitting on the progression of loneliness and depression. LEVEL OF EVIDENCE:2 Laryngoscope, 135:2497-2505, 2025.

Background Depression is associated with an increased risk for type 2 diabetes mellitus. However, depression may take different courses, and it is not fully understood how these affect the development of diabetes. It is further to be determined whether sex modifies the association between depression and type 2 diabetes. Methods We analyzed data from the Gutenberg Health Study, a longitudinal and population-based cohort study (N = 15,010) in Germany. Depressive symptoms (measured by PHQ-9), history of depression, diabetes mellitus, and relevant covariates were assessed at baseline, and the outcomes of prediabetes and type 2 diabetes mellitus were evaluated 5 years later. Logistic regression was used to estimate odds ratios of incident prediabetes and type 2 diabetes mellitus, adjusting for potential confounders as identified in a Directed Acyclic Graph. Results In the confounder adjusted model, current depression (PHQ-9 ≥ 10 at baseline; OR = 1.79, 95% CI = 1.11 to 2.74, p = 0.011), and persistent depression had a statistically significant (OR = 2.44, 95% CI = 1.62 to 3.54, p = 0.005) effect on incident type 2 diabetes mellitus. A history of depression without current depression had no statistically significant effect on type 2 diabetes (OR = 1.00, 95% CI = 0.68 to 1.43, p = 0.999). The effect of depression on incident diabetes did not differ significantly between women (OR = 2.02; 95% CI = 1.32 to 3.09) and men (OR = 2.16; 95% CI = 1.41 to 3.31; p-value for interaction on the multiplicative scale p = 0.832 and on the additive scale p = 0.149). Depression did not have a significant effect on incident prediabetes. Conclusion This study shows how the history and trajectory of depression shape the risk for diabetes. This raises interesting questions on the cumulative effects of depression trajectories on diabetes and body metabolism in general. Depression can negatively affect physical health, contributing to increased morbidity and mortality in people with mental disorders.

Background: Preterm birth is a risk factor for a variety of detrimental health outcomes. Previous studies have identified recalled (or remembered) parental rearing behaviour as a potential modifier of preterm individuals’ mental health in adulthood. However, no investigations to date have contrasted the parents’ and children’s views, explored whether their congruence is associated with preterm individuals’ mental health, or tested associations with maternal self-reported first skin-on-skin contact. Methods: This cohort study involved 199 participants of the Gutenberg Prematurity Eye Study (GPES), with prospective clinical examination and psychological assessment data available for individuals born preterm and term and their mothers’ perspective on recalled parental rearing behaviour. Participants also completed the Patient Health Questionnaire-9 (PHQ-9). Results: There were substantial similarities between reported recalled maternal rearing behaviour of individuals born preterm and at term and their mothers, with individuals born preterm with lower gestational age (age of the pregnancy from the woman’s last menstrual period) recalling mothers as comparatively more controlling and overprotective. Incongruence in recalled rejection/punishment was associated with more depressive symptoms. Late first skin-to-skin contact was related to more recalled maternal rejection/punishment, less emotional warmth, and more control/overprotection. Conclusions: this study expands the knowledge about the interrelations of preterm birth, maternal rearing behaviour, and mental health, underscoring the relevance of first relationship experiences, including close intimate contact.

Purpose Mental distress has become a major public health concern. Temporal trends in psychological distress are complex and depend on numerous factors. In this study, we examined age-period-cohort effects for mental distress including gender and German region over a 15 years’ time span. Methods Data on mental distress from ten cross-sectional surveys of the general German population, covering the years from 2006 to 2021, was used. Hierarchical age-period-cohort analyses including gender and German region as predictors were performed to disentangle age, period, and cohort effects. The Patient Health Questionnaire-4 was used as a brief screener for mental distress. Results We found significant period and cohort effects, with peek values for mental distress in the years 2017 and 2020 and for the oldest birth cohort (born before 1946). Age did not affect mental distress when cohort- and period effects as well as gender and German region were considered. An interaction effect for gender and the German region was found. Women in West Germany reported significantly higher mental distress compared to women in East Germany. Compared to men, women reported the highest prevalence in both regions. Conclusion Important political events as well as major crises can lead to an increase of mental distress in societies. Furthermore, an association between birth cohort and mental distress could be linked to socialization effects of that certain time, causing traumatic experiences or a specific coping style within this cohort group. Prevention and intervention strategies could benefit from acknowledging structural differences linked to period and cohort effects.

Suicidal crises arise from a complex interplay of a person's characteristics, their environment, and the broader social context, all of which are subject to change over time, but comprehensive analyses combining these levels are scarce. In the German context, this presents a research gap due to regional variations in both sociostructural risk/protective factors and suicide rates (which are highest in the Eastern federal states). Hierarchical age-period-cohort analyses (HAPCs) using seven representative cross-sectional population surveys spanning almost two decades (2003–2021) and including 17,542 individuals allowed for an empirical investigation of Durkheim's theory of anomie positing suicide-preventive or -promoting effects, respectively, of the social context. Age effects implied a decrease in suicidal ideation up to the age of about 35 and hereafter an increase but disappeared after including sociodemographic/socioeconomic variables. Predicted suicidal ideation also varied by period, increasing in 2011, decreasing in 2012, and slowly increasing again until 2020. Predicted values of suicidal ideation were higher for the cohort born 1960–1969 (compared to before 1946). In contrast to suicide rates, suicidal ideation was lower in East Germany. Additional effects pertained to income and civil status. These findings challenge stereotyping attributions of regional risk differences but instead point to the influence of precarious conditions and, therefore, highlight the importance of both the closer and broader social context. They also underline that major upheavals affecting society as a whole require responses going beyond the individual level.

IntroductionStigma is an individual and societal process based on attitudes and power and relates to both spatial disparities and social distinction. In this study, we examined differences in desire for social distance toward people with mental illness within a city using social and spatial information.MethodsANOVAs and Scheffé post-hoc tests analyzed varying desires for social distance toward people with mental illness within Leipzig (East Germany). Joint Correspondence Analyses (JCA) explored correspondences between desire for social distance, socio-economic status, age, life orientation, social support, duration of living in Leipzig, and shame toward having a mental illness in five city districts of Leipzig in LIFE study participants (by Leipzig Research Center for Civilization Disease, data collected 2011–2014 and 2018–2021, n = 521).ResultsStigma varied among Leipzig’s districts (F(df = 4) = 4.52, p = 0.001). JCAs showed that a higher desired social distance toward people with mental illness corresponded with spatial differences, high levels of pessimism, high shame of being mentally ill, low social support, low socio-economic status, and older age (75.74 and 81.22% explained variances).ConclusionIn terms of stigma, where people with mental illness live matters. The results identified target groups that should be addressed by appropriate intervention and prevention strategies for mental health care.

BACKGROUND:The present study aimed to investigate how depressive symptoms affect bodyweight change (gain and loss), and how this association is intertwined with other psychosocial and biomedical factors in the adult general population.METHODS:In a population-based, prospective, observational single-center cohort study in the Rhine-Main-Region, Germany (Gutenberg Health Study GHS) with N = 12,220 participants, we analyzed baseline and five year follow-up data with logistic regressions separately for bodyweight gain and loss (vs. stable bodyweight).RESULTS:Overall, 19.8 % of participants gained bodyweight of at least 5 %. More female participants were affected than male participants (23.3 % vs. 16.6 %). Regarding weight loss, overall, 12.4 % lost >5 % of bodyweight; participants were more often female than male (13.0 % vs. 11.8 %). Depressive symptoms at baseline were associated with weight gain (OR = 1.03, 95 % CI = 1.02-1.05). In models controlling for psychosocial and biomedical factors, female gender, younger age, lower socioeconomic status and smoking cessation were associated with weight gain. In weight loss, there was no overall significant effect of depressive symptoms (OR = 1.01 [0.99; 1.03]). Weight loss was associated with female gender, diabetes, less physical activity, and higher BMI at baseline. Only in women, smoking and cancer were associated with weight loss.LIMITATIONS:Depressive symptoms were assessed via self-report. Voluntary weight loss cannot be determined.CONCLUSIONS:Significant weight change frequently occurs in middle to old adulthood resulting from a complex interplay of psychosocial and biomedical factors. Associations with age, gender, somatic illness and health behavior (e.g. smoking cessation) provide important information for the prevention of unfavorable weight change.

BACKGROUND:Mental resources such as optimism and social support are important to face different stressors. The aim of this study is to identify groups in the population that are similar in terms of their mental resources.METHODS:For this purpose, a randomly selected general population community sample was used, representative for the city of Leipzig, Germany. In a two-stage process, three clusters were identified using hierarchical cluster analysis and the K-means method and then tested with a multinomial logistic regression analysis for differences in sociodemographic characteristics.RESULTS:Three clusters were identified which vary in their extent of social support and optimism. In distinguishing between those with higher and lower (medium or poor) mental resources, male gender, unemployment, being born abroad and low household income are risk factors for having fewer mental resources. Internal migrants from West Germany and persons with children at home have a higher chance of being in the type with good mental resources. The groups with medium and lower mental resources differ significantly only by variables living with a partner and employment.CONCLUSION:Our results indicate that good mental resources are associated with good mental health. Special mental health care programs, focusing in particular on the needs of vulnerable groups with poor mental resources within a society, should be implemented.

Associations of preterm birth with later-life mental distress are well-established. A research gap concerns the role of psychosocial factors such as the family context. This study investigated associations of recalled parental rearing behavior with both preterm birth characteristics and psychological symptom burden later in life. Based on birth registry data of the Mainz University Hospital in Germany (infants born between 1969 and 2002) and using a selection algorithm, a cohort study comprising four gestational age (GA) strata was conducted (≥ 37 weeks: n = 138; 33-36 weeks: n = 132; 29-32 weeks: n = 106; ≤ 28 weeks: n = 132). Participants underwent a medical examination and completed standardized questionnaires. We investigated differences in dimensions of recalled parental rearing behavior according to GA and tested pre-/perinatal stress indicators and recalled parental rearing behavior as statistical predictors of depression and anxiety symptoms later in life. Lower GA was associated with more recalled emotional warmth and overprotection. Recalled emotional warmth was associated with fewer depression and anxiety symptoms, while recalled overprotection co-occurred with more depression symptoms. The findings indicate the relevance of parental rearing behavior for the offspring's mental health. As preterm birth implicates stress for the whole family requiring adaptive parental behavior, the latter could be an important modifiable risk factor.

Previous studies on self-rated health and mortality have usually not differentiated between physical and mental health, respectively have not considered physical diseases. This study aims to determine self-rated physical and mental health from middle to old age, examine associations with mortality adjusted for objective risk factors and assess effect modification by gender. In a large population-based sample ( N = 14,993 at baseline), self-rated physical and mental health were rated separately by a single-item. Associations to mortality were modelled by Cox regressions, adjusting for potential confounding variables. Most participants rated their physical (79.4%), resp. mental health (82.3%) as good. Poor self-rated physical health was lowest in the youngest group (19.6%, age 35–44), and highest in midlife (29.1%, age 55–64). Poor self-rated mental health was lowest among the oldest (18.5%), and highest from 45 to 54 years (29.3%). Poor self-rated physical, but not mental health was predictive of mortality when adjusting for objective risk factors. Male gender and poor self-rated physical health interacted (RERI 0.43 95%-CI 0.02–0.85). Self-rated physical health was best in the youngest and worst in the midlife group, this pattern was reversed regarding self-rated mental health. Poor self-rated physical, but not mental health was predictive of mortality, adjusting for objective risk factors. It was more strongly predictive of mortality in men than in women. Poor subjective physical health ratings, should be taken seriously as an unfavorable prognostic sign, particularly in men.

AIM:The present study investigated regional differences in response behaviour for the Patient Health Quetionnaire-9. We tested for measurement invariance and differential item and test functioning between formerly divided East- and West-Germany: the former German Democratic Republic and Federal Republic of Germany. Diverging socialization experiences in socialist versus capitalist and collectivist versus individualist systems may affect culturally sensitive assessments of mental health.SUBJECT AND METHODS:To test this empirically, we used factor analytic and item-response-theoretic frameworks, differentiating between East- and West-Germans by birthplace and current residence based on several representative samples of the German general population (n = 3 802).RESULTS:Across all survey, we discovered slightly higher depression sum scores for East- versus West-Germans. The majority of items did not display differential item functioning-with a crucial exception in the assessment of self-harm tendencies. The scale scores were largely invariant exhibiting only small amounts of differential test functioning. Nonetheless, they made up on average about a quarter of the observed group differences in terms of effect magnitude.CONCLUSION:We explore possible causes and discuss explanations for the item-level differences. Overall, analyses of East- and West-German depressive symptom developments in the wake of reunification are feasible and statistically grounded.

Background Depression, the most frequent and harmful mental disorder, has been associated with specific somatic diseases as the leading cause of death. The purposes of this prospective study were to predict incident chronic diseases based on baseline depressive symptoms and to test sex-dependent effects. Methods In a representative German community sample of over 12 000 participants, baseline depressive symptoms (assessed using the Patient Health Questionnaire-9) were tested as a predictor of new onset of cardiovascular disease (CVD), chronic obstructive lung disease, diabetes, cancer, and migraine at 5-year follow-up. To study disease incidence, we created subsamples for each chronic disease by excluding participants who already had the respective disease at baseline. Potential confounders were included in logistic regression models and sex-specific analyses were performed. Results Controlling for demographic characteristics and loneliness, in men and women, baseline depressive symptoms were predictive of CVD, chronic obstructive lung disease, diabetes, and migraine, but not of cancer. When we additionally adjusted for metabolic and lifestyle risk factors, there was an 8% increase of chronic obstructive lung disease and migraine per point of depressive symptoms. There was a trend for CVD (4%; p = 0.053). Sex-sensitive analyses revealed trends for the relevance of depressive symptoms for CVD in men (p = 0.065), and for diabetes in women (p = 0.077). Conclusions These findings underscore the need to implement screening for depression in the treatment of major somatic illnesses. At the same time, depressed patients should be screened for metabolic and lifestyle risk factors and for somatic diseases and offered lifestyle interventions.

Loneliness is an established risk factor for impaired health. However, the evidence of whether increased alcohol consumption is a coping mechanism to alleviate loneliness for both genders remains sparse. The cross-sectional study included 8898 men and 8910 women (mean age of 56.2 ± 11.5 years) from three population-based cohort studies in Germany (KORA-FF4, GHS, and SHIP. Daily alcohol consumption (g/day) was measured, and risky drinking was identified using gender-specific thresholds (40 g/day for men and 20 g/day for women). Loneliness was assessed by asking if the participants feel lonely. Multivariable regression analyses were employed to examine the association between alcohol use outcomes and loneliness with adjustments for confounders. Women reported feeling lonely more frequently than men (14.8% vs 10.4%). In men, loneliness was positively associated with levels of alcohol consumption (ß = 1.75, SE = 0.76, p = 0.04) and risky drinking (OR = 1.33, 95% CI = 1.07–1.66, p = 0.02) and was even more profound in men with lower educational levels. In women, loneliness was associated with reduced odds of risky consumption (OR = 0.76, 95% CI = 0.60–0.96, p = 0.02) but not with alcohol consumption levels. The findings indicate gender-differential associations of loneliness with increased levels and risky alcohol consumption in men but with decreased risky consumption in women.

Aim The aim of the present study was to determine, if internal German migration was associated with mental distress, somatoform symptoms, depression, and anxiety. Methods Data from two representative studies from 2020 and 2021 were analysed (N=4922). Mental distress, including the dimensions somatoform symptoms, depression, and anxiety, was assessed with the short version of the Brief Symptom Inventory (BSI-18). Linear regression analyses were performed to examine associations between internal migration and mental distress while controlling for sociodemographic factors (gender, age, partner, household equivalised income, and education). Results Internal migrants from East to West Germany reported more mental distress, somatoform symptoms, depression, and anxiety than those who grew up and stayed in the East. This finding remained after controlling for sociodemographic factors. No differences were found between internal migrants from West to East Germany and those who grew up and stayed in West Germany. Discussion German internal migration should be taken into account when examining differences in mental health in East and West Germany. Our results suggest that particularly the group that had moved from the Eastern to the Western part of Germany reported significantly signs of mental distress.

Zusammenfassung Ziel der Studie Das Ziel dieser Studie ist es, zu untersuchen, inwiefern innerdeutsche Migration (Binnenmigration) mit allgemeiner psychischer Belastung, Somatisierung, Depressivität und Angst assoziiert ist. Methode Daten aus zwei bevölkerungsrepräsentativen Befragungen (2020 und 2021; N=4922) wurden genutzt, um mit Hilfe von linearen Regressionsanalysen den Einfluss von Binnenmigration auf psychische Gesundheit zu untersuchen. Die allgemeine psychische Belastung mit den Dimensionen Somatisierung, Depressivität und Angst wurde mit der Kurzform des Brief Symptom Inventory (BSI-18) erfasst. Außerdem wurden soziodemographische Merkmale (Geschlecht, Alter, Partnerschaft, Haushaltsäquivalenzeinkommen und Bildung) kontrolliert. Ergebnisse Binnenmigrierte vom Osten in den Westen berichteten, auch nach Kontrolle der soziodemografischen Faktoren, signifikant höhere Werte in der allgemeinen psychischen Belastung, Somatisierung, Depressivität und Angst als Personen, die im Osten aufgewachsen und geblieben sind. Es wurden keine Unterschiede gefunden zwischen Binnenmigrierten vom Westen in den Osten und Personen, die im Westen aufwuchsen und zur Zeit der Befragung noch im Westen lebten. Fazit Der Vergleich von psychischer Gesundheit in den neuen und alten Bundesländern sollte Binnenmigration als wichtigen Faktor berücksichtigen. Unsere Ergebnisse zeigen, dass sich insbesondere bei den Binnenmigrierten von Ost nach West eine erhöhte psychische Belastung findet.